OITE & AAOS Orthopedic Board Review MCQs: Trauma & Foot

About This Board Review Set

This is Part 205 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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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 205

This module focuses heavily on: Dislocation, Foot, Fracture, Trauma.

Sample Questions from This Set

Sample Question 1: A 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph...

Sample Question 2: Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?...

Sample Question 3: A man sustained the injury shown in Figures 51a and 51b. He underwent closed reduction of the radial head dislocation and open reduction and internal fixation of the ulnar fracture. What is the most common cause of persistent radial head su...

Sample Question 4: Anabolic steroid use has which of the following effects on serum lipoprotein levels?...

Sample Question 5: A 34-year-old male arrives intubated with a closed head injury to the trauma bay after a motor vehicle accident. After initial hospital workup and resuscitation, he is transferred to the intensive care unit. In addition to multiple systemic...

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 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph is shown in Figure 14. Initial management should consist of

Explanation

DISCUSSION: The presence of the relatively long second metatarsal, along with the close approximation of the second and third metatarsal heads, are consistent with second metatarsophalangeal tenosynovitis. The hallmark of initial management is conservative. Modalities include taping, nonsteroidal anti-inflammatory drugs, metatarsal pads, and cortisone injections. Trepman and Yeo combined the use of a cortisone injection with a rocker bottom sole. Mizel and Michelson reported their results using an extended rigid steel shank shoe along with a cortisone injection.
REFERENCES: Trepman E, Yeo SJ: Nonoperative treatment of metatarsophalangeal joint synovitis. Foot Ankle Int 1995;16:771-777.
Mizel MS, Michelson JD: Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint. Foot Ankle Int 1997;18:424-426.

Question 2

Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?

Explanation

DISCUSSION: Rapid fluid resuscitation is the cornerstone of therapy for hypovolemic shock. Fluid should be infused at a rate sufficient to rapidly correct the deficit. If the estimated blood loss is greater than 30% of the total volume(class III), blood replacement is also indicated. In general, a favorable response to fluid replacement therapy includes increased urinary output (at least 0.5ml/kg/hr), improved level of consciousness, increased peripheral perfusion, and changes in vital signs (such as increased BP, increased pulse pressure, and decreased heart rate). Lab values that are important include lactic acid, which is increased if the shock is severe enough to cause anaerobic metabolism, and decreased serum bicarbonate which leads to a negative base deficit. Successful resuscitation in a shock patient will therefore lead to a falling lactate and normalizing pH. Successful resuscitation in a shock patient will therefore lead to a falling lactate (i.e. <2.0mmol/L) and a normalizing pH.

Question 3

A man sustained the injury shown in Figures 51a and 51b. He underwent closed reduction of the radial head dislocation and open reduction and internal fixation of the ulnar fracture. What is the most common cause of persistent radial head subluxation?

Explanation

DISCUSSION: The radiographs reveal a Monteggia injury, with a proximal ulnar shaft fracture and a radial head dislocation. Treatment involves open reduction and internal fixation of the ulnar fracture. With correct reduction of the ulna, the radial head is reducible and remains stable, despite an obvious soft-tissue injury around the elbow. Problems with persistent radial head subluxation are almost always attributed to malreduction of the ulnar fracture. Rare causes of persistent radial head subluxation are interposition of soft tissues in the joint and lateral ligamentous injuries.
REFERENCES: Jupiter JB, Kellam JF: Diaphyseal fractures of the forearm, in Browner B, Jupiter J, Levine A, Trafton P (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1992, pp 1421-1454.
Ring D, Jupiter JB, Simpson NS: Monteggia fractures in adults. J Bone Joint Surg Am 1998;80:1733-1744.

Question 4

Anabolic steroid use has which of the following effects on serum lipoprotein levels?

Explanation

DISCUSSION: The use of anabolic steroids causes a decrease in high-density lipoprotein levels but has no effect on low-density lipoprotein levels. An abnormally low high-density lipoprotein level should alert the physician to the possibility of steroid use in an athlete.
REFERENCES: Hartgens F, Rietjens G, Keizer HA, et al: Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a). Br J Sports Med 2004;38:253-259.
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med
1999;18:667-689.

Question 5

A 34-year-old male arrives intubated with a closed head injury to the trauma bay after a motor vehicle accident. After initial hospital workup and resuscitation, he is transferred to the intensive care unit. In addition to multiple systemic injuries, he sustained the closed injury shown in Figure A. Intracompartmental pressure monitoring of the limb measure in a range from 28-30 mm Hg. Which of the following sustained blood pressure measurements would support the treatment of limb fasciotomy? Review Topic 1 110/60 mmHg 2 115/55 mmHg 3 92/64 mmHg

Explanation

A reported indication to perform fasciotomy includes an ICP measurement that is elevated to 30 mm Hg below the diastolic blood pressure. This would be the case if this patient's blood pressure was consistently around 115/55 mmHg (dBp=55; ICP=30; delta p = dBp-ICP = 25 mmHg).
Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam - especially with intubated patients. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy.
McQueen et al. prospectively reviewed 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of
30 mmHg is a more reliable indicator of compartment syndrome.
Olson et al. provide a review of compartment syndrome for the lower extremity. They discuss a variety of injuries and medical conditions that may initiate acute compartment syndrome, including fractures, bleeding disorders, and other trauma. Although the diagnosis is primarily a clinical one, they also recommend supplementation with compartment pressure measurements in equivocal cases.
Figure A shows a closed comminuted tibial shaft fracture. Incorrect Answers:

Question 6

A 40-year-old right hand-dominant construction worker has had a 6-month history of aching left shoulder pain that is worse after working a long day. Examination reveals limited range of motion and good strength when compared to his asymptomatic right arm. He has not had any orthopaedic intervention to date. Radiographs are shown in Figures 43a and 43b. What is the most appropriate treatment?

Explanation

DISCUSSION: The patient is a young laborer with osteoarthritis. Initial treatment should begin with nonsurgical management that may include anti-inflammatory drugs, cortisone injections, and physical therapy to diminish pain and improve motion. The other choices may eventually be necessary but should only follow a course of nonsurgical management.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 7

A 72-year-old female presents to your office with a 24-month old painful nonunion of a 3-part fracture of the proximal humerus. She has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. Operative management should include:

Explanation

DISCUSSION: Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with arthroplasty when possible. Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, rotator cuff repair (when needed), and treatment of soft tissue contractures. Attempts at internal fixation should be performed with caution in this patient population, due to general osteopenia and significant rates of loss of fracture reduction.
The referenced article by Cheung et al reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain relieving procedure.
Dines reported a case series of 20 chronic post-traumatic proximal humerus fractures including nonunions that were treated with shoulder arthroplasty achieving fair to excellent results in 90% at mid-term follow-up

Question 8

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 9

A 42-year-old man reports the recent onset of right hip pain. A radiograph and MRI scan are shown in Figures 38a and 38b. A WBC count, erythrocyte sedimentation rate, and hip aspiration are within normal limits. Management should now consist of

Explanation

DISCUSSION: Transient osteoporosis of the hip is an uncommon problem, usually affecting women in the last trimester of pregnancy and middle-aged men. Symptoms include pain in the involved hip with temporary osteopenia; however, there is no joint space involvement. In this patient, the imaging findings are consistent with transient osteoporosis. Short TR/TE (repetition time/echo time) images reveal diffusely decreased signal intensity in the femoral head and intracapsular region of the femoral neck. Increased signal intensity is seen with increased T₂-weighting. Within a few months, the pain, as well as the imaging findings, will completely resolve without intervention. Distinguishing the diffuse features of transient osteoporosis of the hip from the segmental findings of osteonecrosis is essential. Unlike transient osteoporosis of the hip, osteonecrosis will have a double-density signal on MRI and may progress radiographically. Surgical intervention and oral corticosteriods are not indicated for treatment. Protected weight bearing until the pain resolves may decrease symptoms while the transient osteoporosis resolves.
REFERENCES: Potter H, Moran M, Scheider R, et al: Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip. Clin Orthop 1992;280:223-229.
Bijl M, van Leeuwen MA, van Rijswijk MH: Transient osteoporosis of the hip: Presentation of typical cases for review of the literature. Clin Exp Rheumatol 1999;17:601-604.
Montella BJ; Nunley JA, Urbaniak JR: Osteonecrosis of the femoral head associated with pregnancy: A preliminary report. J Bone Joint Surg Am 1999;81:790-798.

Question 10

A clinical trial is being conducted on a new orthopaedic device that is different from existing devices that are moderately successful, but have frequent complications when used to treat fractures in the elderly. To comply with international standards for clinical trials, the investigator must include in the study design

Explanation

In any research on human beings, each potential subject must be adequately informed of the aims. methods, anticipated benefits and potential hazards of the study and the discomfort it may entail. He or she should be informed that he or she is at liberty to abstain from participation in the study and that he or she is free to withdraw his or her consent to participation at any time. The physician should then obtain the subject’s freely-given informed consent. preferably in writing.

Question 11

An active 45-year-old man sustained an acute traumatic anteroinferior dislocation. MRI scans and an arthroscopic view are shown in Figures 36a through

Explanation

During an anteroinferior dislocation, the posterosuperior portion of the humeral head impacts the inferior rim of the glenoid, resulting in an impaction injury. This lesion is classically referred to as a Hill-Sachs lesion.

Question 12

Figure 42 shows the radiograph of a patient with spinal muscular atrophy. Examination reveals good upper extremity function, and she can tie her shoes and propel a manual wheelchair. Posterior instrumentation and fusion may result in

Explanation

DISCUSSION: Spinal muscular atrophy is caused by an abnormal survival motor neuron gene that prevents apoptosis of the motor nerves. Spinal fusion results in better sitting balance, stabilized or improved pulmonary function, and high parental satisfaction, but it may result in at least temporary loss of upper extremity function.
REFERENCES: Bentley G, Haddad F, Bull TM, Seingry D: The treatment of scoliosis in muscular dystrophy using modified Luque and Harrington-Luque instrumentation. J Bone Joint Surg Br 2001;83:22-28.
Furumasu J, Swank SM, Brown JC, Gilgoff I, Warath S, Zeller J: Functional activities in spinal muscular atrophy patients after spinal fusion. Spine 1989;14:771-775.
Granata C, Cervellati S, Ballestrazzi A, Corbascio M, Merlini L: Spine surgery in spinal muscular atrophy: Long-term results. Neuromuscul Disord 1993;3:207-215.

Question 13

A patient with myelopathy underwent a one-level corpectomy 1 day ago and is now home. In the middle of the night he calls to report markedly increased difficulty in swallowing, diaphoresis, a change in his voice, and difficulty lying flat. What is the best course of action?

Explanation

DISCUSSION: The patient has respiratory distress as manifested by his difficulty in lying flat. In addition, the diaphoresis and the change in his voice indicate retropharyngeal edema or hematoma that is compressing his larynx. The only appropriate treatment is hospital admission and elective intubation. During intubation it is possible to cause laryngospasm in a patient with a hyperacute airway; therefore, the surgeon should be prepared to perform a cricothyroidotomy. Often a fiberoptically guided intubation is the only way to find the airway in the presence of retropharyngeal edema or hematoma.
REFERENCES: Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.
McAfee PC, Bohlman HH, Riley LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am 1987;69:1371-1383.

Question 14

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Explanation

Whereas ipsilateral fractures of the femoral neck and shaft are uncommon, it is critical to recognize a femoral neck fracture that may occur in conjunction with a femoral shaft fracture. The combined injury is seen in 2% to 9% of femoral shaft fractures and may initially be missed in as many as one third of the cases. Preoperative examination of a thin cut CT scan and dedicated AP internal rotation views of the femoral neck can help identify this injury. In addition, the intraoperative AP and lateral hip fluoroscopic view should be examined, and a dedicated radiograph of the hip obtained at the conclusion of the surgery. At follow-up, Tornetta and associates has recommended
obtaining a dedicated AP radiograph of the hip with the leg internally rotated 15 to 20 degrees. Because the femoral neck is anteverted, 15 to 20 degrees of internal rotation of the hip offers the best view of the femoral neck. Whereas associated lumbar spine pathology may cause groin pain, the presence of a missed femoral neck fracture must first be ruled out prior to investigating other sources of pain.

Question 15

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?

Explanation

DISCUSSION: Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers.

A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has

been shown to be successful in the treatment of traumatic instability.
REFERENCES: Bottoni CR, Franks BR, Moore JH, et al: Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
Williams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209.
Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487.

Question 16

Examination of a 28-year-old woman reveals a moderate hallux valgus deformity and a prominence of the medial eminence. She reports that she can participate in all activities, wear 3-inch heels with minimal discomfort, and walk in a 1-inch heel with no pain. However, she is concerned that the deformity will get worse and requests recommendations regarding surgical correction. What is the best course of action?

Explanation

DISCUSSION: Because the patient is essentially asymptomatic, the most appropriate course of action is observation. Prophylactic hallux valgus surgery is not medically indicated. Steroid injection would only risk infection, as well as joint and capsule damage. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Special shoe wear or an extra-depth shoe is not necessary and is unlikely to be accepted by the patient.
REFERENCES: Donley BG, Tisdel CL, Sferra JJ, Hall JO: Diagnosing and treating hallux valgus: A conservative approach for a common problem. Cleve Clin J Med 1997;64:469-474.
Teitz CC, Hu SS, Arendt EA: The female athlete: Evaluation and treatment of sports-related problems. J Am Acad Orthop Surg 1997;5:87-96.

Question 17

A 12-year-old Little League pitcher has had pain in the dominant shoulder for the past week that prevents him from pitching. Examination reveals normal strength, full range of motion, normal stability, and mild tenderness about the proximal humerus. Radiographs with comparison views of the opposite shoulder show widening of the proximal humerus physis. Management should include

Explanation

Little League’s shoulder is a stress fracture of the proximal humeral epiphyseal plate. The classic history is the adolescent pitcher who has increased his pitching level and now has poorly localized aching shoulder pain after attempts to throw. PE will show discomfort at the proximal humerus and weakness. Early x-ray may show no pathology. Later it shows physis widening, fragmentation, demineralization, periosteal stripping, callus.
Treatment requires cessation of repetitive physeal stress. There is no long-term sequelae. The athlete can return to same sports in the following season with emphasis on preseason conditioning.

Question 18

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Explanation

DISCUSSION: The arthroscopic view shows a HAGL lesion. With the arthroscope directed anteroinferiorly, muscular striations of the subscapularis can be visualized through the avulsion site. In vitro strain studies indicate that glenohumeral ligament failure on the humeral side occurs in approximately 25% of patients, while clinically this lesion has been reported in approximately 9% of patients with shoulder instability. Failure to recognize and treat this lesion leads to persistent anterior instability. An ALPSA lesion, a Bankart variant, occurs on the glenoid side and is characterized by a sleeve-like medial retraction and inferior rotation. A Bankart lesion is the classic avulsion of the glenohumeral ligament from the glenoid rim. The subscapularis tendon and the rotator interval are not shown in the figure.
REFERENCES: Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.
Bigliani LU, Pollack RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197.
Warner JJ, Beim GM: Combined Bankart and HAGL lesion associated with anterior shoulder instability. Arthroscopy 1997;13:749-752.

Question 19

A 68-year-old woman with a history of rheumatoid arthritis has had neck pain and weakness in all four extremities that has become worse in the past 6 months. She has gone from a community to a household ambulator and uses a wheelchair outside of the home. Examination of the extremities reveals poor coordination, diffuse weakness, hyperactive reflexes, and bilateral sustained clonus. She has a broad-based and unsteady gait. The posterior atlanto-dens interval is 12 mm. Based on these findings and the radiograph and MRI scan shown in Figures 13a and 13b, the treatment of choice is surgical decompression and stabilization. However, the patient inquires about the prognosis with surgery compared to nonsurgical management. Assuming there are no complications from surgery, the patient should be informed that, with surgery, she will most likely

Explanation

DISCUSSION: The patient has a cervical myelopathy with more than 10 mm of space available for the cord; therefore, she has a reasonable chance of improved neurologic function following surgery. If not treated with surgery, however, her neurologic condition likely will worsen and she will die earlier than if she had surgery.
REFERENCES: Matsunaga S, Sakou T, Onishi T, et al: Prognosis of patients with upper cervical lesions caused by rheumatoid arthritis: Comparison of occipitocervical fusion between C1 laminectomy and nonsurgical management. Spine 2003;28:1581-1587.
Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am

1993;75:1282-1297.

Question 20

Among the ankle arthroscopy portals described below, which portal is at highest risk for serious complications?

Explanation

Extensor digiti minimi
Flexor digitorum superficialis (FDS) to the index finger 77
Abductor pollicis brevis
First dorsal interossei
DISCUSSION
The intraoperative image shows a piece of glass splitting the ulnar nerve in the cubital tunnel. The extensor digiti minimi is innervated by the radial nerve. The FDS to the index finger and the abductor pollicis brevis are innervated by the median nerve. The first dorsal interossei is the last muscle innervated by the ulnar nerve.
RECOMMENDED READINGS
Miller MD. Review of Orthopaedics. 3rd ed. New York, NY: Saunders; 2000.
Anderson JE. Grant’s Atlas of Anatomy. 8th ed. Baltimore, MD: Williams & Wilkins; 1983.

Question 21

A 32-year-old man sustained a fracture of his upper arm in a motor vehicle accident. Radiographs are shown in Figure 32. Because of other associated injuries, surgical stabilization is chosen. What technique will result in the least complications and the best outcome?

Explanation

DISCUSSION: Most humeral fractures will heal with nonsurgical functional brace management. When the initial pain has subsided in a coaptation splint, the patient is converted to a functional brace and allowed to use the arm for activities. The fracture should heal within 6 weeks to 12 weeks with acceptable results. Surgery is indicated if there is vascular injury, open injury, floating elbow, chest injury, bilateral humeral fractures, or if a reduction cannot be obtained or maintained. The surgical treatment of choice is either antegrade reamed locked intramedullary nailing or plate osteosynthesis. Plate osteosynthesis appears to offer better results with respect to union, function, and risk of complications.
REFERENCES: Schemitsch EH, Bhandari M: Fractures of the humeral shaft, in Browner BD: Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1481-1511.
Chapman JR, Henley MB, Agel J: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166.

Question 22

A 65-year-old woman has had chronic aching discomfort involving her elbow for the past 6 months. Radiographs and a biopsy specimen are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The histologic features of multiple myeloma are distinctive for this lesion. The plasma cells are round or oval and have an eccentric nucleus and prominent nucleolus. These characteristics and a clear area next to the eccentric nucleus representing the prominent Golgi center are pathognomonic for plasma cells. Lymphoma is in the differential diagnosis; the most frequent types that occur in bone are large cell or mixed small and large cell types. The histologic appearance of the specimen is not consistent with the other choices.
REFERENCE: Dorfman HD, Bodgan C: Immunohematopoietic tumors, in Dorfman HD, Bogdan C (eds): Bone Tumors. St Louis, MO, Mosby, 1998, Chapter 12.

Question 23

An 18-year-old man has acute respiratory distress after sustaining injuries in a motorcycle accident. He has a blood pressure of 80/60 mm Hg and a pulse rate of 110/min. Examination reveals chest tympany to percussion, distended neck veins, and deviation of the trachea away from his right hemithorax where the breath sounds are diminished. Heart sounds are regular and normal on auscultation. Initial management should consist of

Explanation

DISCUSSION: Tension pneumothorax occurs when air trapped in the pleural space between the lung and chest wall achieves sufficient pressure to compress the lungs and shift the mediastinum. Urgent needle decompression of the pleural space air followed by definitive chest tube placement is the treatment of choice.
REFERENCE: Mattox KL, Feliciano DV, Moore EE (eds): Management of Shock, ed 4. New York, NY, McGraw Hill, 2000, p 215.

Question 24

The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?

Explanation

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,

pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 25

A 38-year-old man who is an avid tennis player has had persistent pain over the medial aspect of his knee for the past 6 years. He notes that the pain occurs on a daily basis with any significant activity. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 22a and 22b. What is the best course of action?

Explanation

DISCUSSION: In a relatively young patient who is an avid tennis player, the treatment of choice is a joint preserving procedure. The radiographs reveal varus alignment with loading of the medial compartment. After all nonsurgical management options have been used, the best treatment option is a medial opening wedge osteotomy. A lateral closing wedge osteotomy of the proximal tibia is also a reasonable option, but it is not one of the choices. A unicompartmental arthroplasty or a total knee arthroplasty would place significant restrictions in this patient. A unispacer may be a temporizing procedure but is controversial and without substantial data in the literature. The knee arthroscopy will not address the medial compartment osteoarthritis.
REFERENCES: Nagel A, Insall JN, Scuderi GR: Proximal tibial osteotomy: A subjective outcome study. J Bone Joint Surg Am 1996;78:1353-1358.
Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Manifold SG, Kelly MA, Richardson L, et al: Osteotomies about the knee, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 947-961.

Question 26

The sartorius muscle is innervated by which of the following nerves?

Explanation

DISCUSSION: The femoral nerve enters the thigh behind the inguinal ligament, lying on the surface of the iliopsoas muscle lateral to the femoral artery and vein. The nerve divides into numerous muscular and cutaneous branches in the femoral triangle. The first motor branch (sometimes two branches) is to the sartorius. There is a variable branch to the pectineus. Subsequent branches go to the rectus femoris and then the vastus muscles in variable order. The last motor branch is to the articularis genu. The muscular branches can be injured in anterior approaches to the hip, especially the middle window of the ilioinguinal approach.
REFERENCES: Hollinshead WH: Textbook of Anatomy, ed 3. Hagerstown, MD, Harper and Row, 1974, p 404.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 139.

Question 27

Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?

Explanation

DISCUSSION: The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a “bamboo spine” in the lumbar region. HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population. The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration.
REFERENCES: Calin A: Ankylosing spondylitis. Clin Rheum Dis 1985;11:41-60.
Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 431.
van der Linden S, Valkenburg H, Cats A: The risk of developing ankylosing spondylitis in HLA-B27 positive individuals: A family and population study. Br J Rheumatol 1983;22:18-19.

Question 28

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

Explanation

DISCUSSION: The dual plate fixation construct is significantly stronger than single plate or “Y” plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis.
REFERENCES: Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264.
Sodergard J, Sandelin J, Bostman O: Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J Trauma 1992;33:687-690.

Question 29

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Explanation

A patient with an injury at the level of: C4 injury needs puffer control; C5 can use hand controls; C6 can use a manual wheelchair and sliding board transfers; C7 allows independent transfers; and no cervical injury routinely allows ambulation with crutches and leg braces.

Question 30

A 20-year-old basketball player reports a 6-month history of right groin pain that radiates into his testicles with activities of daily living. He denies any history of trauma. Examination reveals tenderness about the groin, and he has full hip range of motion. The abdomen is soft. Radiographs are normal. Nonsurgical management has consisted of rest and physical therapy, but he continues to have pain. What is the next step in management?

Explanation

DISCUSSION: Sports hernias may be one of the most common causes of groin pain in athletes. Resisted hip adduction is painful in the case of groin disruption. Radiation of pain into the testicles and/or adductor region is often present. Sports hernias are associated with weakening of the posterior inguinal wall. In contrast with sports hernias, traditional or classic hernias can be readily detected on physical examination. Diagnostic imaging studies are not helpful and only serve to help exclude other diagnoses. Systemic high-dose steroids or sacroiliac joint injections have no role in treatment. High success rates have been reported for laparoscopic hernia repair in athletes.
REFERENCES: Kluin J, den Hoed PT, van Linschoten R, et al: Endoscopic evaluation and treatment of groin pain in the athlete. Am J Sports Med 2004;32:944-949.
Genitsaris M, Goulimaris I, Sikas N: Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238-1242.
Meyers WC, Foley DP, Garrett WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.

Question 31

A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?

Explanation

DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.

Question 32

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Explanation

DISCUSSION: Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female.
REFERENCES: Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.
Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

Question 33

A 65-year-old man with ankylosing spondylitis has neck pain after falling back over his lawnmower, striking his thoracic spine, and forcing his neck into extension. Examination reveals subtle weakness of the intrinsics and finger flexors at approximately 4+/5. Initial management consists of immobilization in a rigid collar, and placing his head in the anatomic position. Radiographs reveal a subtle extension fracture of the lower cervical spine. Approximately 6 hours after the injury, he reports increasing paresthesias in his upper and lower extremities, and examination now shows his intrinsics are 2/5, finger flexors are 3/5, and his triceps are now weak at 4/5 on manual motor testing. In addition, his lower extremities now show weakness in both dorsal and plantar flexion of the ankle in the range of 4/5. Repeat radiographs appear unchanged. An MRI scan is shown in Figure 2. Management should now consist of

Explanation

DISCUSSION: It is not uncommon for patients with ankylosing spondylitis to sustain extension-type fractures, most typically of the cervicothoracic junction. These fractures can appear nondisplaced or minimally displaced initially, making them difficult to diagnose. Because there is no mobility between vertebrae, fractures tend to occur more like those of a transverse fracture of a long bone. In addition, the vertebral bodies are vascular and their canals are relatively enclosed, making them vulnerable to epidural bleeding. The MRI scan reveals an epidural hematoma located posteriorly on the cord; therefore, the treatment of choice is surgical evacuation and a posterior laminectomy. Because of the intrinsic instability of such fractures at the time of the laminectomy, internal fixation and stabilization with a posterior fusion is warranted. A simple laminectomy will only increase instability, and control is unlikely with halo vest immobilization. An anterior procedure will not effectively treat the problem given the location of the hematoma. Consideration can be given to methylprednisolone and observation; however, this will not eradicate the problem.
REFERENCES: Bohlman HH: Acute fractures and dislocations of the cervical spine. J Bone Joint Surg Am 1979;61:1119-1142.
Weinstein PR, Karpman RR, Gall EP, et al: Spinal cord injury, spine fracture and spinal stenosis in ankylosing spondylitis. J Neurosurg 1982;57:609-616.

Question 34

Figure 1 is the MR image of a 43-year-old man who has left shoulder pain and weakness after a fall. An examination reveals active forward elevation at 120° and positive Yergason and lift-off test examination findings. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 35

A 16-year-old high school football player sustains an injury to the left hip. The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?

Explanation

DISCUSSION: The avulsed fragment represents the origin of the rectus femoris from the anterior inferior iliac spine and the brim of the acetabulum. Avulsion of the anterior inferior iliac spine is much less common than avulsion of the anterior superior iliac spine with its origin of the sartorius. The origin of the gluteus minimus is from the outer cortex of the iliac wing and has not been reported as a source of bony avulsion. The hip capsule is composed of the ischiofemoral and pubofemoral ligaments, in addition to the iliofemoral ligament. The pelvic attachment of the ischiofemoral ligament is from the ischial part of the acetabulum posteriorly, while the pubofemoral ligament attaches to the pubic portion inferiorly. Technically, ligaments do not have origins and insertions as muscle tendon groups do, but have attachment sites.
REFERENCES: Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.
Mader TJ: Avulsion of the rectus femoris tendon: An unusual type of pelvic fracture. Pediatr Emerg Care 1990;6:198-199.

Question 36

During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?

Explanation

DISCUSSION: Retrograde ejaculation is the sequela of superior hypogastric plexus injury. This structure needs protection, especially during anterior exposure of the L5-S1 disk space. Only blunt dissection should be used, and use of monopolar electrocautery should be avoided. If possible, preserve and retract the middle sacral artery. Once the iliac veins are isolated, blunt dissection is begun along the course of the medial edge of the left iliac vein, reflecting the prevertebral tissues toward the patient’s right side. The dissection goes from left to right because the parasympathetic plexus is more adherent on the right side.
REFERENCE: Transperitoneal midline approach to L4-S1, in Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer Verlag, 1983, pp 123-129.

Question 37

Which of the following types of osteosarcoma is associated with the best prognosis & long survival?

Explanation

p. 194 (parosteal): Early adequate treatment [of parosteal osteosarcoma] should lead to cure in most patients. A long-term survival rate of 80%-90% is to be expected for patients who have parosteal osteosarcomas without dedifferentiation.”
p. 163 (in Paget’s disease): “Although long-term survival is rare for patients with this type of sarcoma, four patients have survived more than 10 years.”
p. 164 (in irradiated bone): “The location of these tumors in unresectable locations such as the skull, clavicle, scapula, and spine explains the traditionally poor prognosis.”

Question 38

A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of

Explanation

Most cases of isolated serratus anterior palsy resolve spontaneously, usually within 6 to 9 months after traumatic injury and within 2 years after an infectious cause. Pectoralis major-fascia lata graft is an effective treatment for persistent winging.

Question 39

A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year. The pain is worse with weight bearing and is better with rest and the use of an ankle brace. What findings are shown on the MRI scans shown in Figures 18a through 18c?

Explanation

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath. This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.
REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction). Foot Ankle Clin 1997;2:241-260.
Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle 1992;13:208-214.

Question 40

Figures 177a and 177b are the radiographs of a 7-year-old boy with spastic cerebral palsy. He has quadriparetic involvement and is unable to ambulate. He has very limited abduction, 30 degrees of flexion contractures, and pain on abduction. Bilateral varus osteotomies are scheduled with acetabular procedures to improve stability. Which type of acetabular osteotomy should be performed?

Explanation

Question 41

During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used?

Explanation

DISCUSSION: The most common variation of a Hoffa fracture is a coronal fracture of the lateral femoral condyle. The most appropriate screw placement of the above answer choices in the treatment of the most common Hoffa fracture variant would be anterior to posterior screws across the lateral condyle for fixation.
Hoffa fractures are coronally oriented fractures of the femoral condyles, with most occurring in the lateral condyle. They are commonly associated with high-energy fractures of the distal femur and can often be overlooked during the assessment and treatment of distal femur fractures. Hoffa fractures are best evaluated using CT scans.
Nork et al. studied the association of supracondylar-intercondylar distal femoral fractures and coronal plane fractures. Of 202 supracondylar-intercondylar distal femoral fractures, they found coronal plane fractures were diagnosed in 38%. A coronal fracture of the lateral femoral condyle was involved more frequently than the medial condyle. Eighty-five percent of these coronal fractures involved a single lateral femoral condyle.
Holmes et al. looked at five cases of coronal fractures of the femoral condyle. All cases received open reduction and internal fixation with lag screws through a formal parapatellar approach. They reported good results with all fractures healing within 12 weeks without complications with final range of motion at least 0 degrees to 115 degrees.

Question 42

Pharmacoprophylaxis should be avoided in favor of a pneumatic compression device for a patient with

Explanation

DISCUSSION
For patients with known bleeding disorders, a pneumatic compression device alone is recommended over pharmacoprophylaxis to minimize risk for excessive bleeding and wound complications. Factor VIII deficiency (hemophilia) and active liver disease are the 2 conditions for which support is strongest to withhold anticoagulation. Protein C deficiency and protein S deficiency are associated with increased risk for thrombosis, as is the factor V Leiden mutation.
RESPONSES FOR QUESTIONS 159 THROUGH 162
Lateral femoral cutaneous
Superior gluteal
Inferior gluteal
Obturator
Sciatic
Which nerve listed above is at increased risk for injury when performing hip surgery through the following approaches?

Question 43

Which nerve root contributes to both the sciatic and femoral nerves?

Explanation

DISCUSSION
The lumbosacral plexus is formed from the lumbar and sacral roots that are redistributed into the obturator, femoral, and sciatic nerves. The obturator nerve is composed of the L1, L2, and L3 roots. The femoral nerve has contributions from the L3 and L4 roots. The sciatic nerve contains the L4, L5, S1, and lower sacral roots. Therefore, only the L4 root contributes to the femoral and sciatic (via the lumbosacral trunk) nerves, which allows it to innervate the quadriceps and the anterior tibialis muscles.
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Question 44

A 32-year-old man sustained an injury to the right thumb metacarpophalangeal (MP) joint ulnar collateral ligament (UCL) and is undergoing surgical repair (Figure 1). What structure in the clinical photograph is blocking reduction of the ulnar collateral ligament?

Explanation

EXPLANATION:
When the thumb MP UCL is torn from the proximal phalanx, the distal stump can be displaced superficial to the adductor aponeurosis, known as a Stener lesion. The adductor aponeurosis effectively blocks reduction of the ligament to the normal attachment site. The EPB and EPL tendons are dorsal to the UCL, and the ulnar sesamoid bone/volar plate are in a volar position in relation to the UCL. The dorsal capsule would also not block reduction of the UCL due to it's anatomic location. The other responses do not block the UCL with this type of injury.

Question 45

The biopsy specimens seen in Figures 55a and 55b are from a lytic lesion in the sacrum of a 58-year-old man. What is the most likely diagnosis?

Explanation

DISCUSSION: The lesion is a chordoma and the other listed choices can be eliminated based on the histology. Many tumors can occur in the sacrum including chordoma, multiple myeloma, giant cell tumor, aneurysmal bone cyst, and metastatic disease. The histology in this patient shows a lobulated lesion on low power with fibrous septae separating the lobules. At higher magnification, the cells have eosinophilic vacuolated cytoplasm and are called physaliferous cells. Chordoma is a low-grade neoplasm that most commonly occurs in the sacrum and rarely in the base of the skull. The diagnosis is often delayed. Chordoma is thought to originate from notochordal remnants. Chordoma typically occurs in the midline and has an associated soft-tissue mass.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 372.
Fuchs B, Dickey ID, Yaszemski MJ, et al: Operative management of sacral chordoma. J Bone Joint Surg Am 2005;87:2211-2216.
Fourney DR, Rhines LD, Hentschel SJ, et al: En bloc resection of primary sacral tumors: Classification of surgical approaches and outcome. J Neurosurg Spine 2005;3:111-122.

Question 46

In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?

Explanation

This answer was based on studies by Hooten, Engh. They found that the overall failure rate was 44 %. Selections 1, 3, 4, and 5 were incorrect. They also reported an increase failure rate if more than 50% of the cup rested on allograft. When there is no satisfactory alternative to a bulk allograft available, close radiographic monitoring was recommended. [JBJS 1994, 76B pg. 419-422.

Question 47

Passage of a sodium ion through a voltage-gated channel leads to which of the following?

Explanation

Passage of sodium through a voltage-gated channel will lead to generation of a nerve action potential.
Voltage-gated channel are shut when the membrane potential is near the resting potential of the cell, but they rapidly begin to open if the membrane potential increases to a precisely defined threshold value. When the channels open (in response to depolarization in transmembrane voltage), they allow an inward flow of sodium ions, which changes the electrochemical gradient, which in turn produces a further rise in the membrane potential. This then causes more channels to open, producing a greater electric current across the cell membrane, and so on.
Lee et al. present a review article on nerve conduction and needle electromyography studies. They note that the three types of nerve conduction study are motor, sensory,
and mixed, of which motor is the least sensitive. In addition, they report that peripheral nerve entrapment initially results in focal demyelination; thus, nerve conduction velocity slows across the site. However, with radiculopathy and nerve root compression, the nerve conduction study may be normal.
Catterall presents a review article covering an overview of structural models of voltage-dependent activation, sodium selectivity and conductance, drug block and both fast and slow inactivation. He notes that voltage-gated sodium channels initiate action potentials in nerve, muscle and other excitable cells.
Illustration A is a diagram that shows the electrical recordings of an action potential, along with labels of each section of the process.

Question 48

A healthy 72-year-old woman is seen 14 days after cemented total knee arthroplasty. She reports increasing pain and swelling for the last 4 days accompanied by 4 days of wound drainage. Examination reveals that she is afebrile, and has erythema and moderate serosanguinous drainage from the wound. The knee is moderately swollen. Aspiration of the knee reveals no organisms on Gram stain. Culture results are expected back in 48 hours. Optimal management should consist of

Explanation

AL-Madena Copy
8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.

Figure 3a Figure 3b

Question 49

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Explanation

DISCUSSION: Based on the MR arthrogram in which gadolinium (bright on T1-weighted images) was injected into the joint space prior to imaging, the study shows a tear of the anterior band of the ulnar collateral ligament (UCL). The disruption in the distal end of the UCL is outlined by contrast. A small collection of contrast extravasation into the flexor musculature further confirms the presence of a tear. The UCL has a broad-based attachment on the medial epicondyle and has a pointed or tapered attachment distally on the ulna. Most UCL tears occur distally at the ulnar (coronoid) attachment.
MR arthrography provides improved sensitivity compared to conventional MRI, without contrast, for the detection of UCL pathology, particularly in the subacute or chronic setting. After the soft-tissue edema and joint fluid associated with the injury have resolved, the torn end of the ligament may lie in contact with its adjacent attachment and create a false-negative appearance. In this patient, a noncontrasted MR arthrogram showed no tear, yet the tear is apparent with intra-articular contrast and distention. MR arthrography of the elbow also may be useful in detecting intra-articular bodies or in evaluation for loose osteochondral fragments or flaps.
REFERENCES: Morrey BF: Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117-128.
Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 200-210.

Question 50

The first branch of the lateral plantar nerve innervates the

Explanation

DISCUSSION: The first branch of the lateral plantar nerve innervates the abductor digiti quinti, and more distal branches of the lateral plantar nerve supply the quadratus plantae and the interossei. The medial plantar nerve supplies the abductor hallucis brevis and the flexor digitorum brevis.
REFERENCES: Pansky B, House EH: Review of Gross Anatomy, ed 3. New York, NY, Macmillan, 1975, pp 464-476.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983,

pp 325-328.

Question 51

Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?

Explanation

The images show a full-thickness cartilage defect with significant bony involvement >4 cm2. Microfracture should be considered for lesions <2 cm2 without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm2, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and would not be indicated in this case.

Question 52

A 16-year-old girl has a painful foot mass. A radiograph, MRI scan, and biopsy specimens are shown in Figures 35a through 35d. What is the most likely diagnosis?

Explanation

DISCUSSION: Synovial sarcoma should always be considered in the differential diagnosis of a foot mass; however, the histopathology shows a typical example of PVNS, with hemosiderin, giant cells, and synovium. Synovial chondromatosis would have metaplastic cartilage in the synovium. The radiograph shows subtle erosion of the lateral cortex of the cuboid, and the MRI scan shows a soft-tissue mass.
REFERENCES: Ghert MA, Scully SP, Harrelson JM: Pigmented villonodular synovitis of the foot and ankle: A review of six cases. Foot Ankle Int 1999;20:326-330.
Jones BC, Sundaram M, Kransdorf MJ: Synovial sarcoma: MR imaging findings in 34 patients. Am J Roentgenol 1993;161:827-830.
Sartoris DJ, Resnick D: Magnetic resonance imaging of pediatric foot and ankle disorders. J Foot Surg 1990;29:489-494.
Scully SP, Temple HT, Harrelson JM: Synovial sarcoma of the foot and ankle. Clin Orthop 1999;364:220-226.

Question 53

Biofilm is believed to play a major role in the pathogenesis of periprosthetic joint infection. Biofilm allows for the bacterial population to evade the effects of antimicrobial therapy primarily through

Explanation

DISCUSSION
The intrinsic risk for colonization and subsequent infection associated with implants is exacerbated by implants’ tendency to become coated in host proteins such as fibrinogen and fibronectin shortly after implantation. Following initial adherence and colonization, bacteria are thought to form a complex matrix of an extracellular polymetric substance, serving as a protective scaffold in which they can survive despite the competence of the host’s immune system or the presence of antimicrobial agents. There is no evidence that biofilm directly inhibits antibiotics.
CLINICAL SITUATION FOR QUESTIONS 117 THROUGH 119
A 79-year-old woman is experiencing chronic right hip pain. All of her pain is in her right groin, and it worsens with activity. She has failed nonsurgical treatment with nonsteroidal anti-inflammatory drugs, activity modification, and occasional corticosteroid injections. She would like to proceed with surgical treatment.

Question 54

A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate Review Topic

Explanation

The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.

Question 55

A 7-year-old girl reports foot pain and has difficulty ambulating. History reveals that she fell off a scooter 1 week ago, and there is possible exposure to a tick bite. A radiograph is shown in Figure 29. What is the best course of action?

Explanation

DISCUSSION: The child has Kohler’s disease. This is a self-limiting osteochondritis of the navicular. It is treated symptomatically with initial cast immobilization for 6 to 12 weeks, followed possibly by orthotic management. Findings shown in the radiograph usually will normalize within 1 year, and there are no long-term sequelae.
REFERENCES: Borges JL, Guille JT, Bowen JR: Kohler’s bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 65-78.

Question 56

Figure 46 shows the radiograph of an obese 12-year-old boy who has had left hip pain for the past 3 months. What is the best course of action?

Explanation

DISCUSSION: The patient has an obvious slipped capital femoral epiphysis of the left hip for which the recommended treatment is percutaneus pinning in situ. Development of a contralateral slip is less likely at this age; therefore, observation of the right hip is indicated because there is no general agreement regarding prophylactic fixation. Typically, there is no role for spica casting. Physical therapy is not indicated as a primary treatment, and reduction is contraindicated, as it has been associated with osteonecrosis.
REFERENCES: Loder RT, Aronsson DD, Greenfield ML: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg Am 1993;75:1141-1147.
Aronsson DD, Karol LA: Stable slipped capital femoral epiphysis: Evaluation and management. J Am Acad Orthop Surg 1996;4:173-181.
Hurley JM, Betz RR, Loder RT, Davidson RS, Alburger PD, Steel HH: Slipped capital femoral epiphysis: The prevalence of late contralateral slip. J Bone Joint Surg Am 1996;78:226-230.
Loder RT, Aronson DD, Dobbs MB, Weinstein SL: Slipped capital femoral epiphysis. J Bone Joint Surg Am 2000;82:1170-1188.

Question 57

An otherwise healthy 57-year-old man has persistent, severe hip pain after undergoing total hip arthroplasty 3 months ago. What is the next most appropriate step in management?

Explanation

DISCUSSION: Any patient who is severely symptomatic this quickly after surgery must be evaluated for infection. Loosening is also a possible cause, but infection must be ruled-out. Bone scans are not helpful at this early postoperative stage. Normal laboratory values argue strongly against infection, but when abnormal, need to be supplemented with a hip aspiration. Aspiration remains the most selective and sensitive measure, especially when linked to a WBC count of the synovial tissues in the joint. There is no indication for an antiobiotic trial because it may make future culture sensitivity more difficult.
REFERENCES: Drancourt M, Stein A, Argenson JN, et al: Oral rifampin plus ofloxacin for treatment of staphylococcus-infected orthopedic implants. Antimicrob Agents Chemother 1993;37:1214-1218.
Duncan CP, Beauchamp C: A temporary antibiotic-loaded joint replacement system for the management of complex infections involving the hip. Orthop Clin North Am 1993; 24: 751-759.
Oyen WJ, Claessens RA, van Horn JR, et al: Scintiographic detection of bone and joint infections with indium-111-labeled nonspecifonal human immunoglobulin G. J Nucl Med 1990;31:403-412.

Question 58

The findings in Brown-Sequard syndrome include loss of which of the following? Review Topic

Explanation

Brown-Séquard syndrome is most commonly seen after penetrating injuries to the spinal cord and results in ipsilateral loss of motor function and contralateral loss of pain and temperature sensation. Patients with central cord syndrome have greater weakness in the upper extremities than in the lower extremities. Loss of proprioception is typically seen in patients with posterior cord syndrome.

Question 59

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral Review Topic

Explanation

Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.

Question 60

A 15-year-old girl has had a painful mass on the medial aspect of her left thigh for the past 5 years. The pain is present only when she is performing athletic activities and is completely relieved with rest. A radiograph and MRI scan are shown in Figures 29a and 29b. The patient and her parents would like to have the mass removed. What further diagnostic studies are required prior to considering surgical resection?

Explanation

DISCUSSION: The radiograph and MRI scan show a pedunculated lesion arising from the medial aspect of the distal femoral metaphysis. The cortex of the lesion is contiguous with the cortex of the underlying normal bone. Similarly, the medullary canal of the lesion is contiguous with that of the normal bone. These findings are diagnostic of osteochondroma. Rarely a secondary chondrosarcoma can arise in a preexisting osteochondroma. This diagnosis is suggested by identifying a cartilage cap that is greater than 1.5-cm thick in a skeletally mature patient. MRI is the best study to rule out a secondary chondrosarcoma. CT also may be used for this purpose but is not indicated in this patient because an MRI has already been obtained. A bone scan is not useful to identify a secondary chondrosarcoma. Similarly, there is no role for biopsy in this patient. No further tests are needed.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Murphey MD, Choi JJ, Kransdorf, MJ, et al: Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407-1434.

Question 61

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

Explanation

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

Question 62

What percentage of bone weight is collagen?

Explanation

Bone is a composite of both inorganic and organic material. The inorganic component of bone comprises 60% to 70% of the tissue, water accounts for 5% to 8%, and the organic matrix makes up the remainder. Collagen accounts for 90% of the organic component and thus 20% to 25% of bone weight. Collagen accounts for the flexibility of bone. The inorganic component of bone is made primarily of calcium and phosphorous, in the analogue of hydroxyapatite, and other ions including sodium, magnesium, and carbonate.

Question 63

Which of the following best describes the recommended treatment for a 13-year-old pitcher with a painful chronic stress injury to the proximal humeral physis as confirmed on an MRI scan? Review Topic

Explanation

Little Leaguer's shoulder is a chronic stress injury to the proximal humerus growth plate. Imaging findings demonstrate widening of the proximal humeral growth plate. Treatment consists of rest and avoidance of pitching for the remainder of the season. Surgery is not indicated.

Question 64

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Explanation

The Physician Payments Sunshine Act requires all payments by corporations to physicians beyond $10 per year to be reported to the Centers for Medicare and Medicaid Services.
Under this Act, all manufacturers of drugs and devices covered under Medicare, Medicaid, and SCHIP are obliged to federally report payments beyond $10 annually to physicians and academic centers. The Act was first introduced in 2007, enacted in 2010, and in 2014 the first data (from 2012) was reported publicly online in the Open Payment Program of the Centers for Medicare and Medicaid Services website.
Samuel et al analyze orthopedic surgeons available data from the Sunshine Act regarding industry payments and find over 110 million USD paid to approximately 15,000 orthopedic surgeons over the 5-month study period. No long term data exists to determine if these payments have any affect in healthcare.
Incorrect Answers:

Question 65

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Explanation

DISCUSSION: In the normal adult, the distance between the basion and the tip of the dens is 4 mm to 5 mm. Any distance greater than 5 mm is considered abnormal. This is one way to detect occipitocervical dissociation other than using the Power’s ratio, which relies on an anterior dislocation.
REFERENCES: Wiesel SW, Rothman RH: Occipitoatlantal hypermobility. Spine 1979;4:187-191.
Wholey MH, Browner AJ, Baker HL Jr: The lateral roentgenogram of the neck: With comments on the atlanto odontoid-basion relationship. Radiol 1958;71:350-356.

Question 66

-What is the mechanism of action of tranexamic acid in controlling traumatic hemorrhage?

Explanation

Question 67

A patient has a vertically and rotationally unstable hemipelvis following a motor vehicle accident. An indication for application of an anterior resuscitative pelvic external fixator is made. Two options with regard to pin insertion location are considered as seen in Figure 20. When compared to pins in position A, the pins in position B may be more advantageous because

Explanation

Pelvic external fixation can be used for the acute resuscitation of patients with pelvic fractures and for definitive treatment of certain injury patterns. Typically frames are constructed with anterosuperior half-pin placement within the iliac crest. Intracortical placement of these pins may be difficult and erroneous placement may render purchase inadequate. Recently, external fixation of the pelvic ring with half-pin placement into the dense supra-acetabular bone in the region of the anterior inferior iliac spine has gained popularity. Kim and associates, in a biomechanical model, demonstrated that anterior-inferior pin placement was biomechanically superior to conventional anterior-superior pin placement in rotationally and vertically unstable fracture patterns. Haidukewych and associates performed a cadaveric study that demonstrated the lateral femoral cutaneous nerve is at risk within a mean distance of 10 mm from the inferior half-pin site but the femoral nerve and femoral artery are not at risk. The average superior extent of the hip capsule was 16 mm above the joint. They suggested that these pins be inserted at least 2 cm above the hip to avoid potential hip capsule penetration. Poelstra and Kahler described a case during which the lower pins were inserted without the benefit of imaging using only palpable landmarks. However, this technique is better reserved for nonresusitative purposes permitting the use of multiplanar fluoroscopic imaging. Image guidance better ensures proper pin placement within the pelvic cortices, minimizing penetration of the hip joint and sciatic notch. No anterior external fixator, regardless of design or region of application, offers sufficient posterior stability to serve as definitive treatment for vertically unstable pelvic fracture variants.

Question 68

Figures 76a and 76b are the sagittal T1-weighted MRI scans of an active 27-year-old man who has had left dominant extremity shoulder pain and weakness for the past 5 months. He denies any history of a precipitating event but recalls that the pain began around the time he started lifting weights after a year off from lifting. Examination reveals full range of active and passive motion, negative Hawkins and Neer impingement signs, 5/5 abduction strength, 5/5 external rotation strength with arm adducted at his side, and a negative belly press, Gerber lift-off, and O'Brien's test. He does have weakness with resisted external rotation with the arm abducted to 90 degrees. Radiographs are unremarkable. An MRI arthrogram shows no rotator cuff tear or labral tears. What is the most likely diagnosis? Review Topic

Explanation

Examination reveals weakness of the teres minor muscle, and the MRI scan shows moderate isolated atrophy of the teres minor muscle belly. This is consistent with quadrilateral space syndrome, which is compression of the axillary nerve and posterior circumflex humeral artery in the quadrilateral space (bounded by the teres minor, teres major, long head of triceps and the humerus). This syndrome has been related to compression of the neurovascular structures by muscle hypertrophy consistent with the patient's history of lifting weights near the onset of symptoms. The next step in confirming the diagnosis is a subclavian arteriogram with the arm in adduction as well as in abduction and external rotation. Suprascapular nerve compression would be manifested by atrophy and weakness of both the supraspinatus and infraspinatus (if occurring at the suprascapular notch) or just infraspinatus (if occurring at the spinoglenoid notch). The patient does not demonstrate signs or symptoms of either impingement syndrome or scapular dyskenisia.

Question 69

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 2010 Pediatric Orthopaedic Examination Answer Book • 55 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include

Explanation

DISCUSSION: The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
REFERENCES: Wattenbarger JM, Gerardi J, Johnson CE: Late open reduction internal fixation of lateral condyle fractures. J Pediatr Orthop 2002;223:94-398.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 70

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 71

A 50-year-old woman reports a burning sensation on the plantar aspect of her left forefoot, distal to the metatarsal heads between her third and fourth digits. Palpation of the third web space recreates her symptoms. Which of the following will most accurately aid in confirming a diagnosis?

Explanation

DISCUSSION: The diagnosis of an interdigital neuroma is best made by a thorough history and careful physical examination. Radiographs are helpful in excluding other pathologic processes such as a metatarsal stress fracture. MRI and ultrasound have both been reported to aid in the diagnosis of an interdigital neuroma.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 145-151.
Quinn TJ, Jacobson JA, Craig JG, et al: Sonography of Morton’s neuromas. Am J Roentgenol 2000;174:1723-1728.

Question 72

A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.” He could not finish the game but was able to bear weight with a limp. He has had two similar episodes but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was otherwise ligamentously stable, and there were no other noteworthy findings. What do Figures 1 and 2 reveal?

Explanation

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 73

A 58-year-old man has a painful right hip 3 years after undergoing a large head metal-on-metal total hip arthroplasty (THA) in which the components are well positioned. MR imaging confirms a cystic mass around the hip and metal ion levels show a marked increase in cobalt compared to chromium levels. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are within defined limits. What is the most likely cause for his discomfort?

Explanation

CLINICAL SITUATION FOR QUESTIONS 42 THROUGH 45
Figures 42a through 42e are the radiographs, MR image, and MR arthrogram of a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has either competed or practiced 5 to 6 times per week since the age of

Question 74

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Explanation

The mass or volume of a muscle is proportional to its work capacity, and the fiber length of a muscle is proportional to its potential excursion. By dividing the fiber length into the volume of each muscle, the cross-sectional area of the muscle is determined.
The concept of physiologic cross section of a muscle from Weber and Fick, identifies the critical importance of the cross sectional area of all the fibers of a muscle as proportional to maximum tension. (Relationship between muscle size and muscle strength).

Question 75

A 47-year-old woman falls and sustains a direct blow to her middle finger. She notes pain and swelling and is unable to move the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. Radiographs are shown in Figures 8a through 8c. Proper management should consist of

Explanation

DISCUSSION: The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 76

The arrow in Figure 39 is pointing to which of the following ligaments?

Explanation

DISCUSSION: The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The scapholunate interosseous ligament stabilizes the scapholunate joint. The ulnolunate ligament originates from the base of the ulnar styloid and inserts in the lunate. The ulnotriquetral ligament originates from the base of the ulnar styloid and inserts on the triquetrum. The ulnolunate and the ulnotriquetral ligaments are important stabilizers to the ulnar side of the wrist. The short radiolunate ligament originates on the volar ulnar margin of the distal radius and inserts in the ulnar margin of the lunate.
REFERENCES: Berger RA: Ligament anatomy, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist, Diagnosis and Operative Management. St Louis, MO, Mosby, 1998,

pp 73-105.
Adams BD, Divelbiss BJ: Anatomy of the wrist ligaments, in Trumble TE (ed): Carpal Fracture-Dislocatons. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 1-5.

Question 77

A young active patient with a complete isolated posterior cruciate ligament (PCL) tear undergoes a double bundle PCL reconstruction. The tensioning pattern of the anterolateral (AL) and posteromedial (PM) bundles most likely to reproduce the most normal knee kinematics would be to tension

Explanation

DISCUSSION: During flexion and extension of the normal knee, the AL bundle of the PCL is taut in flexion, and the PM bundle is taut when the knee is near extension. The AL bundle is approximately two times larger at its midsubstance, stiffer, and has a higher ultimate load than the PM bundle. In vitro testing has demonstrated that by tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 0 degrees of flexion, essentially normal knee kinematics are restored. Tensioning the AL bundle at 45 degrees of flexion and the PM bundle at 0 degrees of flexion would result in increased laxity with flexion at 90+ degrees. Tensioning the AL bundle at 90 degrees of flexion and the PM bundle at 45 degrees of flexion would result in increased laxity near extension.
REFERENCES: Harner CD, Janaushek MA, Kanamori A, Yagi M, Vogrin T, Woo SL: Biomechanical analysis of a double-bundle posterior cruciate ligament reconstruction. Am J Sports Med 2000;28:144-151.
Mannor DA, Shearn JT, Grood ES, Noyes FR, Levy MS: Two-bundle posterior cruciate ligament reconstruction: An in vitro analysis of graft placement and tension. Am J Sports Med 2000;28:833-845.

Question 78

Which of the following is considered a risk factor for the development of low back pain?

Explanation

DISCUSSION: Risk factors associated with low back pain include poor physical fitness, smoking, a history of repetitive bending or stooping on the job, or whole body vibration exposure. Some radiographic factors such as stenosis, spondyloarthropathy, severe deformity, or instability are also associated with low back pain. Gender, weight, transitional anatomy, or facet trophism are not associated with low back pain.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 627-643.

Question 79

What procedure can eliminate a sulcus sign? Review Topic

Explanation

A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.

Question 80

At the level of the midcalf, the plantaris tendon is found at which of the following locations?

Explanation

DISCUSSION: The plantaris tendon is often harvested to augment a tendon reconstruction. The origin of the plantaris muscle is on the posterolateral aspect of the distal femur, and the muscle lies lateral to the tibial nerve and the posterior tibial artery. The tendon then courses posteriorly between the soleus and the medial head of the gastrocnemius.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 475.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 491.

Question 81

Receptor activator of nuclear factor kappa b (RANKL) and macrophage colony stimulating factor (MCSF) signaling pathways are necessary for the formation of multinucleated osteoclasts that resorb bone. Which of the following cells are known to produce RANKL?

Explanation

Osteoclast differentiation and function depend on the establishment of specific patterns of gene expression achieved through networks of transcription factors activated by osteoclastogenic cytokines such as RANKL and MCSF. RANKL and MCSF are produced by osteoblasts and T cells. Key transcriptional factors responsible for osteoclatogenesis require activation of transcriptional factors such as PU.1, NF-kappaB, AP-1, NFATc1, Mitf, Myc, and Src in osteoclast precursors that are of monocyte/macrophage origin.

Question 82

A 78-year-old male presents to clinic 4 weeks after left total shoulder arthroplasty. He has not been wearing his sling and reports that he developed increased pain after slipping in the shower. He used the arm to catch himself from falling. On examination, he can flex the shoulder to 70 degrees, limited by pain. Active external rotation with arm at the side is 50 degrees and active internal rotation is 5 degrees. Passive external rotation is to 80 degrees. A radiograph of the left shoulder is shown below in Figure A. What other complaint is the patient most likely to have? Review Topic

Explanation

The clinical presentation is consistent with a tear of the subscapularis, which is a well-described complication after total shoulder arthroplasty. The most likely additional complaint this patient will have is anterior shoulder instability, noticeable with external rotation of the shoulder.
Total shoulder arthroplasty is the preferred treatment for glenohumeral arthritis in patients with intact rotator cuff and good glenoid bone stock. The surgical approach involves detaching the subscapularis and capsule from the anterior humerus and dislocating the humeral head anteriorly. Post operatively, external rotation is limited to protect the subscapularis repair. If there is suspicion of a postoperative subscapularis tear, and ultrasound can be performed to confirm the diagnosis.
Miller et al. reported 7 cases of subscapularis tendon rupture after total shoulder arthroplasty, all of which were subsequently repaired. Decreased functional outcomes were observed in these patients, with lengthening techniques to address internal rotation contractures and prior surgery involving the subscapularis tendon as risk factors for rupture
Westoff et al. performed static and dynamic ultrasounds on 22 patients after total shoulder arthroplasty evaluating for numerous periarticular pathologies. The authors concluded that sonography is a useful tool for evaluation of peri-implant tissues after TSA.
Figure A shows an intact left total shoulder arthroplasty without evidence of fracture, dislocation, or hardware loosening. Illustration A shows the incision for the subscapularis tendon during TSA.
Incorrect Answers:

Question 83

A 10-year-boy has had thigh pain for the past several months. He denies any history of trauma. Examination reveals no soft-tissue mass, and mild tenderness. Figures 33a and 33b show the plain radiograph and MRI scan, and the biopsy specimens are shown in Figures 33c and 33d. What is the most likely diagnosis?

Explanation

DISCUSSION: The diagnosis is eosinophilic granuloma. The plain radiograph and MRI scan show a lesion in the midshaft of the femur. There is no soft-tissue mass. There is reactive bone about the lesion that suggests a less aggressive tumor. The histology reveals eosinophils in an otherwise bland cellular background with no evidence of mitotic figures or malignant cells to suggest sarcoma. The diagnostic elements are the amphophilic (ie, pale purple) histiocytes with cigar-shaped nuclei, some of which have linear longitudinal grooves. There is no histologic evidence of infection. Lymphoma of bone would be an unusual occurrence in this age group, and the histology is not consistent with that diagnosis.
REFERENCE: Simon MA, Springfield DS, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-200.

Question 84

An 18-year-old collegiate basketball player has had a 3-month history of activity-related back pain. She describes isolated low back pain without radiation that increases with training and playing basketball. Her pain resolves with rest. Physical therapy for 6 weeks has failed to provide relief. An axial CT scan is shown in Figure 17a, and Figures 17b and 17c show sagittal CT reconstructions through the right and left lumbar facets, respectively. Further management should consist of which of the following?

Explanation

DISCUSSION: The sagittal and axial CT scans show a bilateral spondylolysis at L5. The defect is in the pars interarticularis on the right side but at the base of the pedicle on the left. Having failed a trial of physical therapy with only a 3-month history of pain, the next most appropriate step in management should consist of activity modification and bracing in an antilordotic lumbosacral orthosis. Surgical intervention is reserved for patients who have failed to respond to a trial of bracing and activity restriction.
REFERENCES: Debnath UK, Freeman BJ, Grevitt MP, et al: Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine 2007;32:995-1000.
Bono CM: Low-back pain in athletes. J Bone Joint Surg Am 2004;86:382-396.

Question 85

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Explanation

DISCUSSION: Talar compression syndrome is also known as os trigonum syndrome or posterior ankle impingement syndrome and occurs in activities involving extreme ankle plantar flexion. It involves pinching of the posterior talus (os trigonum or posterior process of the talus) between the calcaneus and tibia. The flexor hallucis longus also may be impinged. The other structures are not commonly injured in this syndrome.
REFERENCES: Brodsky AE, Khalil MA: Talar compression syndrome. Am J Sports Med 1986;14:472-476.
Wredmark T, Carlstedt CA, Bauer H, Saartok T: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.
Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.

Question 86

A 9-month-old nonambulatory girl is seen in the emergency department with a fracture of her right forearm. The mother says she fell from the changing table yesterday and continues to cry and not use her right arm. Radiographs are shown in Figure 31. Treatment should consist of which of the following? Review Topic

Explanation

The occurrence of a forearm fracture in a 9-month-old child has a greater than 50% chance that the injury is due to child abuse. It is mandatory to report this to child protective services unless there is some compelling reason that it is definitely not child abuse. In addition, a skeletal survey should be requested to look for other injuries. A bone scan would show other injuries, but a skeletal survey is a more
efficient way to evaluate for other fractures. A MRI of the brain is not indicated unless fundoscopic examination reveals an abnormality.

Question 87

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Explanation

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the

median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 88

A 21-year-old man sustains multiple gunshot wounds to his right upper extremity. He can not extend his digits or his thumb but can extend and radially deviate his wrist. An injury to the radial nerve or one of its branches has most likely occurred at which of the following locations?

Explanation

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 89

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

Explanation

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.

J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes

of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 90

A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Explanation

The plain films demonstrate lumbar AP and Lateral radiographs with 32 degree anteriorly wedged compression fracture of L1. On closer evaluation one notices the adjacent disc spaces are narrowed. The center of the vertebra is sclerotic with the anterior inferior endplate irregular.
The MR demonstrates involvement of L1 and adjacent disc spaces. With peri-vertebral edema and mass involving the posterior aspect of the vertebral body, placing pressure on the spinal cord. There is also involvement of the L2-3 disc with early signal changes.
The slow clinical course of the patients symptoms, being from a third world country and the findings on imaging studies, with an anterior wedge compression fracture. The level most commonly involved with TB is lower thoracic and upper lumbar. The anterior wedging results in the classic “Gibbus”.
Some of the MR findings are also consistent with metastatic disease, but with the localized mass, peri-vertebral abscess make this choice more unlikely.
The usual findings on MR found with TB are: Confluently decreased signal intensity of the vertebral bodies associated interspace with poor distinction between these on short TR/short TE images: Abnormal increased signal of the disk on long TR/long TE images with an abnormal configuration (i.e., absent intranuclear cleft): Increased signal of the vertebral endplates at the abnormal disk level on long TR/long TE images.

Question 91

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

Explanation

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

Question 92

-An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 44 AND 45
Figure 44 is the MRI scan of a 14-year-old soccer player who injured his right knee during a game.He describes feeling a “pop” and he needed help walking off the field. His knee is visibly swollen. A Lachman test demonstrates asymmetry with no endpoint.

Question 93

A 72-year-old woman who sustained a cerebrovascular accident 9 months ago now has a fixed elbow flexion contracture of 80 degrees. Management should consist of

Explanation

DISCUSSION: A flexion contracture of the elbow is commonly seen in hemiplegic patients following cerebrovascular accidents. Spasticity and myostatic contracture of the joint are both causative factors. In patients with a flexion deformity of less than 90 degrees, musculocutaneous neurectomy is recommended, followed by serial casting to treat any residual deformity. At 9 months after injury, physical therapy will not significantly improve motion. Nerve blocks may be used in the early stages of recovery to facilitate therapy and serial casting.
REFERENCE: Waters RL, Keenan ME: Surgical treatment of the upper extremity after stroke, in Chapman MW (ed): Operative Orthopedics. Philadelphia, PA, JB Lippincott, 1988, vol 2,

pp 1449-1450.

Question 94

A 65-year-old woman with a history of diabetes mellitus and plantar ulcers has an erythematous and swollen right foot and ankle. Despite IV antibiotics, the erythema spreads to her lower calf within 24 hours. She has a systolic blood pressure of 80/55 mm Hg and a pulse rate of 120. Laboratory studies show a creatinine level of 1.5 mg. Initial management should consist of

Explanation

DISCUSSION: Necrotizing fasciitis is an aggressive and rapidly spreading soft-tissue infection, usually caused by group A beta-hemolytic Streptococcus pyogenes. Presentation is typical of a rapidly ascending cellulitis, recalcitrant to antibiotic treatment. Differentiation between cellulitis and impetigo is difficult, and success depends on a high level of suspicion. The skin and subcutaneous tissues are affected, with sparing of the muscles. Septic shock and multi-organ system failure can be fatal. Treatment is aggressive surgical debridement with broad-spectrum antibiotics. Repeat irrigation and debridement may be necessary. Hyperbaric oxygen studies have shown inconsistent results.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003, pp 199-205.
Fontes RA Jr, Ogilvie CM, Miclau T: Necrotizing soft-tissue infections. J Am Acad Orthop Surg 2000;8:151-158.

Question 95

Figures 38a and 38b

Explanation

DISCUSSION
Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.
RECOMMENDED READINGS
Schepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013 Sep;37(9):1833-8. PubMed PMID: 23959223. View Abstract at PubMed
Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516. View Abstract at PubMed
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165. View Abstract at PubMed
Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511. View Abstract at PubMed

Question 96

Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?

Explanation

DISCUSSION: TIp-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs. This is shown in Illustration A.
TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of <25mm has been shown to minimize the risk of fixation cut-out in stable and unstable intertrochanteric hip fractures.
Baumgaertner et al examined factors leading to the failure of sliding hip screws (SHS) in the treatment of 198 intertrochanteric fractures. They determined that the tip-apex distance (TAD) is a reproducible, standard measurement to predict SHS failure. The average TAD for successful fractures was 24mm while the average TAD for failures was 38mm. No screw with a TAD <25mm failed. Calculation of the TAD is shown in Illustration B.
Kyle et al reviewed 622 intertrochanteric fractures. For unstable patterns, a SHS was superior to a fixed angle nail. Early ambulation and weight bearing contributed to improved results

Question 97

In obstetrical brachial plexus palsy, which of the following signs is associated with the poorest prognosis for recovery in a 2-month-old infant?

Explanation

DISCUSSION: Persistent Horner’s sign (ptosis, myosis, and anhydrosis) is a sign of proximal injury, usually avulsion of the roots from the cord which disrupts the sympathetic chain. Root rupture or avulsion proximal to the myelin sheath has less chance of healing. Two-month-old infants with persistent weakness in the other areas described may still have a good prognosis for recovery. Concurrent clavicle fracture has been shown to have no prognostic value.
REFERENCES: Clarke HM, Curtis CG: An approach to obstetrical brachial plexus injuries. Hand Clin 1995;11:563-581.
Narakas AO: Injuries to the brachial plexus, in Bora FW (ed): The Pediatric Upper Extremity: Diagnosis and Management. Philadelphia, PA, WB Saunders, 1986, p 247.

Question 98

A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of

Explanation

DISCUSSION: Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.
White KK, Williams SK, Mubarack SJ: Definition of two types of anterior superior iliac spine avulsion fractures. J Pediatr Orthop 2002;22:578-582.

Question 99

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Explanation

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.
Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

Question 100

A still active 86-year-old pastry chef falls in her kitchen and notes pain and deformity of her little finger. There are no open wounds. Radiographs are shown in Figures 49a and 49b. What is the most appropriate management?

Explanation

DISCUSSION: The fracture of the proximal phalanx is clearly displaced. There is slight comminution at the area of the fracture. Closed reduction is likely to fail due to the forces of the extensor, flexor, and intrinsic mechanisms. Percutaneous fixation, unlike open fixation techniques, avoids likely problems with stiffness.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

resectional arthroplasty.
metatarsophalangeal joint arthrodesis.
dorsal closing wedge osteotomy.
physical therapy.
a rigid steel shank shoe with a rocker bottom sole.

Correct Answer: a rigid steel shank shoe with a rocker bottom sole.

Explanation:

Question 2:

Which of the following is indicative of a patient who has been successfully resuscitated following a trauma?

Options:

Urine output of 0.25 mL/kg/hour
Lactic acid of 1.9 mmol/L
Base deficit of -5.5
Gastric mucosal pH of 6.3
Pulse pressure of 15

Correct Answer: Urine output of 0.25 mL/kg/hour

Explanation:

Question 3:

Options:

Interosseous ligament disruption
Annular ligament disruption
Avulsion of the common extensor origin
Malreduction of the ulnar fracture
Intra-articular osteochondral debris

Correct Answer: Malreduction of the ulnar fracture

Explanation:

Question 4:

Anabolic steroid use has which of the following effects on serum lipoprotein levels?

Options:

Decrease in low-density lipoprotein only
Decrease in high-density lipoprotein only
Increase in high-density lipoprotein only
Increase in low-density lipoprotein only
Increase in both high- and low-density lipoproteins

Correct Answer: Decrease in high-density lipoprotein only

Explanation:

Question 5:

Options:

both a and b
a, b and c

Correct Answer: both a and b

Explanation:

Question 6:

Options:

Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy
Total shoulder arthroplasty
Shoulder fusion
Arthroscopic debridement and capsular release
Humeral head resurface arthroplasty

Correct Answer: Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy

Explanation:

DISCUSSION: The patient is a young laborer with osteoarthritis. Initial treatment should begin with nonsurgical management that may include anti-inflammatory drugs, cortisone injections, and physical therapy to diminish pain and improve motion. The other choices may eventually be necessary but should only follow a course of nonsurgical management.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 7:

Options:

Closed reduction and percutaneous pinning
Open reduction and internal fixation
Rotator cuff repair with possible latissimus dorsi tendon transfer
Shoulder arthroplasty
Open bone grafting

Correct Answer: Closed reduction and percutaneous pinning

Explanation:

Question 8:

Options:

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

Correct Answer: Isthmic spondylolysis

Explanation:

Question 9:

Options:

core decompression.
biopsy of the femoral head.
protected weight bearing and observation.
total hip arthroplasty.
percutaneous cannulated pin fixation of the femoral neck.

Correct Answer: protected weight bearing and observation.

Explanation:

DISCUSSION: Transient osteoporosis of the hip is an uncommon problem, usually affecting women in the last trimester of pregnancy and middle-aged men. Symptoms include pain in the involved hip with temporary osteopenia; however, there is no joint space involvement. In this patient, the imaging findings are consistent with transient osteoporosis. Short TR/TE (repetition time/echo time) images reveal diffusely decreased signal intensity in the femoral head and intracapsular region of the femoral neck. Increased signal intensity is seen with increased T
2
-weighting. Within a few months, the pain, as well as the imaging findings, will completely resolve without intervention. Distinguishing the diffuse features of transient osteoporosis of the hip from the segmental findings of osteonecrosis is essential. Unlike transient osteoporosis of the hip, osteonecrosis will have a double-density signal on MRI and may progress radiographically. Surgical intervention and oral corticosteriods are not indicated for treatment. Protected weight bearing until the pain resolves may decrease symptoms while the transient osteoporosis resolves.
REFERENCES: Potter H, Moran M, Scheider R, et al: Magnetic resonance imaging in diagnosis of transient osteoporosis of the hip. Clin Orthop 1992;280:223-229.
Bijl M, van Leeuwen MA, van Rijswijk MH: Transient osteoporosis of the hip: Presentation of typical cases for review of the literature. Clin Exp Rheumatol 1999;17:601-604.
Montella BJ; Nunley JA, Urbaniak JR: Osteonecrosis of the femoral head associated with pregnancy: A preliminary report. J Bone Joint Surg Am 1999;81:790-798.

Question 10:

- A clinical trial is being conducted on a new orthopaedic device that is different from existing devices that are moderately successful, but have frequent complications when used to treat fractures in the elderly. To comply with international standards for clinical trials, the investigator must include in the study design

Options:

reassurance that Medicare will pay for the treatment.
consent forms that patients or their guardians are able to understand.
a detailed description of the device, omitting the fact that it is part of a study.
a provision that the patient’s care will be discontinued if he or she does not enroll in the study.
a provision that the study will be carried out to completion, whether or not the device is as effective as those currently in existence.

Correct Answer: consent forms that patients or their guardians are able to understand.

Explanation:

Question 11:

An active 45-year-old man sustained an acute traumatic anteroinferior dislocation. MRI scans and an arthroscopic view are shown in Figures 36a through

Options:

Greater tuberosity
Lesser tuberosity
Posterosuperior humeral head
Superior glenoid
Central portion of the humeral head

Correct Answer: Posterosuperior humeral head

Explanation:

Question 12:

Options:

decreased longevity.
worsening of sitting balance.
worsening of pulmonary function.
temporary loss of upper extremity function.
poor patient or parent satisfaction.

Correct Answer: temporary loss of upper extremity function.

Explanation:

Question 13:

Options:

Reassure the patient that the symptoms should subside gradually and that he should remain as upright as possible and loosen his cervical collar.
Prescribe methylprednisolone and diazepam.
Admit the patient for observation.
Advise the patient to come to the office first thing in the morning for a lateral radiograph of the cervical spine.
Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Correct Answer: Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Explanation:

Question 14:

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Options:

Obtain a radiograph of the hip
Obtain radiographs of the lumbar spine
Obtain an MRI scan of the lumbar spine
Review the radiographic report from the time of injury
Reassure the patient that the pain will improve and order physical therapy

Correct Answer: Obtain a radiograph of the hip

Explanation:

Question 15:

Options:

Anterior glenoid rim fracture tear
Anterior inferior labral tear
Posterior labral tear
Total capsular laxity
Osteochondral defect of the humeral head

Correct Answer: Posterior labral tear

Explanation:

DISCUSSION: Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers.
A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has
been shown to be successful in the treatment of traumatic instability.
REFERENCES: Bottoni CR, Franks BR, Moore JH, et al: Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
Williams RJ III, Strickland S, Cohen M, et al: Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209.
Kim SH, Ha KI, Park JH, et al: Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487.

Question 16:

Options:

Hallux valgus correction
Custom orthosis to prevent further deformity
Observation only
Steroid injection to decrease inflammation
Extra-depth shoes

Correct Answer: Observation only

Explanation:

Question 17:

- A 12-year-old Little League pitcher has had pain in the dominant shoulder for the past week that prevents him from pitching. Examination reveals normal strength, full range of motion, normal stability, and mild tenderness about the proximal humerus. Radiographs with comparison views of the opposite shoulder show widening of the proximal humerus physis. Management should include

Options:

Diagnostic arthroscopy
Arthroscopy and subacromial decompression
Reduction and fixation of the proximal humeral epiphysis
Temporary cessation of throwing
Physical therapy for rotator cuff strengthening

Correct Answer: Temporary cessation of throwing

Explanation:

Question 18:

The view from an anterosuperior portal of the right shoulder shown in Figure 12 reveals which of the following findings?

Options:

Rupture of the subscapularis tendon
Tear of the rotator interval
Humeral avulsion of the glenohumeral ligament (HAGL) lesion
Anterior ligamentous periosteal sleeve avulsion (ALPSA) lesion
Bankart lesion

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

Explanation:

Question 19:

Options:

live longer and have stable neurologic function.
live longer and have improved neurologic function.
not live longer and deteriorate neurologically.
not live longer but will have improved neurologic function.
not live longer but will have stable neurologic function.

Correct Answer: live longer and have improved neurologic function.

Explanation:

DISCUSSION: The patient has a cervical myelopathy with more than 10 mm of space available for the cord; therefore, she has a reasonable chance of improved neurologic function following surgery. If not treated with surgery, however, her neurologic condition likely will worsen and she will die earlier than if she had surgery.
REFERENCES: Matsunaga S, Sakou T, Onishi T, et al: Prognosis of patients with upper cervical lesions caused by rheumatoid arthritis: Comparison of occipitocervical fusion between C1 laminectomy and nonsurgical management. Spine 2003;28:1581-1587.
Boden
SD
, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am
1993;75:1282-1297.

Question 20:

Among the ankle arthroscopy portals described below, which portal is at highest risk for serious complications?

Options:

Posterolateral: lateral to the Achilles tendon
Anterolateral: lateral to the peroneus tertius tendon
Anteromedial: medial to the tibialis anterior tendon
Posteromedial: medial to the Achilles tendon

Correct Answer: Posteromedial: medial to the Achilles tendon

Explanation:

DISCUSSION
All of the portals listed pose risk for some structures. Because they have been shown to be the safest, the most common anterior portals are the anteromedial and the anterolateral. The safest posterior portal is the posterolateral portal. Because of the location of the posterior medial tendons and the neurovascular bundle, the posteromedial portal is at highest risk for serious complications.
RECOMMENDED READINGS
Golanó P, Vega J, Pérez-Carro L, Götzens V. Ankle anatomy for the arthroscopist. Part I: The portals. Foot Ankle Clin. 2006 Jun;11(2):253-73, v. Review. PubMed PMID: 16798511.
View Abstract at PubMed
Ferkel RD, Hommen JP. Arthroscopy of the ankle and foot. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1641-1726.
Figure 90 is an intraoperative image showing the medial approach to the elbow. The arm is proximal and to the right, and the forearm is distal and to the left. The blue arrow points to the medial epicondyle. A black arrow points to a piece of glass in a nervous structure. This injury most likely would affect which distal muscular structure?
Extensor digiti minimi
Flexor digitorum superficialis (FDS) to the index finger
77
Abductor pollicis brevis
First dorsal interossei
DISCUSSION
The intraoperative image shows a piece of glass splitting the ulnar nerve in the cubital tunnel. The extensor digiti minimi is innervated by the radial nerve. The FDS to the index finger and the abductor pollicis brevis are innervated by the median nerve. The first dorsal interossei is the last muscle innervated by the ulnar nerve.
RECOMMENDED READINGS
Miller MD. Review of Orthopaedics. 3rd ed. New York, NY: Saunders; 2000.
Anderson JE. Grant’s Atlas of Anatomy. 8th ed. Baltimore, MD: Williams & Wilkins; 1983.

Question 21:

Options:

Retrograde locked intramedullary nail
Antegrade reamed locked intramedullary nail
Flexible nails
Open reduction and plate fixation
External fixation

Correct Answer: Open reduction and plate fixation

Explanation:

Question 22:

Options:

Metastatic carcinoma (thyroid)
Multiple myeloma
Lymphoma
Synovial cell sarcoma
Osteomyelitis

Correct Answer: Multiple myeloma

Explanation:

Question 23:

Options:

administration of 2 L of saline solution.
subxiphoid pericardial aspiration.
rapid infusion of 500 mL of colloid solution.
insertion of a large-bore needle in the right third or fourth intercostal space.
intubation followed by mechanical ventilation.

Correct Answer: insertion of a large-bore needle in the right third or fourth intercostal space.

Explanation:

Question 24:

Options:

Anatomic alignment
Indirect reduction
Anatomic reduction of the fragments
Relatively stable fixation
Functional aftercare

Correct Answer: Anatomic reduction of the fragments

Explanation:

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,
pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 25:

Options:

Total knee arthroplasty
Unicompartmental arthroplasty
Insertion of a unispacer
Tibial osteotomy
Knee arthroscopy

Correct Answer: Tibial osteotomy

Explanation:

DISCUSSION: In a relatively young patient who is an avid tennis player, the treatment of choice is a joint preserving procedure. The radiographs reveal varus alignment with loading of the medial compartment. After all nonsurgical management options have been used, the best treatment option is a medial opening wedge osteotomy. A lateral closing wedge osteotomy of the proximal tibia is also a reasonable option, but it is not one of the choices. A unicompartmental arthroplasty or a total knee arthroplasty would place significant restrictions in this patient. A unispacer may be a temporizing procedure but is controversial and without substantial data in the literature. The knee arthroscopy will not address the medial compartment osteoarthritis.
REFERENCES: Nagel A, Insall JN, Scuderi GR: Proximal tibial osteotomy: A subjective outcome study. J Bone Joint Surg Am 1996;78:1353-1358.
Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Manifold SG, Kelly MA, Richardson L, et al: Osteotomies about the knee, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 947-961.

Question 26:

The sartorius muscle is innervated by which of the following nerves?

Options:

Femoral
Obturator
Superior gluteal
Inferior gluteal
Ilioinguinal

Correct Answer: Femoral

Explanation:

Question 27:

Options:

HLA-B27
Prostate-specific antigen
Rheumatoid factor
Antinuclear antibody
Serum protein electrophoresis

Correct Answer: HLA-B27

Explanation:

Question 28:

Options:

Posterior “Y” plate fixation
Dual one third tubular plate fixation with a hinged external fixator
Dual one third tubular plate fixation
Dual 3.5-mm reconstruction plate fixation
Single lateral plate fixation with transcortical screw fixation

Correct Answer: Dual 3.5-mm reconstruction plate fixation

Explanation:

Question 29:

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Options:

An electric wheelchair with puffer control
An electric wheelchair with hand controls
A manual wheelchair and sliding board transfers
A manual wheelchair and independent transfers
Crutches with long leg braces for short distance ambulation

Correct Answer: A manual wheelchair and sliding board transfers

Explanation:

Question 30:

Options:

Bone scan
CT
High-dose steroids
Sacroiliac joint injection
Hernia repair

Correct Answer: Hernia repair

Explanation:

Question 31:

Options:

hip and knee extension
hip flexion to 90, knee extension
hip internal rotation, knee flexion to 90
hip and knee flexion to 90
hip extension, knee flexion to 90

Correct Answer: hip and knee extension

Explanation:

Question 32:

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Options:

Insufficient caloric intake
Physical stress
Use of oral contraceptives
Diabetes mellitus
Chromosomal abnormalities

Correct Answer: Insufficient caloric intake

Explanation:

Question 33:

Options:

methylprednisolone and observation.
posterior laminectomy and spinal fusion.
anterior spinal fusion.
halo vest immobilization.
posterior laminectomy followed by halo vest immobilization.

Correct Answer: posterior laminectomy and spinal fusion.

Explanation:

Question 34:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor
may experience a better functional result with latissimus dorsi transfer.

Question 35:

A 16-year-old high school football player sustains an injury to the left hip. The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?

Options:

Ischiofemoral ligament
Pubofemoral ligament
Rectus femoris
Sartorius
Gluteus minimus

Correct Answer: Rectus femoris

Explanation:

Question 36:

Options:

Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the sacral promontory
Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the confluence of the iliac veins
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the right iliac vein extending toward the left iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues bilaterally away from the midline

Correct Answer: Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein

Explanation:

Question 37:

Which of the following types of osteosarcoma is associated with the best prognosis & long survival?

Options:

Parosteal
Periosteal
High-grade intramedullary
Osteosarcoma occurring in Paget’s disease
Osteosarcoma occurring in irradiated bone

Correct Answer: Parosteal

Explanation:

Question 38:

- A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of

Options:

scapulothoracic fusion
strengthening of the periscapular muscles
pectoralis minor-fascia lata graft transfer to the scapula
pectoralis major-fascia lata graft transfer to the scapula
exploration of the long thoracic nerve, with sural nerve graft

Correct Answer: strengthening of the periscapular muscles

Explanation:

Question 39:

Options:

The flexor digitorum longus tendon is ruptured.
The posterior tibial tendon has a normal appearance.
The posterior tibial tendon has a physiologic amount of fluid in its sheath.
The posterior tibial tendon is completely ruptured and retracted (type III tear).
The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Correct Answer: The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Explanation:

Question 40:

Options:

Dega iliac
Salter iliac
Pemberton iliac
Steele triple
Ganz or Bernese periacetabular

Correct Answer: Dega iliac

Question 41:

During surgical treatment of the most common variation of distal femoral "Hoffa" fractures, which of the following orientations for screw fixation should be used?

Options:

Medial to lateral screw placement across lateral femoral condyle
Anterior to posterior screw placement across medial femoral condyle
Medial to lateral screw placement across medial femoral condle
Anterior to posterior screw placement across lateral femoral condyle
Anterior to posterior screw placement across intercondylar notch

Correct Answer: Medial to lateral screw placement across lateral femoral condyle

Explanation:

Question 42:

Pharmacoprophylaxis should be avoided in favor of a pneumatic compression device for a patient with

Options:

protein C deficiency.
protein S deficiency.
factor V Leiden mutation.
factor VIII deficiency.

Correct Answer: factor VIII deficiency.

Explanation:

Question 43:

Which nerve root contributes to both the sciatic and femoral nerves?

Options:

Correct Answer: L4

Explanation:

Question 44:

Options:

Extensor pollicis longus (EPL) tendon
Adductor aponeurosis
EPB and dorsal capsule
Ulnar sesamoid bone and volar plate

Correct Answer: Adductor aponeurosis

Explanation:

Question 45:

The biopsy specimens seen in Figures 55a and 55b are from a lytic lesion in the sacrum of a 58-year-old man. What is the most likely diagnosis?

Options:

Chondrosarcoma
Metastatic renal cell carcinoma
Chondromyxoid fibroma
Chordoma
Giant cell tumor

Correct Answer: Chordoma

Explanation:

DISCUSSION: The lesion is a chordoma and the other listed choices can be eliminated based on the histology. Many tumors can occur in the sacrum including chordoma, multiple myeloma, giant cell tumor, aneurysmal bone cyst, and metastatic disease. The histology in this patient shows a lobulated lesion on low power with fibrous septae separating the lobules. At higher magnification, the cells have eosinophilic vacuolated cytoplasm and are called physaliferous cells. Chordoma is a low-grade neoplasm that most commonly occurs in the sacrum and rarely in the base of the skull. The diagnosis is often delayed. Chordoma is thought to originate from notochordal remnants. Chordoma typically occurs in the midline and has an associated soft-tissue mass.
REFERENCES: Wold LE, Adler CP, Sim FH, et al: Atlas of Orthopedic Pathology, ed 2. Philadelphia, PA, WB Saunders, 2003, p 372.
Fuchs B, Dickey ID, Yaszemski MJ, et al: Operative management of sacral chordoma. J Bone Joint Surg Am 2005;87:2211-2216.
Fourney DR, Rhines LD, Hentschel SJ, et al: En bloc resection of primary sacral tumors: Classification of surgical approaches and outcome. J Neurosurg Spine 2005;3:111-122.

Question 46:

- In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?

Options:

20% with cemented and uncemented sockets
40% with cemented and uncemented sockets
60% with cemented sockets
90% with cemented and uncemented sockets
90% with cemented sockets

Correct Answer: 40% with cemented and uncemented sockets

Explanation:

Question 47:

Passage of a sodium ion through a voltage-gated channel leads to which of the following?

Options:

Apoptosis of gram negative bacteria
Binding of RANKL to osteoblasts
Inhibition of micturition
Generation of a nerve action potential
Deposition of salts in adipose tissue

Correct Answer: Generation of a nerve action potential

Explanation:

Question 48:

Options:

initiation of a first-generation cephalosporin while awaiting culture results.
initiation of broad-spectrum antibiotics while awaiting culture results.
ultrasound to evaluate for fluid collection around the knee.
surgical debridement of the knee before culture results are available.
inpatient observation and no antibiotics until culture results are available.

Correct Answer: surgical debridement of the knee before culture results are available.

Explanation:

AL-Madena Copy
8 • American Academy of Orthopaedic Surgeons
DISCUSSION: Increased pain, swelling, erythema, and drainage 2 weeks removed from the primary arthroplasty are all signs of a probable infection. Erythrocyte sedimentation rate and C-reactive protein may not be helpful as they are elevated postoperatively even in the absence of infection. Even in the absence of infection, persistent wound drainage is an indication for surgical debridement to prevent subsequent infection. When a postoperative infection is easily recognized by clinical examination, there is no need to wait for a positive culture before proceeding with debridement.
REFERENCES: Weiss AP, Krackow KA: Persistent wound drainage after primary total knee arthroplasty. J Arthroplasty 1993;8:285-289.
Jaberi FM, Parvizi J, Haytmanek CT, et al: Procrastination of wound drainage and malnutrition affect the outcome of joint arthroplasty. Clin Orthop Relat Res 2008;466:1368-1371.
Insall JN, Windsor RE, Scott, WN: Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 959-964.
Figure 3a Figure 3b

Question 49:

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Options:

Common flexor tendon
Anconeus
Radial collateral ligament
Ulnar collateral ligament
Lateral ulnar collateral ligament

Correct Answer: Ulnar collateral ligament

Explanation:

Question 50:

The first branch of the lateral plantar nerve innervates the

Options:

interossei.
quadratus plantae.
flexor digitorum brevis.
abductor hallucis brevis.
abductor digiti quinti.

Correct Answer: abductor digiti quinti.

Explanation:

DISCUSSION: The first branch of the lateral plantar nerve innervates the abductor digiti quinti, and more distal branches of the lateral plantar nerve supply the quadratus plantae and the interossei. The medial plantar nerve supplies the abductor hallucis brevis and the flexor digitorum brevis.
REFERENCES: Pansky B, House EH: Review of Gross Anatomy, ed 3. New York, NY, Macmillan, 1975, pp 464-476.
Sarrafian
SK
: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983,
pp 325-328.

Question 51:

Options:

Microfracture
Autologous chondrocyte implantation
Osteochondral allograft transfer
Dejour trochleoplasty

Correct Answer: Osteochondral allograft transfer

Explanation:

The images show a full-thickness cartilage defect with significant bony involvement >4 cm
2
. Microfracture should be considered for lesions <2 cm
2
without an underlying osseous defect. Autologous chondrocyte implantation, although used for lesions between 1 and 10 cm
2
, should be restricted for defects with minimal (<8 mm depth) bone loss. Osteochondral allograft transfer with the mosaicplasty technique (transfer of multiple plugs) would be well-suited for this large defect with significant osseous involvement. Dejour trochleoplasty is performed for patellar instability to correct trochlear dysplasia and
would not be indicated in this case.

Question 52:

A 16-year-old girl has a painful foot mass. A radiograph, MRI scan, and biopsy specimens are shown in Figures 35a through 35d. What is the most likely diagnosis?

Options:

Synovial sarcoma
Pigmented villonodular synovitis (PVNS)
Malignant fibrous histiocytoma
Synovial chondromatosis
Lyme disease

Correct Answer: Pigmented villonodular synovitis (PVNS)

Explanation:

Question 53:

Options:

adherence and colonization.
formation of a protective scaffold.
coating with host proteins.
direct inhibition of antibiotics.

Correct Answer: formation of a protective scaffold.

Explanation:

Question 54:

Options:

immobilization with a halo ring and vest with reduction when medically stable.
closed traction reduction using Gardner-Wells tongs.
posterior open reduction, stabilization, and fusion.
cervical MRI followed by reduction.
anterior open reduction, stabilization, and fusion.

Correct Answer: cervical MRI followed by reduction.

Explanation:

Question 55:

Options:

Consultation with an infectious disease specialist
Symptomatic treatment, with a full return to activities in 4 to 6 weeks
Cast immobilization for 6 to 12 weeks with the expectation of full recovery
A rheumatologic work-up with the expectation of significant long-term sequelae
Bone biopsy

Correct Answer: Cast immobilization for 6 to 12 weeks with the expectation of full recovery

Explanation:

Question 56:

Figure 46 shows the radiograph of an obese 12-year-old boy who has had left hip pain for the past 3 months. What is the best course of action?

Options:

Decreased activities and physical therapy
Left hip reduction and internal fixation
Left hip pinning in situ
Bilateral hip pinning in situ
Spica cast immobilization

Correct Answer: Left hip pinning in situ

Explanation:

Question 57:

An otherwise healthy 57-year-old man has persistent, severe hip pain after undergoing total hip arthroplasty 3 months ago. What is the next most appropriate step in management?

Options:

Serial radiographs to assess progressive radiolucency from osteolysis or mechanical loosening
Assessment of C-reactive protein, erythroctye sedimentation rate, and CBC, followed by aspiration
Technetium and/or indium-labeled leukocyte scintigraphy
A trial of broad-spectrum cefalosporin antibiotics to assess for a change in pain intensity
Injection with lidocaine and methylprednisolone acetate

Correct Answer: Assessment of C-reactive protein, erythroctye sedimentation rate, and CBC, followed by aspiration

Explanation:

Question 58:

The findings in Brown-Sequard syndrome include loss of which of the following? Review Topic

Options:

Greater loss of upper extremity motor function than lower extremity function
Ipsilateral motor function and ipsilateral pain and temperature sensation
Ipsilateral motor function and contralateral pain and temperature sensation
Contralateral motor function and ipsilateral pain and temperature sensation
Lower of extremity proprioception and balance

Correct Answer: Ipsilateral motor function and contralateral pain and temperature sensation

Explanation:

Question 59:

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral Review Topic

Options:

abduction and external rotation.
abduction and internal rotation.
adduction and external rotation.
adduction and internal rotation.
external rotation and forward flexion.

Correct Answer: adduction and internal rotation.

Explanation:

Question 60:

Options:

Bone scan
CT
Needle biopsy
Incisional biopsy
No further tests are needed

Correct Answer: No further tests are needed

Explanation:

DISCUSSION: The radiograph and MRI scan show a pedunculated lesion arising from the medial aspect of the distal femoral metaphysis. The cortex of the lesion is contiguous with the cortex of the underlying normal bone. Similarly, the medullary canal of the lesion is contiguous with that of the normal bone. These findings are diagnostic of osteochondroma. Rarely a secondary chondrosarcoma can arise in a preexisting osteochondroma. This diagnosis is suggested by identifying a cartilage cap that is greater than 1.5-cm thick in a skeletally mature patient. MRI is the best study to rule out a secondary chondrosarcoma. CT also may be used for this purpose but is not indicated in this patient because an MRI has already been obtained. A bone scan is not useful to identify a secondary chondrosarcoma. Similarly, there is no role for biopsy in this patient. No further tests are needed.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Murphey MD, Choi JJ, Kransdorf, MJ, et al: Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407-1434.

Question 61:

Options:

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

Correct Answer: Anatomic total shoulder arthroplasty and pectoralis major transfer

Explanation:

Question 62:

What percentage of bone weight is collagen?

Options:

1 5% to 10%
2 20% to 25%
3 50% to 60%
4 70% to 75%
90% to 95%

Correct Answer: 2 20% to 25%

Explanation:

Question 63:

Which of the following best describes the recommended treatment for a 13-year-old pitcher with a painful chronic stress injury to the proximal humeral physis as confirmed on an MRI scan? Review Topic

Options:

Brief shoulder immobilization followed by avoidance of pitching and throwing for the remainder of the season
Brief shoulder immobilization followed by avoidance of pitching and throwing until skeletal maturity
In situ screw fixation of the proximal humeral growth plate
Arthroscopic shoulder debridement
Arthroscopic repair of the Bankart lesion

Correct Answer: Brief shoulder immobilization followed by avoidance of pitching and throwing for the remainder of the season

Explanation:

Question 64:

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Options:

Patient Protection and Affordable Care Act
Medicare Payment Reform Act
Physician Financial Transparency Act
Physician Payments Sunshine Act
Health Insurance Portability and Accountability Act

Correct Answer: Physician Financial Transparency Act

Explanation:

Question 65:

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Options:

2 to 3
4 to 5
6 to 7
7 to 8
9 to 10

Correct Answer: 4 to 5

Explanation:

Question 66:

-What is the mechanism of action of tranexamic acid in controlling traumatic hemorrhage?

Options:

Inhibition of vitamin K reductase
Inhibition of topoisomerase II and IV
Antithrombin-III selective inhibition of Factor Xa
Competitive inhibition of plasminogen activation
Stimulation of integrin-mediated platelet adhesion and activation

Correct Answer: Competitive inhibition of plasminogen activation

Question 67:

Options:

there is less risk to regional neurologic structures.
of superior bone purchase.
they more definitively stabilize the posterior fracture.
they may be more easily applied in the emergency department setting.
there is less risk of intra-articular hip joint penetration.

Correct Answer: of superior bone purchase.

Explanation:

Question 68:

Options:

Scapular dyskenisia
Quadrilateral space syndrome
Subacromial impingement syndrome
Suprascapular nerve compression by a spinoglenoid notch
Suprascapular nerve compression at the suprascapular notch

Correct Answer: Quadrilateral space syndrome

Explanation:

Question 69:

Options:

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

Correct Answer: open reduction and internal fixation.

Explanation:

Question 70:

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 71:

Options:

History and physical examination
Ultrasonography
MRI
Radiographs
Nerve conduction velocity studies

Correct Answer: History and physical examination

Explanation:

Question 72:

Options:

Medial femoral condyle physeal widening
An osseous or osteochondral loose fragment
Osgood-Schlatter disease
A patella nondisplaced fracture

Correct Answer: An osseous or osteochondral loose fragment

Explanation:

Question 73:

Options:

Chronic periprosthetic infection
Trochanteric bursitis
Pseudotumor related to corrosion at the head/neck taper junction
Tendonitis from iliopsoas tendon impingement

Correct Answer: Pseudotumor related to corrosion at the head/neck taper junction

Explanation:

DISCUSSION
This patient presents with a pseudotumor likely attributable to local tissue reaction resulting from either articular metal wear debris and/or corrosion and fretting of the trunnion. The trunnion is a more likely source of the problem for a number of reasons: good position of metal articulation, increased trunnion corrosion and fretting associated with large-head THA, and markedly increased cobalt levels compared to chromium levels. Infection is very unlikely
in the setting of normal ESR and CRP findings. MR imaging findings are consistent with pseudotumor and not iliopsoas tendonitis or trochanteric bursitis.
CLINICAL SITUATION FOR QUESTIONS 42 THROUGH 45
Figures 42a through 42e are the radiographs, MR image, and MR arthrogram of a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has either competed or practiced 5 to 6 times per week since the age of

Question 74:

ofhat parameter is most commonly used to estimate the maximum tension a muscle can generating?

Options:

Length
Moment arm
Total volume
Physiologic cross-sectional area
Distribution of slow and fast twitch fibers

Correct Answer: Physiologic cross-sectional area

Explanation:

Question 75:

Options:

closed reduction and splinting in metacarpophalangeal (MCP) and PIP joint extension.
closed reduction and splinting in MCP joint flexion and PIP joint extension.
reduction and percutaneous intramedullary Kirschner wire fixation.
reduction and lag screw fixation.
buddy taping and early range of motion.

Correct Answer: reduction and lag screw fixation.

Explanation:

DISCUSSION: The oblique nature of the fracture and extension of the fracture to the condyles implies an unstable fracture. Lag screw fixation provides an excellent chance of union, and the ability to start early range of motion.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 76:

The arrow in Figure 39 is pointing to which of the following ligaments?

Options:

Scapholunate interosseous
Lunotriquetral interosseous
Ulnolunate
Ulnotriquetral
Short radiolunate

Correct Answer: Lunotriquetral interosseous

Explanation:

DISCUSSION: The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The scapholunate interosseous ligament stabilizes the scapholunate joint. The ulnolunate ligament originates from the base of the ulnar styloid and inserts in the lunate. The ulnotriquetral ligament originates from the base of the ulnar styloid and inserts on the triquetrum. The ulnolunate and the ulnotriquetral ligaments are important stabilizers to the ulnar side of the wrist. The short radiolunate ligament originates on the volar ulnar margin of the distal radius and inserts in the ulnar margin of the lunate.
REFERENCES: Berger RA: Ligament anatomy, in Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist, Diagnosis and Operative Management. St Louis, MO, Mosby, 1998,
pp 73-105.
Adams BD, Divelbiss BJ: Anatomy of the wrist ligaments, in Trumble TE (ed): Carpal Fracture-Dislocatons. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 1-5.

Question 77:

Options:

both bundles at 45 degrees of flexion.
bundle AL at 45 degrees of flexion and bundle PM at 0 degrees of flexion.
bundle AL at 45 degrees of flexion and bundle PM at 90 degrees of flexion.
bundle AL at 90 degrees of flexion and bundle PM at 0 degrees of flexion.
bundle AL at 90 degrees of flexion and bundle PM at 45 degrees of flexion.

Correct Answer: bundle AL at 90 degrees of flexion and bundle PM at 0 degrees of flexion.

Explanation:

Question 78:

Which of the following is considered a risk factor for the development of low back pain?

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 79:

What procedure can eliminate a sulcus sign? Review Topic

Options:

Rotator interval closure
SLAP repair
Bankart repair
Supraspinatus repair
Subacromial decompression

Correct Answer: Rotator interval closure

Explanation:

Question 80:

At the level of the midcalf, the plantaris tendon is found at which of the following locations?

Options:

Superficial to the fascia of the gastrocnemius
Between the medial and lateral heads of the gastrocnemius
Between the soleus and lateral head of the gastrocnemius
Between the soleus and medial head of the gastrocnemius
Between the soleus and posterior tibialis muscle

Correct Answer: Between the soleus and medial head of the gastrocnemius

Explanation:

DISCUSSION: The plantaris tendon is often harvested to augment a tendon reconstruction. The origin of the plantaris muscle is on the posterolateral aspect of the distal femur, and the muscle lies lateral to the tibial nerve and the posterior tibial artery. The tendon then courses posteriorly between the soleus and the medial head of the gastrocnemius.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 475.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 491.

Question 81:

Options:

Macrophages
Osteoclasts
Osteoblasts
Monocytes
Histiocytes

Correct Answer: Osteoblasts

Explanation:

Question 82:

Options:

Pain with palpation of the bicipital groove
Pain with palpation over the subdeltoid bursa
Sensory loss over the lateral shoulder
Sensation of shoulder instability with external rotation
Sensation of shoulder instability with internal rotation

Correct Answer: Sensory loss over the lateral shoulder

Explanation:

Question 83:

Options:

Osteomyelitis
Eosinophilic granuloma
Osteosarcoma
Ewing’s sarcoma
Lymphoma of bone

Correct Answer: Eosinophilic granuloma

Explanation:

Question 84:

Options:

CT-guided needle biopsy followed by radiation therapy
L5-S1 fusion with instrumentation
L5-S1 hemilaminotomy and partial diskectomy
Activity restriction and bracing
L5-S1 total disk arthroplasty

Correct Answer: Activity restriction and bracing

Explanation:

DISCUSSION: The sagittal and axial CT scans show a bilateral spondylolysis at L5. The defect is in the pars interarticularis on the right side but at the base of the pedicle on the left. Having failed a trial of physical therapy with only a 3-month history of pain, the next most appropriate step in management should consist of activity modification and bracing in an antilordotic lumbosacral orthosis. Surgical intervention is reserved for patients who have failed to respond to a trial of bracing and activity restriction.
REFERENCES: Debnath UK, Freeman BJ, Grevitt MP, et al: Clinical outcome of symptomatic unilateral stress injuries of the lumbar pars interarticularis. Spine 2007;32:995-1000.
Bono CM: Low-back pain in athletes. J Bone Joint Surg Am 2004;86:382-396.

Question 85:

Talar compression syndrome in ballet dancers typically involves injury to which of the following structures?

Options:

Sustentaculum tali
Lateral process of the talus
Posterior process of the calcaneus
Os tibialis externum
Os trigonum

Correct Answer: Os trigonum

Explanation:

Question 86:

Options:

Closed reduction and a long arm cast
Closed reduction, a long arm cast, and a skeletal survey
Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services
Closed reduction and a long arm cast, a bone scan, and referral to child protective services
Closed reduction and a long arm cast, MRI of the brain, and a referral to child protective services

Correct Answer: Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services

Explanation:

Question 87:

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Options:

Volar interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and both heads of the flexor pollicis brevis
All of the interossei and the abductor pollicis brevis
All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Correct Answer: All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Explanation:

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the
median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 88:

Options:

Spiral groove of the humerus
Midshaft of the radius
Radial neck
Anatomic neck of the humerus
Surgical neck of the humerus

Correct Answer: Radial neck

Explanation:

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 89:

Options:

Observation as the deformity should resolve in time
Wearing of straight last shoes
Serial stretching and casting for the next 6 to 12 weeks
Heyman, Herndon, and Strong capsular release at the tarsometatarsal and intermetatarsal joints
Berman and Gartland dome-shaped osteotomies of the metatarsal bases

Correct Answer: Serial stretching and casting for the next 6 to 12 weeks

Explanation:

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.
J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes
of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 90:

- A 31-year-old man who is a recent immigrant from Guatemala has had pain in his back and thighs for the past 12 months. History notes a recent diagnosis of gout, and the patient reports falling a distance of 3 feet on his buttocks immediately before the pain began. Examination reveals that he is neurologically intact. Plain radiographs are shown in Figures 44a and 44b, and T2-weighted MRI scans are shown in Figures 44c and 44d. The most likely cause of the pathologic fracture is

Options:

gout.
osteoporosis.
eosinophilic granuloma.
tuberculosis of the spine.
metastatic disease of the spine.

Correct Answer: tuberculosis of the spine.

Explanation:

Question 91:

Options:

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

Correct Answer: Poor because it is a late infection

Explanation:

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

Question 92:

-An otherwise healthy 15-year-old wrestler has a 6-cm cutaneous lesion on the posterior aspect of his right elbow that he reports as a spider bite. What is the most likely diagnosis?

Options:

Psoriasis
Tinea corporis
Herpes simplex virus
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) DISCUSSION-Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite.Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture,leaving moist ulcers or crusted plaques.

Correct Answer: Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) DISCUSSION-Patients who have skin and soft-tissue infections caused by CA-MRSA often describe the lesion as a spider bite. The cytotoxin Panton-Valentine leukocidin that is produced by many strains of CA-MRSA causes tissue necrosis, resulting in rapid development of an abscess and the appearance of a spider bite.Patients with psoriasis have thick, red skin with flaky, silver-white patches. Tinea corporis is a general term for a cutaneous fungal infection. The lesion appears as a well-demarcated erythematous plaque with a raised border and central hypopigmentation, giving it a ring-like appearance. Primary infection with herpes simplex virus can produce constitutional symptoms with burning, tingling, or stinging at the site. Grouped vesicles with clear fluid 1 to 2 mm in size form on an erythematous base and then rupture,leaving moist ulcers or crusted plaques.

Explanation:

CLINICAL SITUATION FOR QUESTIONS 44 AND 45
Figure 44 is the MRI scan of a 14-year-old soccer player who injured his right knee during a game.He describes feeling a “pop” and he needed help walking off the field. His knee is visibly swollen. A Lachman test demonstrates asymmetry with no endpoint.

Question 93:

A 72-year-old woman who sustained a cerebrovascular accident 9 months ago now has a fixed elbow flexion contracture of 80 degrees. Management should consist of

Options:

passive physical therapy.
musculocutaneous neurectomy and serial casting.
musculocutaneous nerve block.
lengthening of the biceps tendon.
distraction arthroplasty.

Correct Answer: musculocutaneous neurectomy and serial casting.

Explanation:

Question 94:

Options:

continued IV antibiotics and observation.
hyperbaric oxygen treatment.
rapid IV fluid boluses.
surgical debridement.
whirlpool therapy.

Correct Answer: surgical debridement.

Explanation:

Question 95:

Figures 38a and 38b

Options:

Open reduction and internal fixation (ORIF)
Walking boot and weight bearing as tolerated until pain subsides
Nonweight-bearing cast for 6 weeks
Physical therapy
Closed reduction and weight bearing as tolerated
Closed reduction and percutaneous fixation
Figures 38a and 38b

Correct Answer: Open reduction and internal fixation (ORIF)

Explanation:

DISCUSSION
Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.
RECOMMENDED READINGS
Schepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013 Sep;37(9):1833-8. PubMed PMID: 23959223.
View Abstract at PubMed
Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516.
View Abstract at PubMed
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165.
View Abstract at
PubMed
Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511.
View Abstract at PubMed

Question 96:

Which of the following methods accurately describes the measurement of tip-apex-distance as it relates to placement of a lag screw in the femoral head?

Options:

Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the acetabular teardrop to the tip of the screw on an AP radiograph of the hip
Multiplication of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs
Distance from the center of the lesser trochanter to the tip of the screw on an AP hip radiograph
Summation of the distance between the tip of the greater trochanter and end of the screw on AP and lateral hip radiographs

Correct Answer: Summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs

Explanation:

Question 97:

In obstetrical brachial plexus palsy, which of the following signs is associated with the poorest prognosis for recovery in a 2-month-old infant?

Options:

Persistent inability to bring the hand to the mouth with the elbow stabilized at the side
Persistent inability to actively abduct the arm past 90 degrees
Persistent inability to externally rotate the shoulder past 20 degrees
Persistent unilateral ptosis, myosis, and anhydrosis
History of clavicle fracture at birth

Correct Answer: Persistent unilateral ptosis, myosis, and anhydrosis

Explanation:

DISCUSSION: Persistent Horner’s sign (ptosis, myosis, and anhydrosis) is a sign of proximal injury, usually avulsion of the roots from the cord which disrupts the sympathetic chain. Root rupture or avulsion proximal to the myelin sheath has less chance of healing. Two-month-old infants with persistent weakness in the other areas described may still have a good prognosis for recovery. Concurrent clavicle fracture has been shown to have no prognostic value.
REFERENCES: Clarke HM, Curtis CG: An approach to obstetrical brachial plexus injuries. Hand Clin 1995;11:563-581.
Narakas AO: Injuries to the brachial plexus, in Bora FW (ed): The Pediatric Upper Extremity: Diagnosis and Management. Philadelphia, PA, WB Saunders, 1986, p 247.

Question 98:

Options:

open reduction and internal fixation of the fragment along with the rectus femoris.
open reduction and internal fixation of the fragment along with the sartorius.
open reduction and internal fixation of the fragment along with the iliopsoas.
rest and protected weight bearing with crutches.
excision of the fragment.

Correct Answer: rest and protected weight bearing with crutches.

Explanation:

Question 99:

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Options:

Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation

Correct Answer: Can be protective to an injured spine

Explanation:

Question 100:

Options:

Closed reduction and splinting in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint extension
Closed reduction and splinting in MCP joint flexion and PIP joint extension
Reduction and percutaneous fixation
Open reduction and internal fixation
Buddy taping and early range of motion

Correct Answer: Reduction and percutaneous fixation

Explanation:

DISCUSSION: The fracture of the proximal phalanx is clearly displaced. There is slight comminution at the area of the fracture. Closed reduction is likely to fail due to the forces of the extensor, flexor, and intrinsic mechanisms. Percutaneous fixation, unlike open fixation techniques, avoids likely problems with stiffness.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

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

Orthopedic Board Review MCQs: Trauma & Foot Surgery | Part 205

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 205

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index