OITE & AAOS Orthopedic Board Review MCQs | Part 207

About This Board Review Set

This is Part 207 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 207

This module focuses heavily on: Foot, Fracture, Knee, Pediatric, Wrist.

Sample Questions from This Set

Sample Question 1: A 12½-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full...

Sample Question 2: A 70-year-old male with longstanding diabetic neuropathy sustains a fall down a flight of stairs and sustains the injury shown in Figures A and B. In the operating room, direct reduction of the fracture is performed. The syndesmosis is asse...

Sample Question 3: Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate tre...

Sample Question 4: A cortisone injection in the subacromial space will most likely result in...

Sample Question 5: Radiographs of a pediatric patient reveal a suspected osteosarcoma of the distal femur. Additional staging studies should consist of...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

00:00

Start Quiz

Question 1

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

Explanation

Agenesis of the anterior cruciate ligament
Thickened medial plica
Grade IV chondral flap
Pigmented villonodular synovitis
Abnormal meniscal morphology
This child presents with an asymptomatic click in the knee. It is associated with widening of the lateral joint space of the knee on X-ray. These features are highly suggestive of a discoid lateral meniscus in this age category.
The principal diagnostic feature of a discoid meniscus is the complaint of snapping or clicking in the knee. Children are usually asymptomatic. Although, less frequently, children may present with pain that is largely secondary to an underlying meniscal tear. MRI scans of the knee have show to have the greatest sensitivity for identifying discoid menisci. The presence of a contiguous central meniscus on three consecutive slices is usually indicative of the diagnosis. Treatment is mostly focused on conservative modalities. Surgical intervention is reserved for symptomatic cases with recurrent locking, swelling or persistent pain is present in older children.
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Figure A shows an AP radiograph of a pediatric knee. There is an increased lateral joint space suggestive of a discoid meniscus.
Illustrations A-C show an MRI of the knee with 3 consecutive coronal cuts showing an abnormal appearing discoid meniscus.
Incorrect Answers:

Question 2

A 70-year-old male with longstanding diabetic neuropathy sustains a fall down a flight of stairs and sustains the injury shown in Figures A and B. In the operating room, direct reduction of the fracture is performed. The syndesmosis is assessed and found to be intact. The fibula is fixed with a small fragment locking plate and the medial malleolus is fixed with screws. What is the next best step? Review Topic

Explanation

Ankle fractures in diabetics with neuropathy should be treated with enhanced fixation comprising stiff plates with syndesmotic screws, even in the absence of syndesmotic injury. Weightbearing should be delayed for 8 to 12 weeks after surgery, rather than 4-8 weeks (as for normal patients).
Diabetics with ankle fractures are prone to complications. Nonoperatively treated cases have up to a 50% incidence of skin breakdown in a cast. Surgically treated patients have up to 40% complication rate. Supplemental fixation can include include multiple syndesmotic screws, spanning external fixation, tibio-talar Steinmann pins, more rigid fibular plates, supplemental intramedulary fibular pinning. Weightbearing after surgery should be delayed (8-12weeks).
McCormack and Leith reviewed the complications in 26 diabetic ankle fractures. 19 patients had surgery. The incidence of complications was 42%. Two required amputation and died. None of the non-diabetic control group had complications. They concluded that in the older, diabetic patient with lower demands, especially if insulin-dependent, it may be preferable to accept a loss of reduction and malunion rather than risk the potentially devastating complications associated with operative intervention. If surgery is necessary, the results of this study provides a more accurate prognosis and allows for better discussion of surgical risks with the patient.
Roseunbaum et al polled AOFAS members on the treatment of diabetic ankle fractures. (1) For nondisplaced bimalleolar fracture with diabetic neuropathy, respondents preferred casting and nonweightbearing (NWB) for 8-12 weeks. (2) For Weber B fracture dislocation without neuropathy, without syndesmotic injury,
respondents preferred either 1/3 tubular or small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks. (3) For bimalleolar fracture dislocation with neuropathy, without syndesmotic injury, respondents preferred small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks.
Wukich and Kline reviewed the management of ankle fractures in diabetics. They found that neuropathy is more prevalent in patients with ankle fractures than without. They stress that 1% reduction in HbA1C results in 30% reduction in complication rate. Fracture healing is slower, callus is smaller, with less stiffness, tensile strength and collagen content. Amputation rate is up to 5% for patients treated operatively or nonoperatively. Complications are higher in patients with vasculopathy, neuropathy, or Charcot arthropathy.
Incorrect Answers:

Question 3

Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate treatment option?

Explanation

EXPLANATION:
This patient sustained a lesser-arc perilunate dislocation. As a result of the injury, he also developed acute carpal tunnel syndrome. The closed reduction attempt was unsuccessful; therefore, this injury is best managed with emergent surgery, an open carpal tunnel release, an open reduction of the perilunate dislocation, scapholunate ligament repair, and intercarpal pinning. Outpatient surgery in a delayed fashion is not advised because of the acuity and severity of the carpal tunnel syndrome. Closed reduction and casting is not advised, because it commonly leads to continued carpal instability with subsequent dorsal
intercalated segment instability deformity and scaphoid lunate advanced collapse wrist arthritis.

Question 4

A cortisone injection in the subacromial space will most likely result in

Explanation

DISCUSSION: A cortisone injection in the subacromial space will most likely result in elevated blood glucose levels in patients with type I diabetes mellitus. Patients should be warned of this potential complication. Cortisone does not have an effect on instability or proprioception, and a single injection would not affect osteoporosis. Repetitive injections or injection into the tendon itself could accelerate rupture of the biceps tendon.
REFERENCES: Matsen FA III, Arntz CT: Subacromial impingement, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 623-646.
Koehler BE, Urowitz MB, Killinger DW: The systemic effects of intra-articular corticosteroid. J Rheumatol 1974;1:117-125.

Question 5

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

Explanation

DISCUSSION: CT of the abdomen and pelvis is not part of the staging of osteosarcoma. Staging studies should consist of CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan. The MRI should be obtained prior to the biopsy.
REFERENCE: O’Reilly R, Link M, Fletcher B, et al: NCCN pediatric osteosarcoma practice guidelines: The National Comprehensive Cancer Network. Oncology (Huntingt) 1996;10:1799-1806, 1812.

Question 6

A newborn girl with an isolated unilateral dislocatable hip is placed in a Pavlik harness with the hips flexed 100 degrees and at resting abduction. Figure 23 shows an ultrasound obtained 2 weeks later. What is the next step in management? Review Topic

Explanation

The infant has a well-positioned hip in the Pavlik harness and treatment should be continued in the current position. The success rate is over 90% with the use of this device for a dislocatable hip. Ultrasound is a useful tool to confirm appropriate positioning of the cartilaginous femoral head during treatment. If the femoral head is
not reduced after 2 to 3 weeks in the harness, this mode of treatment should be abandoned. Forceful extreme abduction can cause osteonecrosis of the femoral epiphysis and should be avoided. Closed reduction, arthrography, and spica casting are indicated if the hip cannot be maintained in a reduced position with the harness.

Question 7

Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Explanation

[Radiograph: Well positioned G-H joint. Mild degenerative changes.]
Late onset of pain (average 13 years) was noted following this procedure in a small number of patients. The pain is attributed to excessive G-H compressive forces due to limited external rotation. NSAIDS and PT are first line treatments. If these fail, the authors demonstrated good results with release of the anterior structures. Choices 3 & 4 would probably be reserved for patients older than 50 with more advanced signs of degenerative disease.

Question 8

A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

Explanation

Absolute stability with direct healing by callus formation
Relative stability with indirect healing by callus formation
Absolute stability with direct healing by internal remodeling
Relative stability with indirect healing by internal remodeling
Absolute stability with endochondral bone formation
Definitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole

Question 9

What is the most likely long-term sequela of the injury shown in Figures 47a and 47b?

Explanation

DISCUSSION: The imaging studies show a comminuted lateral talar process fracture. This injury is often missed on plain radiographs; therefore, CT provides the best method of diagnostic evaluation. The most likely long-term sequela of this injury is subtalar joint arthrosis. Although this injury involves the fibular gutter region, progression to true ankle arthritis is unlikely. There does not appear to be any association with this injury and chronic mechanical instability of the ankle or disruption of the superior peroneal retinaculum and subsequent peroneal tendon instability. Entrapment of the flexor hallucis longus tendon may occur with fractures of the sustentaculum tali but not with injuries of the lateral talar process. Surgical management includes open reduction and internal fixation versus excision; the goal is preservation of the large articular surface fragments. In this patient, there is significant comminution and early fragment excision may be the best option for acute treatment.
REFERENCES: Tucker DJ, Feder JM, Boylan JP: Fractures of the lateral process of the talus: Two case reports and a comprehensive literature review. Foot Ankle Int 1998;19:641-646.
Sanders R: Fractures and fracture-dislocations of the talus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1465-1518.

Question 10

A patient undergoes a proximal tibial resection that is reconstructed with a fresh frozen osteoarticular allograft. Eleven months later, the graft is retrieved. Histologically, the articular cartilage and subchondral bone retrieved would be expected to show evidence of

Explanation

DISCUSSION: Osteoarticular allografts are devoid of host chondrocytes but do contain “mummified” cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact.
REFERENCES: Enneking WF, Campanacci DA: Retrieved human allografts:

A clinicopathological study. J Bone Joint Surg Am 2001;83:971-986.
Enneking WF, Mindell ER: Observations on massive retrieved human allografts.

J Bone Joint Surg Am 1991;73:1123-1142.

Question 11

-Postsurgically, the patient recovers well and is fully rehabilitated. He demonstrates full motion with no instability or pain and is cleared to return to play 12 months after the surgery. He asks for your advice regarding use of a functional brace for playing basketball following his reconstruction. What is the most appropriate recommendation?

Explanation

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 12

A 16-year-old cheerleader reports an ache in the right shoulder and arm that is worse after activity. She denies any history of acute trauma. Examination reveals a positive sulcus sign and an AP glide test with a posterior and anterior apprehension sign. To confirm a diagnosis of multidirectional instability, which of the following imaging studies is most appropriate?

Explanation

DISCUSSION: Multidirectional instability is a common finding in young female athletes. The anatomic structures are all intact but are hypermobile; therefore, CT and bone scans and scapular Y-views are often normal. Obtaining a weighted or AP stress view while applying downward traction on the arm will document instability and hypermobility of the joint. MRI generally is not indicated in this condition. Ultrasound is used primarily for rotator cuff pathology.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
Warner JJ, Johnson D, Miller M, Caborn DN: Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability. J Shoulder Elbow Surg 1995;4:352-364.

Question 13

A 38-year-old man is being considered for medial meniscus transplantation following an arthroscopic subtotal meniscectomy performed at the time of ACL reconstruction. His body mass index (BMI) is 28kg/m2. Laboratory tests are shown in Figure A. Standing long-leg radiographs reveal a 4 degree valgus deformity compared with the contralateral side, with the weightbearing line running through the lateral tibial spine. His arthroscopic photos also revealed a 1.7cm wide Outerbridge II chondral lesion over the lateral femoral condyle and synovitis. What factor in this patient is an absolute contraindication to meniscal transplantation? Review Topic

Explanation

This patient has rheumatoid arthritis. Inflammatory arthritis is an absolute contraindication to meniscal transplantation.
Besides inflammatory arthritis, other absolute contraindications include diffuse arthritis, Outerbridge grade IV changes, untreated tibiofemoral subluxation, synovial disease, previous joint infection, skeletal immaturity, or marked obesity.
Lee et al. reviewed meniscal transplantation. They recommend meniscal transplantation only after nonoperative measures (unloading braces, weight loss, activity modification, analgesia) have failed. Indications include young patients (<50yo) with symptoms referable to a meniscus-deficient tibiofemoral compartment, with a stable knee with normal alignment, with intact articular surfaces (grade I or II).
Figure A is a table showing this patient's lab results. He has positive RF and anti-CCP antibody. In addition, he has synovial changes on arthroscopy. These findings are significant for active RA.
Incorrect Answers:
Meniscus transplantation can be attempted if cruciate ligament deficiency was addressed, or there are plans for concurrent or staged reconstruction. Answer 3: Varus/valgus malalignment is not an absolute contraindication although concurrent/staged treatment is necessary to correct alignment. Answer 4: Outerbridge Grade I and II chondral defects are not contraindications. Knees with Outerbridge III lesions may still be considered if defects are focal and concomitant treatment is performed. Answer 5: Marked obesity is a contraindication. This is not present in this individual.

Question 14

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Explanation

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 15

A 40-year-old man with a history of Legg-Calve-Perthes disease underwent a right hip resurfacing 3 years ago with no perioperative complications. Hip pain has developed gradually during the last 4 months. Radiographs show no evidence of fixation loosening or any adverse changes at the femoral neck. No periarticular osteolysis is evident. A large intra-articular and intrapelvic pseudotumor has developed. What predominant histological feature(s) is/are present in such a lesion?

Explanation

DISCUSSION:
Controversy persists over what exactly is the best approach to managing patients with metal-on-metal (MOM) hip arthroplasties. All patients with painful MOM hip arthroplasties should be examined for fixation loosening, wear/osteolysis, and infection—no differently than patients without MOM hip arthroplasties. It is recommended to obtain serum trace element levels. If the levels are high, cross- sectional imaging should be obtained to determine whether any pseudotumor or tissue necrosis is present around the hip arthroplasty. Hip aspiration should be considered if concern for infection exists. Adverse tissue reaction has been identified to occur around MOM hip arthroplasties. The predominant histologic
feature is tissue necrosis with infiltration of lymphocytes and plasma cells.

Question 16

Examination of a 4-year old child with obstetrical palsy reveals weak deltoids, pectoralis major strength of 4-5, and normal hand function. External rotation of the shoulder is limited. What is the most appropriate surgical procedure to restore external rotation?

Explanation

DISCUSSION: Transfer of the latissimus dorsi and teres major to the posterior rotator cuff will restore external rotation and some abduction. The procedure should be performed in children who are approximately age 4 years, following spontaneous recovery and prior to significant stiffness. External rotation osteotomy is more appropriate for an older child. Fusion should not be performed until skeletal maturity. Distal biceps rerouting restores pronation for a supination deformity. Latissimus dorsi and teres major transfer to the subscapularis would accentuate the internal rotation. In younger patients without significant bony deformity, a subscapularis slide or lengthening can restore external rotation.
REFERENCES: Strecker WB, McAllister JW, Manske PR, Schoenecker PL, Dailey LA: Sever-L’Episcopo transfers in obstetrical palsy: A retrospective review of twenty cases. J Pediatr Orthop 1990;10:442-444.
Hoffer MM, Wickenden R, Roper S: Brachial plexus birth palsies. J Bone Joint Surgery Am 1978;60:692-695.

Question 17

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Explanation

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882. View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219. View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 18

A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status?

Explanation

The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing.
Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates.
Brumback et al evaluated the feasibility, safety and efficacy of immediate
weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred.
OrthoCash 2020

Question 19

A 10-lb, 2-oz infant who was born via a difficult breech delivery 12 hours ago is now being evaluated for hip pain. Although the infant is resting comfortably, examination reveals that the patient is not moving the right lower extremity and manipulation of the right hip causes the infant to cry. The Galeazzi sign is positive. An AP radiograph of the pelvis shows proximal and superior migration of the right proximal femoral metaphysis. What is the most likely diagnosis?

Explanation

DISCUSSION: Transphyseal fractures of the proximal femur at birth are more likely to occur in large newborns after a difficult delivery. At rest, the patients are comfortable and show a pseudoparalysis; however, passive motion of the lower extremity results in discomfort. Teratologic hip dislocations will have a positive Galeazzi sign, but are not painful. Development of a septic hip would be unlikely within 12 hours postpartum. Congenital coxa vara is typically painless. Postpartum ligamentous laxity might account for a positive Ortolani sign, but is painless.
REFERENCES: Weinstein JN, Kuo KN, Millar EA: Congenital coxa vara: A retrospective review. J Pediatr Orthop 1984;4:70-77.
Beaty JH: Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 409-425.

Question 20

A 52-year-old, right hand dominant man comes for evaluation of right shoulder pain that has been intermittently bothering him for three months. The pain is worse with overhead activities. He denies any history of trauma. His range of forward elevation in the plane of the scapula is painful and is limited to 145 degrees, compared to 170 degrees on his unaffected side. A radiograph is shown in Figure A. He saw another orthopedist a month ago, who ordered an MRI, which showed a small, partial thickness supraspinatus tendon tear. He received a subacromial injection of lidocaine at that time which temporarily relieved 90 percent of the pain he felt with passive forward elevation of his shoulder past 90 degrees. Today he is requesting a subacromial injection of platelet rich plasma (PRP). You tell him that with regard to pain, function and range of motion, subacromial injection of PRP: Review Topic

Explanation

At one year, quality of life, pain, disability and shoulder range of motion are the same for patients treated with therapy and placebo versus patients treated with therapy and
PRP injection.
Platelet rich plasma has been used for the treatment of chronic tendinopathy in different areas with mixed results. No benefit to patients with symptoms of subacromial impingement has been demonstrated for subacromial injection of PRP, when added to a standard therapy program.
Kesikburun et al. conducted a randomized controlled trial in which patients with rotator cuff tendinopathy or partial rotator cuff tears were randomized to receive ultrasound-guided subacromial injection of either PRP or lidocaine, followed by a standard six-week therapy program. The authors found no difference in pain, range of motion or validated outcome scores at one year follow up.
Hall et al. reviewed sports medicine applications for PRP. At that time (2009), with regard to PRP, they concluded that there was "little clinical evidence for its use."
Ketola et al. sought to determine the effectiveness of subacromial decompression for the treatment of subacromial impingement syndrome. They randomized 140 patients to a supervised exercise program or arthroscopic subacromial decompression followed by a supervised exercise program. They found no clinically important differences between the two groups at 24 months follow up.
Figure A shows a right shoulder radiograph without osseous pathology. Incorrect answers:

Question 21

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Explanation

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.View Abstract at PubMed

Question 22

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 23

During a Lisfranc (tarsometatarsal) amputation of the foot, which of the following is crucial to prevent the patient from having a supinated foot during gait.

Explanation

DISCUSSION: A Lisfranc amputation is through the tarsometatarsal joints, except the 2nd metatarsal, which is osteotomized to preserve the stability of the medial cuneiform. To prevent the patient from supinating the foot following this amputation, the evertors on the foot must be maintained. The principal evertors are the peroneus brevis and longus (Illustration A). Therefore, the function of the peroneus brevis must be preserved. Technically this is done preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base.
Illustration B depicts the level of a Lisfranc amputation of the foot. Incorrect Answers:
The posterior tibialis is the primary supinator of the foot, and releasing it would lead to an eversion deformity. The tibialis posterior tendon attachment to the bases of the second and third metatarsals will actually be released with this amputation, but the main attachment to the navicular preserved. 3-The anterior tibialis dorsiflexes and inverts the foot, but transferring it to the medial and middle cuneiforms would mimick its native function to dorsiflex and invert the foot. 4-A lengthened Achilles would lead to increased dorsiflexion, not supination. 5-Osteotomy of 2nd MT is crucial to preserve the medial cuneiform and midfoot stable.

Question 24

An active 23-year-old man has right groin pain that increases with sports activity. Examination reveals decreased internal rotation of the affected hip. He has a positive impingement test and radiographs reveal no crossover sign. An MRI scan is most likely to reveal which of the following? Review Topic

Explanation

Young patients with hip pain and a positive impingement test are likely to have femoroacetabular impingement. The triad seen in these patients is a reduced concavity at the femoral head-neck junction, which leads to an increase in alpha angle and a chondrolabral tear. MR-arthrogram is the cross-sectional imaging modality of choice. These patients usually have reduced internal rotation and a positive impingement sign. The other findings, though possible, are not the most likely scenario in this young and active patient.

Question 25

-Figures 14a through 14d are the radiographs and sagittal T1- and T2-weighted MRI scans of an otherwise healthy 10-year-old girl who has experienced 3 weeks of worsening pain with weight bearing and is now refusing to bear weight to either of her lower extremities. She denies any history of injury or trauma.She has not had any fevers or recent illnesses. She denies any numbness or parasthesias. She has had no bowel or bladder incontinence. In the emergency department she is afebrile and tender to palpation over the midlumbar spine. She has pain with hyperextension and flexion of her back. Her white blood cell count is 11.4 (reference range, 4.5-11.0 x109/L), erythrocyte sedimentation rate is 40 mm/h (reference range, 0-20 mm/h), and C-reactive protein is 2.6 mg/L (reference range, 0.08-3.1 mg/L). What is the most appropriate course of action at this time?

Explanation

Question 26

An 80-year-old African American woman who lives in a large city is scheduled for total hip arthroplasty to address primary osteoarthritis. Part of the presurgical protocol includes nasal swab screening to assess for methicillin-resistant Staphylococcus aureus (MRSA) colonization. Which demographic factor places this patient at highest risk for a positive result?

Explanation

DISCUSSION:
Demographic factors are associated with increased risk for MRSA colonization, so it is important to identify vulnerable patients. Female gender and advanced age reduce the risk for colonization, whereas African American race increases this risk. Urban environments do not influence MRSA colonization.

Question 27

An 18-year-old hockey player sustains an acute anterior shoulder dislocation that requires manual reduction. At arthroscopy, the lesion shown in Figure 24 will be observed in what percent of patients?

Explanation

DISCUSSION: The clinical photograph shows an acute capsulolabral avulsion from the anterior glenoid, also referred to as a Perthes-Bankart lesion. In patients who sustain an acute dislocation that requires a manual reduction, this pathologic lesion is observed with high frequency. In several research studies, it has been visualized in 80% to 95% of patients at arthroscopy.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
Baker CL, Uribe JW, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18:25-28.

Question 28

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

Explanation

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have

shown some healing response with callus formation, but these techniques are not successful

in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions

of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 29

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Explanation

DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment.
REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.

Question 30

A Canale view best visualizes which of the following structures?

Explanation

DISCUSSION: The Canale view, which visualizes the talar neck, is taken with the ankle in maximum plantar flexion and the foot pronated 15°. The radiograph is directed at a 75° angle from the horizontal plane in the anteroposterior plane. The Broden view, which is different from the Canale view, is best for imaging the posterior facet of the subtalar joint.
REFERENCES: Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156.
Bruden B: Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol 1949;31:85-91.

Question 31

A 36-year-old woman was injured in a train derailment. She has a significant open depressed skull fracture with active bleeding, a hemopneumothorax, and blood in the left upper quadrant and colic gutter by Focused Assessment with Sonography for Trauma (FAST) examination. Additionally, she has the pelvic injury seen on the CT scans in Figures 18a and 18b. The mortality rate for this patient approaches

Explanation

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.

J Trauma 1982;22:691-693.

Question 32

A 55-year-old woman is referred for evaluation of a painful knee replacement. She underwent total knee arthroplasty (TKA) more than 1 year ago without perioperative complications but has had consistent pain since the surgery. The patient’s preoperative radiographs and postoperative radiographs are shown in Figures below. Examination reveals medial laxity during valgus stress testing and range of motion of 0° to 70°. Her erythrocyte sedimentation rate and C-reactive protein level are normal. What is the best next step?

Explanation

DISCUSSION:
The radiographs show substantial valgus malalignment of the femoral component, with lateral mechanical axis deviation. Clinically, by examination she displays instability and stiffness as a result. Revision knee replacement is appropriate and should consist of total revision to stemmed femoral and tibial components with a varus-valgus constrained insert, given the likely attenuation of the medial collateral ligament. Open debridement with ligament balancing and polyethylene exchange do not address the underlying cause and are inappropriate. Distal femoral osteotomy is not useful in the setting of previous total knee replacement. Nonsurgical treatment with an unloader brace would be ineffective in correcting the alignment.

Question 33

A 12-year-old boy reports knee discomfort after prolonged strenuous activities. He denies knee swelling or catching and has no pain with activities of daily living. A radiograph is shown in Figure 4. Prognosis for the pathology shown is most influenced by

Explanation

DISCUSSION: While many factors play a role in the outcome of osteochondritis dissecans, ample evidence has shown that the prognosis is most influenced by the growth status of the plates. If the growth plates are open, the chance of a successful outcome is significantly greater than if they are closed.
REFERENCES: Federico DJ, Lynch JK, Jokl P: Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197.
Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study. J Bone Joint Surg Am 1977;59:769-776.

Question 34

A 53-year-old woman reports a 4-month history of gradual onset diffuse shoulder pain and limited function. She has had no prior treatment, and her medical history is unremarkable. Examination reveals globally painful active range of motion to 120 degrees forward elevation, 25 degrees external rotation with the arm at the side, and internal rotation to the sacrum. Passive range of motion is also limited in comparison with the contralateral shoulder. Radiographs are shown in Figures 31a through 31c. What is the most appropriate management? Review Topic

Explanation

The patient has stage II adhesive capsulitis. Patients most commonly affected are women between the ages of 40 and 60, and most cases are considered idiopathic. The preferred method of treatment is an intra-articular corticosteroid injection to decrease inflammation in the joint and allow for a gentle stretching therapy program. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. Aggressive capsular stretching in the early stages of the disease is often counterproductive, unless pain can be adequately controlled with medication or injections. Manipulation under anesthesia and arthroscopic surgical treatment are used when symptoms remain refractory despite initial nonsurgical management.

Question 35

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management? Review Topic

Explanation

Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.

Question 36

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 37

Cell signaling through the activation of a transmembrane receptor complex formed by serine/threonine kinase receptors occurs with which of the following growth factors?

Explanation

DISCUSSION: Cell activation and transcription varies with the target cell, the growth factor-receptor combination, and the biologic state of the cell. The growth factors in the transforming growth factor-beta (TGF-β) superfamily signal through serine/threonine kinase receptors. Fibroblast growth factors, insulin-like growth factors, and platelet-derived growth factors signal through tyrosine kinase receptors. Growth hormone is released by the pituitary and circulates to the liver where target cells are stimulated to release insulin-like growth factor.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Schmitt JM, Hwang K, Winn SR, et al: Bone morphogenetic proteins: An update on basic biology and clinical relevance. J Orthop Res 1999;17:269-278.

Question 38

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Explanation

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 39

Survival rates for children with soft-tissue sarcoma other than rhabdomyosarcoma are best correlated with

Explanation

DISCUSSION: In review of 154 patients with nonrhabdomyosarcoma, Rao reported that histologic grade, tumor invasiveness, and adequate surgical margin were the most important prognostic factors. Histologic subtype, use of adjuvant chemotherapy, and patient age were not as important. Size related to degree of invasiveness was not statistically significant.
REFERENCES: Rao BN: Nonrhabdomyosarcoma in children: Prognostic factors influencing survival. Semin Surg Oncol 1993;9:524-531.
Andrassy R, et al: Non-rhabdomyosarcoma Soft-Tissue Sarcomas: Pediatric Surgical Oncology. Philadelphia, PA, WB Saunders, p 221.

Question 40

A 70-year-old healthy man had total knee arthroplasty 18 years ago, and it now is painful. Radiographs reveal aseptic loosening and the range of motion before surgery is 15 to 85 degrees. The strongest indication for performing a tibial tubercle osteotomy to aid in exposure in his knee would be

Explanation

Question 41

A 65-year-old man has a painful and often audible crepitus after undergoing a total knee arthroplasty 8 months ago. His symptoms are reproduced with active extension of about 30°. Examination reveals no effusion or localized tenderness, a stable knee, and a range of motion of 5° to 120°. Radiographs are shown in Figures 37a and 37b. Management should consist of

Explanation

DISCUSSION: This is a typical presentation of the patellar clunk syndrome. The syndrome usually follows implantation of a posterior stabilized prosthesis. It is thought to be the result of femoral component design and altered extensor mechanics. The condition usually resolves with arthroscopic debridement of the suprapatellar fibrous nodule. Arthrotomy or revision is seldom warranted.
REFERENCES: Beight JL, Yao B, Hozack WJ, Hearn SL, Booth RE Jr: The patellar “clunk” syndrome after posterior stabilized total knee arthroplasty. Clin Orthop 1994;299:139-142.
Lintner DM, Bocell JR, Tullos HS: Arthroscopic treatment of intra-articular fibrous bands after total knee arthroplasty: A follow-up note. Clin Orthop 1994;309:230-233.

Question 42

82 • American Academy of Orthopaedic Surgeons A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 43

Figures below depict the radiographs obtained from a 76-year-old woman who comes to the emergency department after experiencing a fall. She is an unassisted community ambulator with a history of right hip pain. What is the most appropriate surgical treatment for this fracture?

Explanation

DISCUSSION:
This patient has pre-existing right hip osteoarthritis. The most correct option for the treatment of this active patient is a right total hip arthroplasty. Hemiarthroplasty would not address the patient's pain from osteoarthritis, and open reduction and internal fixation would not fix the femoral head issue or the
osteoarthritis.

Question 44

Which of the following procedures is associated with the highest risk of osteonecrosis of the metatarsal head?

Explanation

1 – Complications of distal chevron osteotomy with soft tissue release are incomplete correction and avascular necrosis (1 – 2%). 2 – Complications of distal soft tissue realignment only are recurrence of deformity, inadequate lateral release, are hallux varus. 3 – Complications of the Aken procedure are an increase in the hallux valgus deformity. 4 ,5 – Complications of proximal first metatarsal osteotomy are hallux varus and shortening.

Question 45

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

Explanation

DISCUSSION: The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.

Question 46

A 27-year-old professional rugby player is sprinting down the field during a game and sustains a twisting injury to his right knee with immediate onset of swelling, pain, and difficulty with ambulation. Imaging of his right knee is demonstrated in Figures A, B, and C. Which of the following structures has most likely been injured? Review Topic

Explanation

The rugby player has sustained an injury to his anterior cruciate ligament (ACL), as demonstrated by the Segond fracture on radiograph and bone-bruising pattern on magnetic resonance imaging (MRI).
The ACL is the most commonly injured knee ligament, with an incidence of between
100,000 and 200,000 ruptures per year in the United States. The majority of ACL tears occur from non-contact athletic injuries. Acute ACL tears are associated with lateral meniscal tears. Physical examination findings include positive Lachman and Pivot shift tests. Imaging includes radiographs which are usually normal; however, the presence of a Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL rupture and represents bony avulsion by the anterolateral ligament (ALL). MRI demonstrates bone bruising of the middle third of the lateral femoral condyle (sulcus terminalis) and posterior third of the lateral tibial plateau in more than 50% of acute ACL tears.. Bone bruise patterns correlate with the direction of the abnormal anterior translation and abutment of the posterolateral tibia against the middle third of the lateral femur during the injury. Treatment options include nonoperative management with physical therapy and lifestyle modification or operative intervention if failure of conservative measures.
Bathala et al present a radiologic case study of a Segond fracture visualized on AP radiograph of the knee of a patient who sustained an ACL rupture. They discuss the critical nature of this finding and the need for further imaging, as it is associated with ACL tears, meniscal tears, and damage to structures in the posterolateral corner.
Viskontas et al discuss different patterns of bone bruising demonstrated on MRI in acute anterior cruciate ligament ruptures of 100 patients, 86 with non-contact and 14 with contact injuries. They found that the non-contact mechanism correlates with more severe bone bruising in both the medial and lateral compartments as demonstrated on MRI.
Figures:
Figure A - AP radiograph of the knee that demonstrates a Segond fracture Figures B and C - coronal T1 and T2 MRI slices that demonstrate bone bruising of the middle third of the lateral femoral condyle and posterior third of the lateral tibial plateau
INCORRECT ANSWERS:

Question 47

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of

Explanation

DISCUSSION: The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis.
REFERENCES: Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.
Post WR: Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999;15:841-851.

Question 48

A 27-year-old man has had pain in the right index finger for the past 9 months. The pain is completely relieved with ibuprofen. An AP radiograph and CT scan are shown in Figures 80a and 80b. What is the most likely diagnosis?

Explanation

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a

radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic

features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 49

A 31-year-old man sustained an unstable closed left posterior hip dislocation in a motorcycle accident. A postreduction radiograph is shown in Figure 51a. 3-D CT scans are shown in Figures 51b and 51c. What is the optimal surgical approach that will allow for the most appropriate treatment?

Explanation

The radiograph and CT scans show a posterior wall acetabular fracture with an associated femoral head fracture. As is the case in most of these injuries, the femoral head fracture is located on the anterior aspect of the femoral head. Surgical dislocation with a trochanteric flip osteotomy as described by Solberg and associates and Henle and associates allows for exposure and treatment of the posterior wall fracture as well as surgical dislocation for treatment of the femoral head fracture. A Smith-Peterson approach or Watson-Jones approach would allow for anterior exposure and may help to address the femoral head fracture, but not the posterior wall fracture. A Kocher-Langenbach approach would allow exposure of the posterior wall fracture, but not the femoral head fracture. An extensile iliofemoral approach is unnecessary for this injury pattern.

Question 50

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Explanation

DISCUSSION: The MRI scan reveals a full-thickness rotator cuff tear with retraction and increased signal in the subacromial space indicating joint fluid.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.

Question 51

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 52

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle?

Explanation

DISCUSSION: The clinical picture reveals medial scapular winging, which involves the serratus anterior muscle, potentially due to an injury to the long thoracic nerve that innervates this muscle. Injury to the long thoracic nerve is usually due to closed trauma, direct compression, traction or stretching injury, a direct blow, or, very rarely, viral infection such as Parsonage-Tumer syndrome. The nerve is easily injured in surgical dissection of the axilla, and is predisposed to injury due to its relatively long course, it is small in diameter, and it has little surrounding connective tissue. If rehabilitation and time are unsuccessful, both nerve and muscle transfers have been described with mixed results.
REFERENCES: Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res 1999;368:17 -27.
Warner JJ, Navarro RA: Serratus anterior dysfunction: Recognition and treatment. Clin Orthop Relat Res 1998;349:139-148.

Question 53

A 53-year-old woman has severe neck and left shoulder pain after a rollover motor vehicle accident. Radiographs and a CT scan of the cervical spine are shown in Figures 34a through 34c. Management should consist of

Explanation

DISCUSSION: The plain radiographs show a horizontal orientation of the C5 facet joint. The CT scan through C5 reveals an ipsilateral pedicle and lamina fracture (floating facet). This injury involves two adjacent motion segments and is extremely unstable. Lateral mass plates, with or without the purchase of the “floating facet,” provide the best means of stabilization and should include the facet above (C4) and below (C6) the level of injury. Orthotic immobilization is insufficient for this particular injury. Halo vest treatment does not control the subaxial spine well and is of limited value. While simple midline (Rogers) wiring provides some tension band restoration, it is not optimal for rotational control. The use of lateral mass plates provides rotational stability. Another option would be anterior fusion and plating, which would save cervical segments.
REFERENCES: Levine AM, Mazel C, Roy-Camille R: Management of fracture separations of the articular mass using posterior cervical plating. Spine 1992;17:S447-S454.
Levine AM: Facet fractures and dislocations, in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 360-362.
Whitehill R, Richman JA, Glaser JA: Failure of immobilization of the cervical spine by the halo vest: A report of five cases. J Bone Joint Surg Am 1986;68:326-332.
Garvey TA, Eismont FJ, Roberti LJ: Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations. Spine 1992;17:S431-S435.

Question 54

A displaced pediatric supracondylar humerus fracture is treated with closed manipulation and placement of 2 Kirschner wires placed from the lateral side. What would be the effect of adding a third pin from the lateral side? Review Topic

Explanation

Multiple biomechanical studies have shown that the addition of a third pin from the lateral side improves construct stiffness in the presence of medial column loss or slight internal rotation of the distal fragment. The same studies show that addition of a medial pin (cross pinning) has essentially the same benefit. Placement of a medial pin increases risk for iatrogenic nerve injury.

Question 55

Which of the following treatments for osteoporosis is a direct inhibitor of RANK ligand (RANK-L)?

Explanation

Prolia, or denosumab, is a newly approved drug used to treat osteoporosis and has a mechanism of action similar to osteoprotegerin (inhibits binding of RANKL to RANK).
RANKL (Receptor activator of nuclear factor kappa-B ligand) is a key molecule for osteoclast differentiation and activation. Inhibition of RANKL activity with anti-RANKL antibody reduces osteoclastogenesis, resulting in inhibition of bone resorption.
Capozzi et al. author a review article on denosumab. They state the medication confers improved bone mineral density and prevents new fragility fractures similar to alendronate. However, denosumab presents less risk of atypical femoral fractures and
osteonecrosis of the jaw.
Yasuda et al. present a review that details the creation of three elegant animal models to mimic metabolic bone disease and how the animal models can create a template to help cure human metabolic bone disease. These enable modeling of osteoporosis, hypercalcemia, and osteopetrosis by treating normal mice with soluble RANKL (sRANKL), adenovirus expressing sRANKL, and anti-mouse RANKL neutralizing antibody, respectively. They report that these animal models can be established in about 14 days using normal mice.
Illustration A demonstrates the mechanism of action of bisphosphonates and denosumab.
Incorrect Answers:
1: Romosozumab is the first humanized anti-sclerostin monoclonal antibody that has been demonstrated to increase bone formation. 2: Zoledronic acid (Reclast) is a nitrogen containing bisphosphonates that inhibits osteoclast resorption by inhibiting the enzyme farnesyl diphosphate synthase. 4: Teriparatide (Forteo) comprises the first 34 amino acids of the 84 amino acid parathyroid hormone (PTH) and can reproduce the primary effects of PTH by activating adenyl cyclase. 5: Blosozumab is an investigational monoclonal anti-sclerostin antibody showing osteoanabolic properties with the potential to improve clinical outcomes in patients with osteoporosis.

Question 56

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

Explanation

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of

the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 57

You perform an ACL reconstruction with bone-patella tendon-bone (BTB) autograft and are explaining the postoperative rehabilitation protocol to your patient. Which of the following is associated with increased quadriceps volume and improved quadriceps strength at 1 year without a higher risk of knee instability? Review Topic

Explanation

Early eccentric strengthening following ACL reconstruction has been associated with increased quadriceps volume and improvement in strength at 1 year without a higher risk of knee laxity.
Proper rehabilitation following ACL reconstruction is vital to a successful outcome. The cornerstone of ACL rehabilitation is range of motion, strengthening and functional exercises without risk of destabilizing the knee. There are a variety of rehabilitation protocols and recently an effort has been made to standardize the approach to postoperative ACL care. An accelerated protocol starting at 3 weeks postoperatively has been deemed safe and may enhance the speed and safety with which an athlete returns to play.
Kruse et al completed a meta-analysis of 29 Level I and II studies focused on the ACL rehabilitation process. The authors concluded that immediate postoperative weightbearing and knee range of motion 0-90 is safe. Early eccentric strengthening appears to accelerate and improve strength gains at 1 year as compared to delayed eccentric strengthening. Home-based rehabilitation programs can be as effective as formal physical therapy. Postoperative bracing and CPM use is neither necessary nor beneficial.
Van Grinsven et al conducted a systematic review of ACL rehabilitation programs and physical therapy modalities to develop an evidence-based rehabilitation protocol. The authors demonstrated that an accelerated protocol without postoperative bracing focused on reduction of pain, swelling and inflammation and regaining range of motion, strength and neuromuscular control has significant advantages and does not lead to stability problems.
Gerber et al performed a randomized trial comparing two accelerated postoperative rehabilitation protocols – early eccentric (ECC) rehabilitation versus traditional (TRAD) rehabilitation starting at 3 weeks. There were no significant differences in knee pain, effusion or stability. However, quadriceps strength, hopping distance and activity level improved by a significantly greater amount in the ECC group versus the TRAD group at 26 weeks postoperatively. In a separate analysis of these patients, quadriceps and gluteus muscle cross-sectional area and volume in ECC patients were more than twice those in the TRAD group.
Illustration A depicts two eccentric ergometers that can be used in postoperative ACL rehabilitation.
Incorrect Responses:
another Answer
type of brace,
2:
There
duration is
of
bracing or no bracing at all.
no
advantage
to
CPM
use.

Question 58

Figure 3 shows the clinical photograph of a wrestler who has an acute mass in his ear. He does not wear protective headgear. The area is mildly tender and without erythema. Management should consist of

Explanation

DISCUSSION: The patient has an auricular hematoma. This injury is typically related to blunt trauma, occuring in wrestlers who do not use protective headgear. The goal of treatment is to remove the fluid, reapproximate the perichondrium to the underlying articular cartilage, and limit reaccumulation of the fluid in attempt to prevent cartilage necrosis. Aspiration and application of a compressive dressing offers the best chance to achieve this goal. There are no signs of infection such as marked tenderness, erythema, or surrounding edema to justify antibiotic use or irrigation and debridement. The mass does not warrant excision.
REFERENCES: Kaufman BR, Heckler FR: Sports-related facial injuries. Clin Sports Med 1997;16:543-562.
Griffin CS: Wrestler’s ear: Pathophysiology and treatment. Ann Plastic Surg 1992;28:131-139.

Question 59

Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

Explanation

DISCUSSION: The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
REFERENCES: Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.
Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.

Question 60

-A 23-year-old man had a laparotomy and splenectomy with packing of the abdomen after a motorcycle collision. Laboratory studies show a hemoglobin level of 7.1 g/dL (reference range [rr], 14.0-17.5 g/dL) and a lactate level of 8.0 mmol/L (rr, 0.6-1.7 mmol/L). He also has a left humeral fracture,an anteroposterior compression I pelvic fracture, bilateral distal third femur fractures, and an open GustilotypeIIIA tibial diaphysis fracture with moderate contamination. What is the most appropriate treatment to administer before leaving the operating room?

Explanation

Question 61

Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing total contact casts. The deformity does not correct passively. Dorsalis pedis and posterior tibial pulses are palpable. The patient is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. The ulcer is currently healed. What is the best option to prevent recurrent ulceration and infection?

Explanation

DISCUSSION: This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear.
REFERENCES: Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.
Pinzur M: Surgical versus accommodative treatment for Charcot arthropathy of the midfoot.

Foot Ankle Int 2004;25:545-549.

Question 62

What muscle attaches to the site shown by the arrow in Figure 2?

Explanation

DISCUSSION: The latissimus dorsi inserts on the humerus metaphysis between the pectoralis major (posterior) and teres major (anterior). Teres minor inserts on the base of the greater tuberosity. Pectoralis minor does not insert on the humerus.
REFERENCES: Williams PL, Warwick R, Dyson M, Bannister LH: Neurology, in Gray’s Anatomy, ed 37. Edinburgh, Scotland, Churchill Livingstone, 1989, pp 1131-1132.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 131-132.

Question 63

Which of the following statements is correct regarding Vitamin D?

Explanation

24,25-dihydroxycholecalciferol in an inactive form of Vitamin D. High levels of 1,25-dihydroxyvitamin D stimulate the enzymatic production of 24,25-dihydroxyvitamin D, the inactive form of vitamin D, thereby self-regulating the action of 1,25-dihydroxyvitamin D.
Vitamin D is paramount to proper calcium homeostasis and has important clinical implications in the orthopaedic patient. Vitamin D3 is synthesized in the skin and is converted to 25-hydroxycholecalciferol in the liver. 25-hydroxycholecalciferol is then converted in the kidney into 1,25-dihydroxycholecalciferol, the active form of vitamin
D. The best test to determine Vitamin D deficiency is the measurement of 25-hydroxycholecalciferol, as it has a longer half-life and circulating levels are 1,000x more than 1,25-dihydrocholecalciferol.
Patton et al. review the importance of Vitamin D in the orthopaedic patient. They discuss the implications of Vitamin D deficiency, and urge orthopaedic surgeons to be proficient in both the diagnosis and treatment of the condition.
Bogunovic et al. measured the levels of 25-hydroxycholecalciferol in 723 patients who were to undergo orthopaedic surgery. 40% of these patients were noted to be deficient in Vitamin D, with the highest rates in patients scheduled to undergo trauma and sports surgery.
Illustration A reviews Vitamin D metabolism. 24,25-dihydroxycholecalciferol is referred to as pre-Vitamin D.
Incorrect Answers:

Question 64

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Explanation

DISCUSSION: There is a negative change of calcium balance with a decrease

in intestinal absorption and an increase in urinary calcium loss. The reduction of

intestinal absorption is accompanied by reduced circulating concentrations of total, but

not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 65

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 66

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 67

Contracture of which structure causes hammertoe deformity?

Explanation

DISCUSSION
A patient with a flexible hammertoe deformity has the deformity while standing, but practically no deformity when seated with the foot in equinus. The metatarsophalangeal joint is not involved. The deformity is created by contracture of the flexor digitorum longus tendon.
RECOMMENDED READINGS
Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-44. Review. PubMed PMID: 12690869.View Abstract at PubMed
Couglin MJ. Lesser toe deformities. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 1. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:363-464.

Question 68

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Explanation

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 69

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

Explanation

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

Question 70

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be

Explanation

DISCUSSION: Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient’s negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 71

Figure 37 shows a coronal T2-weighted MRI scan. What is the name of the labeled torn structure?

Explanation

DISCUSSION: The labeled structure is the LCL, and it is avulsed from the lateral humeral epicondyle. This is the most common site of injury for the LCL. The biceps and brachialis tendon insertions are not well visualized in this section. The MCL and flexor/pronator origin

are intact.
REFERENCES: Potter HG, Weiland AJ, Schatz JA, et al: Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis. Radiology 1997;204:185-189.
King JC, Spencer EE: Lateral ligamentous instability: Techniques of repair and reconstruction. Techniques in Orthopaedics 2000;8:93-104.

Question 72

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Explanation

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament

Question 73

A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?

Explanation

DISCUSSION: An increased density of the talar body compared to the distal tibia following fracture of the talar neck is highly suggestive of vascular compromise of the talar body. Subchondral osteopenia of the talus at 6 to 8 weeks (Hawkins sign) is a favorable sign but does not eliminate the possibility of osteonecrosis.
REFERENCES: Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J: Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.
Berlet GC, Lee TH, Massa EG: Talar neck fractures. Orthop Clin North Am 2001;32:53-64.

Question 74

A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?

Explanation

DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 75

The use of radiation therapy is most effective in metastatic bone disease from which of the following tumors?

Explanation

DISCUSSION: Both myeloma and lymphoma are more responsive to radiation therapy. The other types of tumors are relatively more resistant to radiation. Doses of 25 to 50 Gy (2,500 to 5,000 cGy) are usually sufficient for myeloma and lymphoma, while carcinomas frequently require a higher dosage. Large cell lymphoma of bone is usually of B-cell origin and is treated with chemotherapy and radiation therapy.
REFERENCES: Simon MA, Springfield DS, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 683.
Riley LH III, Frassica DA, Kostuik JP, Frassica FJ: Metastatic disease to the spine: Diagnosis and treatment. Instr Course Lect 2000;49:471-477.

Question 76

A 13-year-old girl has had right groin pain for the past 3 weeks. She denies any history of trauma. Examination of the hip reveals no palpable soft-tissue mass or lymphadenopathy, and there is full range of motion. A plain radiograph and MRI scan are shown in Figures 15a and 15b. Biopsy specimens are shown in Figures 15c and 15d. What is the most likely diagnosis?

Explanation

DISCUSSION: Fibrous dysplasia frequently occurs in the proximal femur. Microfractures and remodeling can lead to the classic “Shepherd’s crook deformity.” The lesion has a ground-glass appearance on plain radiographs. The histologic appearance shows proliferating fibroblasts in a loose spindle cell background. Dysplastic metaplastic trabeculae are arranged in an irregular or “Chinese letter” appearance.
REFERENCES: Enneking WF, Gearen PF: Fibrous dysplasia of the femoral neck: Treatment by cortical bone grafting. J Bone Joint Surg Am 1986;68:1415-1422.
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 77

A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6. Radiographs of the shoulder are normal. What is the next most appropriate step in management? Review Topic

Explanation

The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear.

Question 78

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment? Review Topic

Explanation

The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.

Question 79

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Explanation

DISCUSSION: Studies examining the impact of graded water debt have clearly shown that the magnitude of core temperature and heart rate increase accompanying work are proportional to the magnitude of water debt at the onset of exercise. Though added thermal burden from hot climates is a factor, it appears to be less significant.
REFERENCES: Latzka WA, Montain SJ: Water and electrolyte requirements for exercise. Clin Sports Med 1999;18:513-524.
Montain SJ, Sawka MN, Latzka WA, et al: Thermal and cardiovascular strain from hypohydration: Influence of exercise intensity. Int J Sports Med 1998;19:87-91.
Sawka MN, Young AJ, Francesconi RP, et al: Thermoregulatory and blood responses during exercise at graded hypohydration levels. J Appl Physiol 1985;59:1394-1401.

Question 80

During fracture healing, granulation tissue tolerates the greatest strain before failure so that mature bone can eventually bridge the fracture gap during healing. What is the definition of strain?

Explanation

Strain is defined as the change in length/original length (L) and is created by a deformation of a material from an applied force.
The mechanical environment at the fracture site has a major influence on fracture healing. Granulation tissue can withstand higher strain, which stabilizes the mechanical environment and forms a scaffold on which cartilage and bone eventually form; this occurs after strain decreases incrementally. Optimal healing, however, depends on duration, rate, timing and type of mechanical influence. Bone is formed by osteoblasts that are adapted to the very low strains of over 1% change in length. Osteoblast synthesis and proliferation is stimulated at uniaxial strain of between 0.3% and 2.8%. It is known that limited inter-fragmentary movement of 0.2 mm to 1 mm is optimal for fracture healing, resulting in promotion of callus and increase in rigidity. Excessive movement, on the other hand, prolongs fracture healing. Researchers have identified that tissue strain of 2% is suitable for primary bone healing and secondary bone healing takes place at tissue strain of 2-10%. Strain of 10-100% results in fibrous tissue formation and 100% strain to non-union. This is known as Perren's theory.
Stokes published a review article on the effects of stress on bone healing and growth, and notes the importance of the 'Hueter-Volkmann Law' (growth is retarded by increased mechanical compression, and accelerated by reduced loading in comparison with normal values) in bone growth. Stokes also notes that sustained compression of physiological magnitude inhibits growth by 40% or more, while distraction increases growth rate by a much smaller amount.
Illustration A shows an example of a stress-strain curve, with several key definitions labeled on the diagram.
Incorrect Answers:

Question 81

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Explanation

DISCUSSION: Most patients who undergo transmetatarsal amputation do not require custom shoe wear or an orthosis above the ankle. A molded toe filler is used to prevent excessive shear that can lead to ulceration. Use of a soft toe filler without stiffening of the sole results in excessive flexibility from the shortened lever arm, which reduces the efficiency of gait. A firm footplate or carbon fiber base adds rigidity to aid in push-off. A rocker bottom also may be added to the shoe.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, Donley BG: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Marks RM: Mid-foot/mid-tarsus amputations. Foot Ankle Clin 1999;4:1-16.

Question 82

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured? Review Topic

Explanation

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.

Question 83

Figure 57a and 57b show the radiographs of a 57-year-old man who has pain in the ulnar side of the wrist and hand. Examination shows tenderness at the base of the hypothenar area. Additional diagnostic testing should include

Explanation

"The major symptom of dysfunction at the pisotriquetral joint is pain at the hypothenar eminence. It is often vague and poorly localized. The patient may complain of clicking or locking sensation with certain motions of the wrist. Careful clinical evaluation reveals that there is usually well localized tenderness to pressure over the pisiform. Side-to-side passive motion of the pisiform may reproduce pain and occasionally crepitus. Forced hyperextension of the wrist and resistance to palmar flexion and ulnar deviation, as well as to pronation and supination, may reproduce the symptoms. Excessive mobility of the pisiform is a common finding with pain often produced at the extremes of its mobility. A small injection of a local anesthetic agent into the isotriquetral joint at the ulnar aspect of the wrist with relief of symptoms helps confirm the diagnosis."

Question 84

A 25-year-old man underwent a Putti-Platt repair for recurrent anterior dislocation of his right shoulder 9 months ago. He reports no further episodes of instability but continues to have severely restricted motion, with external rotation limited to less than 0 degrees with the arm at the side. He has pain at the ends of range of motion and restricted activities of daily living despite undergoing nearly 9 months of physical therapy. Radiographs of the shoulder show no arthritic changes. Management should now consist of

Explanation

DISCUSSION: Open release allows lengthening of the shortened subscapularis and is preferred when there are extra-articular contractures. Arthroscopic release, combined with the use of an interscalene catheter postoperatively, is an excellent treatment for capsular contractures but is contraindicated after procedures that result in extracapsular shortening (ie, Magnuson-Stack, Putti-Platt). Additional physical therapy or manipulation under anesthesia is not likely to be helpful. Shoulder hemiarthroplasty is contraindicated with normal articular surfaces, but prosthetic arthroplasty is sometimes necessary for arthritis associated with instability or overly tight instability repairs.
REFERENCES: Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.
Warner JJ: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg 1997;5:130-140.
Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.
MacDonald PB, Hawkins RJ, Fowler PJ, Miniaci A: Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder. J Bone Joint Surg Am 1992;74:734-737.

Question 85

Which of the following anatomic structures is often difficult to visualize during elbow arthroscopy?

Explanation

DISCUSSION: The ulnar collateral ligament is often difficult to visualize during elbow arthroscopy. It can be seen clearly in only 10% to 30% of elbow arthroscopies. All of the other structures should be easily and thoroughly seen and palpated during elbow arthroscopy.
REFERENCES: Johnson LL: Arthroscopic Surgery: Principles and Practice. St Louis, MO, CV Mosby, 1988.
Morrey BF: Arthroscopy of the elbow. Instr Course Lect 1986;35:102-107.

Question 86

A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

Explanation

DISCUSSION: While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.

Question 87

A 75-year-old man has persistent radial sided hand and wrist pain. Radiographs demonstrate severe scaphotrapezial trapezoidal arthritis. His basal joint is unaffected. His pain has failed to improve with bracing, activity modification, and image-guided corticosteroid injection. He has elected surgical treatment. What longterm complication can arise from a distal scaphoid resection?

Explanation

EXPLANATION:
Resection of the distal pole of the scaphoid eliminates the arthritic contact at the scaphotrapeziotrapezoid joint; however, it functionally shortens the scaphoid. Theoretically, the lunate is at equilibrium between the extension moment of the capitate and the triquetrum and the flexion moment of the scaphoid. Shortening the scaphoid allows the extension moment of the triquetrum to predominate, pulling the lunate into extension and creating a DISI deformity. Concomitant capsulodesis or interposition is recommended by some authors to prevent this complication.

Question 88

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Explanation

Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient's history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.

Question 89

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Explanation

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not

require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am

2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 90

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the emergency department after a motor vehicle collision. He is complaining of isolated knee pain. Examination reveals swelling, blood filled blisters, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. The surgical approach for definitive reduction and stabilization of this pattern is

Explanation

Discussion: Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.
Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally
stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

Question 91

Figures below show the radiographs, and the CT obtained from a 58-year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

Explanation

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

Question 92

Increased hip intracapusular pressures can lead to diminished femoral head perfusion. What leg position has been shown to create the lowest intracapsular hip pressures after femoral neck fracture?

Explanation

DISCUSSION: In the referenced study by Bonnaire et al, extension and internal rotation had the highest intercapsular pressure. They found that the greatest decrease in pressure was found with flexion, abduction and external rotation. This is a possible etiology to the common position in which these patients will present to the emergency room. Traction was shown to increase pressure in the joint capsule.

Question 93

A 69-year-old man has nonpainful weakness in the upper and lower extremities. He also notes progressive instability in his gait and increasing difficulty ambulating, as well as manipulating small objects with his hands. MRI scans of his cervical spine are shown in Figures 85a and 85b. When would be the most appropriate time to proceed with surgical treatment? Review Topic

Explanation

The natural history of cervical myelopathy is one of slow deterioration over time, typically in a stepwise fashion with a variable period of stable neurologic function. More recent studies suggest that surgery should be performed as soon as possible when cervical spondylotic myelopathy has been diagnosed. Both anterior and posterior are effective and there is no statistical difference between their outcomes. Surgical outcome is related to the patient's age, disease course, the presence of osseous spinal stenosis, preoperative comorbidities, the preoperative spinal cord functional score, and the presence of high-signal abnormalities on T2-weighted images. To improve the operative result, all the influencing factors should be considered. Patients with focal high-intensity intramedullary signal changes on T2-weighted images have better clinical outcomes following surgery than do patients with demonstrable multisegmental high-intensity intramedullary signal changes on T2-weighted sequences. The transverse area and shape of the spinal cord at the involved segment may also be predictive of surgical outcome. With progressive compression, the cross section of the spinal cord changes from a boomerang shape to a teardrop shape to a triangular shape. In patients with a Nurick grade of I, there are signs of cord involvement, but gait remains normal. With a Nurick grade of II, there are mild gait abnormalities, not affecting the patient's employment status. With a Nurick grade of III, gait abnormalities prevent employment, but the patient remains able to ambulate without assistance. In Nurick grade IV, the patient is only able to ambulate with assistance. In Nurick grade V, the patient is chair-bound or bedridden. Clearly, it is desirable to operate when the patient is functioning with a Nurick grade of I or II. Whereas many patients presenting with cervical spondylotic myelopathy also report axial neck pain and radicular symptoms in the upper extremities, this is not always the case. Surgical intervention will generally be effective in eliminating this pain; however, the pain is not the determining factor for performing surgery. Surgery is performed to preserve and restore function. Changes in bowel and bladder function can occur in extremely severe cases of myelopathy, but this is quite rare.

Question 94

Which of the following is most likely to decrease surgical mortality and inpatient morbidity while simultaneously increasing surgical team adherence to life-saving steps in operating room crisis situations?

Explanation

The utilization of a surgical safety checklist has demonstrated substantial reductions in surgical morbidity and mortality. Checklist use has also demonstrated efficacy in increasing team adherence to life-saving care plans in operating room crises.
The World Health Organization concept of a surgical safety checklist concept was validated in 2009 as a way of improving surgical outcomes. Successful implementation of a surgical checklist relies upon surgeon leadership to educate staff on its rationale and the practical components of implementation in the operating room.
Haynes et al. evaluated a 19-item surgical safety checklist and evaluated its ability to reduce complications and deaths associated with surgery in a global population. Across 8 diverse hospitals in 8 cities around the world, their study demonstrated that implementation of a pre-surgical checklist resulted in a 50% reduction in mortality (1.5% to 0.8%) and a 37% reduction in inpatient complications (11% to 7%). The patients in the study were over the age of 16 and undergoing non-cardiac surgery.
Conley et al. evaluated the effectiveness of implementation of surgical safety checklists in five hospitals using a series of interviews conducted with surgeons. Analysis of the survey results demonstrated that effective implementation relied upon surgeon leadership to explain the necessity of the checklist and how to effectively implement its use. When surgeon leadership failed in these functions, hospital staff failed to comprehend the utility of the checklist and were not able to appropriately use it. These failures eventually led to institutional abandonment of the safety checklist.
Arriaga et al. evaluated the utility of checklists to guide the surgical team through intraoperative crisis situations (e.g., massive hemorrhage, cardiac arrest). Their study of 17 surgical teams undergoing 106 simulated surgical-crises demonstrated that use of a crisis checklist led to greater adherence to life-saving steps of a care plan. 97% of participants agreed that they desired a checklist to be present if a crisis were to occur while they themselves were undergoing surgery.
Incorrect answers:

Question 95

What is the most common mechanism of injury that produces turf toe?

Explanation

DISCUSSION: The most common mechanism of injury for turf toe is a hyperextension injury to the MTP joint. The foot is typically in a dorsiflexed position with the heel raised when an external force drives the MTP joint into further dorsiflexion. The joint capsule usually tears at the metatarsal neck because its attachment is weaker there than at the proximal phalanx. Some compression injuries to the dorsal articular surface of the metatarsal head can result from extension or hyperextension.
REFERENCES: Clanton TO, Ford JJ: Turf toe injury. Clin Sports Med 1994;13:731-741.
Rodeo SA, O’Brien S, Warren RF, et al: Turf toe: An analysis of metatarsophalangeal joint sprains in professional football players. Am J Sports Med 1990;18:280-285.

Question 96

A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 36, the arrow is pointing at which of the following arteries?

Explanation

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 97

Which of the following methods most reliably detects mechanical loosening of the hip?

Explanation

DISCUSSION: Mechanical loosening of the hip is best revealed by serial radiographs of the prosthetic joint. None of the other methods of evaluation is considered reliable in diagnosing mechanical loosening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Miniaci A, Bailey WH, Bourne RB, McLaren AC, Rorabeck CH: Analysis of radionuclide arthrograms, radiographic arthrograms, and sequential plain radiographs in the assessment of painful hip arthroplasty. J Arthroplasty 1990;5:143-149.

Question 98

15% to 2.5%. Acute Charcot arthropathy almost always appears with signs of inflammation. Profound unilateral swelling, an increase in local skin temperature (generally, an increase of 3° to 7° above the nonaffected foot's skin temperature), erythema, joint effusion, and bone resorption in an insensate foot are present. These characteristics, in the presence of intact skin and a loss of protective sensation, are often pathognomonic of acute Charcot arthropathy. Cellulitis is an infection of the skin. Examination would reveal erythema, edema, and pain. Osteomyelitis is an infection of the bone. Examination may reveal edema, drainage, and pain.

Explanation

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.
Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?
Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution
Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.
What is the post-amplification product of reverse transcription polymerase chain reaction (RT-PCR)?
RNA
DNA
Protein
Mitochondria
Immunoglobulins
Reverse transcription polymerase chain reaction (RT-PCR) is a variant of polymerase chain reaction (PCR) used in molecular biology to generate many copies of a DNA sequence from fragments of RNA. The RNA strand is first reverse transcribed into its DNA complement, followed by amplification of the resulting DNA using polymerase chain reaction. Polymerase chain reaction amplifies short segments of DNA by using the temperature stable DNA polymerase enzyme.
A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma?
Bone mineral density T-score < -2.5
Low vitamin D levels
Family history of osteoporosis
History of a prior fragility fracture
Ten year history of oral prednisone use
Each of the answer choices is a risk factor for subsequent fragility fracture, but patient history of a prior fragility fracture is the strongest predictor.
Bouxsein et al reviews the proper care, diagnosis, and prevention of fragility fractures. History of a fragility fracture is the greatest predictor of a future fracture from low energy trauma. Appropriate care includes not only treatment of the fracture itself, but also proper evaluation to identify the etiology of the fracture and appropriate intervention to rectify the underlying pathology. Evaluation includes bone densitometry, lab testing of Vitamin D and calcium.
A T-score compares your bone density to the optimal peak bone density for your gender. It is reported as number of standard deviations below the average. A T-score of -1 to -2.5 is considered osteopenia, and a risk for developing osteoporosis. A T- score of less than -2.5 is diagnostic of osteoporosis.
Long-term alendronate (Fosamax) use for osteoporosis has been associated
with which of the following?
Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures
Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with
uterine cancer or a detached retina.
Implants composed of polylactic acid are excreted by what system after they are absorbed?
Hepatic
Renal
Respiratory
Gastrointestinal
Polylactic acid suture and suture anchors are popular bioabsorbable orthopaedic implants. This material undergoes hydrolysis of the ester background in vivo. Resulting lactic acid enters the tricarboxylic acid (Krebs)
cycle and is excreted as carbon dioxide by the lungs. Polyglycolic acid and poly(p- dioxanone) may also be excreted by the kidneys.
A patient sustains a grade III medial collateral ligament injury. One year later, when compared to collagen in an uninjured ligament, an increase is likely in the
gross number of fibers.
proportion of type III fibers.
cross-linking.
mass and diameter of fibers.
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?
Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (ß-catenin) pathway
Parathyroid hormone (PTH) pathway
Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the ß-catenin. The unphosphorylated ß-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, ß- catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/ß- catenin pathway. The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation. BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.
During endochondral ossification of the growth plate, the process that most contributes to the longitudinal growth of long bones is
chondrocyte apoptosis.
chondrocyte hypertrophy.
chondrocyte proliferation.
growth plate matrix synthesis.
The growth plate is divided into 5 distinct zones: reserve, proliferative, maturation, hypertrophy, and vascular invasion. During growth-plate chondrocyte hypertrophy, intracellular volume and an increase in chondrocyte height are responsible for most growth of long bones. Other factors that contribute to bone growth are chondrocyte proliferation and matrix synthesis, but to a lesser degree than chondrocyte hypertrophy. Growth plate chondrocytes undergo programmed cell death (apoptosis) after hypertrophy
takes place.
Bacterial resistance to tetracycline is confirmed by ribosome protection, tetracycline modification, and
altered RNA polymerase.
altered membrane binding protein.
increased drug efflux.
DNA gyrase mutation.
Mutations of bacterial DNA gyrase can decrease the effectiveness of quinolones. Altered membrane-binding protein is observed with resistance to ?
-lactam antibiotics. Tetracyclines are antibiotics that inhibit bacterial growth by stopping protein synthesis. Three specific mechanisms of tetracycline
resistance have been identified: increased tetracycline efflux, ribosome protection, and tetracycline modification. Alteration of RNA polymerase is found in resistance to rifampin.
A 14-year-old boy has failed physical therapy management for Scheuermann kyphosis, and an extension thoracolumbosacral orthosis brace is recommended. The boy and his parents are told that the brace will force his thoracic spine into normal sagittal alignment and put the anterior vertebral bodies of the thoracic segment into tension, which will induce bone growth and normalization of wedge- shaped
vertebrae. What name is associated with this process?
Hooke's law
Kirchhoff's law
Wolff's law
Heuter-Volkmann principle
The Heuter-Volkmann principle shows that bone placed in longitudinal tension will tend to stimulate longitudinal growth, and that compressive longitudinal forces inhibit longitudinal growth, making this response the best choice. Hooke's law relates to stress being proportional to strain and is not directly related to bone growth. Kirchhoff's laws apply to electrical circuit design. Wolff's law states that bone remodels in response to mechanical stress, with the correlate that increased stress causes increased growth, and decreased stress leads to bone loss.
A tendon repair is thought to be weakest during which phase of tendon healing?
Inflammatory
Proliferation
Maturation
Remodeling
Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest
5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth
factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor- beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.
A 4-year-old boy has bilateral genu varum and is in the fifth percentile for height for his age. A younger sister has less severe genu varum. Radiographs reveal physeal cupping and widening on both the distal femur and proximal tibia. Laboratory studies show sodium 145 mEq/L (reference range, 136-142 mEq/L), potassium 4.0 mEq/L (reference range, 3.5-5.0 mEq/L), calcium 9.0 mg/dL (reference range, 8.2-10.2 mg/dL), phosphorous 2 mg/dL (reference range, 4-

Question 99

Figure 27 shows the radiograph of a 68-year-old woman with a history of rheumatoid arthritis who was injured in a fall. History reveals that she has been asymptomatic since undergoing a left total knee arthroplasty 9 years ago. Management should consist of

Explanation

DISCUSSION: A supracondylar fracture of the femur that occurs after total knee replacement can be treated effectively by a number of methods. For this fracture, the use of a retrograde supracondylar nail has been found to be effective in several series. The treatment of these complex injuries needs to be individualized based on the stability of the implant, the quality of the bone, and the extent of comminution of the fracture. Revision with the use of an unstemmed implant will not result in effective stabilization of the knee or the fracture.
REFERENCE: Ayers DC: Supracondylar fracture of the distal femur proximal to a total knee replacement, in Springfield DS (ed): Instructional Course Lectures 46. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-203.

Question 100

A 35-year-old patient is involved in a motor vehicle accident and sustains multiple fractures including a closed comminuted proximal meta-diaphyseal tibia fracture. The surgeon is considering bridge plating the fracture using a minimally invasive approach. Which of the following is true regarding bridge plating? Review Topic

Explanation

In bridged plating, only the most proximal and distal screw holes are filled. This creates a flexible, axially stable construct.
Bridge plating is applicable to all long-bone fractures with complex fragmentation and where intramedullary nailing or conventional plate fixation is not suitable. The construct preserves the blood supply to the fracture fragments as the fracture site is undisturbed during the operative procedure. It provides RELATIVE stability, allowing for some motion at the fracture site, leading to callus formation and secondary bone healing. The construct is FLEXIBLE because of increased distance between the 2 screws closest to the fracture (long working length), allowing for stress distribution and permitting more motion at the fracture site. The construct is also
AXIALLY STABLE because the plate acts as an extramedullary splint and resists axial compression.
Livani et al. advocate using an anterior or antero-lateral approach for minimally invasive plating of the humerus. They recommend that distal access is obtained first, allowing identification of the lateral antebrachial cutaneous nerve. For distal fractures, they recommend extending the plate down to the lateral column.
Apivatthakakul et al. defined minimally-invasive plate osteosynthesis (MIPO) danger zones from the lateral epicondyle. They found the musculocutaneous nerve averaged 18-43% of the humeral length, the danger zone for the radial nerve averaged 36-59% of the humeral length, and the most dangerous screws that penetrated or touched the radial nerve lay 47-53% of the humeral length.
Illustration A shows a distal tibia fracture. Illustration B shows radiographs 5 months after bridge plating of this fracture. There is callus formation, characteristic of indirect bone healing.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

activity modification
arthroscopic evaluation of fragment stability.
transarticular drilling of the lesion with 0.045 Kirschner wire.
arthroscopic excision of the fragment and microfracture of underlying cancellous bone.
excision of the fragment and mosaicplasty.

Correct Answer: activity modification

Explanation:

This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of activity modification and limited weight bearing until pain resolves is the best initial choice.
Cessation of sport activities for 4 to 6 months may allow healing of the lesion. Surgical treatment of juvenile OCD lesions is reserved for unstable lesions, patients
who have not shown radiographic evidence of healing and are still symptomatic after
6 months of nonsurgical management, or patients who are approaching skeletal maturity. Good results with stable in situ lesions that have failed to respond to nonsurgical management have been reported with both transarticular and retroarticular drilling. Results after excision alone are poor at 5-year follow-up, and it is unclear if microfracture will improve the long-term outcome. Mosaicplasty may be the next best option for patients who remain or become symptomatic after excision of the fragment and microfracture.
Wall et al. reviewed juvenile OCD. They state that JOCD has better potential for healing than adult OCD, but several series have shown up to a 50% failure to heal with nonsurgical techniques. The presence of a loose body is an indication for surgical fixation, drilling or regenerative procedures, depending on the presence/extent of subchondral bone sclerosis and the surgeon's experience.
Figure A and B are coronal MRI images showing a stable appearing JOCD lesion of the medial femoral condyle.
Incorrect
in the first
(SBQ13PE.9) A 6-year-old boy complains of a 'clunking' sensation in his left knee. He has no associated pain and denies trauma. He can elicit the sensation when moving his knee from flexion into full extension. He is otherwise healthy, with no birth or developmental issues. On examination, there is a palpable clunk felt over the anterior knee through range of motion. There is no obvious instability or tenderness and he had normal patellar tracking. An AP radiograph of the knee is shown in Figure A. What would be the most likely diagnosis?
Review
Topic
Agenesis of the anterior cruciate ligament
Thickened medial plica
Grade IV chondral flap
Pigmented villonodular synovitis
Abnormal meniscal morphology
This child presents with an asymptomatic click in the knee. It is associated with widening of the lateral joint space of the knee on X-ray. These features are highly suggestive of a discoid lateral meniscus in this age category.
The principal diagnostic feature of a discoid meniscus is the complaint of snapping or clicking in the knee. Children are usually asymptomatic. Although, less frequently, children may present with pain that is largely secondary to an underlying meniscal tear. MRI scans of the knee have show to have the greatest sensitivity for identifying discoid menisci. The presence of a contiguous central meniscus on three consecutive slices is usually indicative of the diagnosis. Treatment is mostly focused on conservative modalities. Surgical intervention is reserved for symptomatic cases with recurrent locking, swelling or persistent pain is present in older children.
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Figure A shows an AP radiograph of a pediatric knee. There is an increased lateral joint space suggestive of a discoid meniscus.
Illustrations A-C show an MRI of the knee with 3 consecutive coronal cuts showing an abnormal appearing discoid meniscus.
Incorrect Answers:

Question 2:

Options:

No syndesmotic fixation. Immediate touch-down weightbearing in CAM walker boot.
No syndesmotic fixation. Non-weightbearing for 4 to 6 weeks, followed by progressive weightbearing in CAM walker boot.
No syndesmotic fixation. Non-weightbearing for 8 to 12 weeks.
Syndesmotic screws. Non-weightbearing for 4 to 8 weeks.
Syndesmotic screws. Non-weightbearing for 8 to 12 weeks.

Correct Answer: No syndesmotic fixation. Immediate touch-down weightbearing in CAM walker boot.

Explanation:

Question 3:

Options:

Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open carpal tunnel release, closed reduction of the perilunate dislocation, and casting
Elective outpatient surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Correct Answer: Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Explanation:

Question 4:

A cortisone injection in the subacromial space will most likely result in

Options:

elevated blood glucose levels in patients with diabetes.
increased instability in multidirectional patients.
accelerated rupture of the long head of the biceps.
accelerated osteoporosis of the tuberosity.
altered proprioception of the glenohumeral joint.

Correct Answer: elevated blood glucose levels in patients with diabetes.

Explanation:

Question 5:

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

Options:

a radiograph and CT of the chest and a bone scan.
a radiograph and MRI of the primary tumor.
CT of the abdomen and pelvis.
CT of the abdomen, chest, and pelvis, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.
CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.

Correct Answer: CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.

Explanation:

Question 6:

Options:

Reposition the harness to hold the hips in 70 degrees of abduction
Closed reduction and arthrography under anesthesia
Open reduction and a spica cast
Continued harness treatment in the current position
Spica cast

Correct Answer: Continued harness treatment in the current position

Explanation:

Question 7:

- Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Options:

Manipulation Under Anesthesia
Arthroscopic acromioplasty
Arthroscopic debridement of G-H joint
Replacement of the humeral head
Lengthening of the subscapularis and release of the anterior capsule

Correct Answer: Lengthening of the subscapularis and release of the anterior capsule

Explanation:

Question 8:

A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

Options:

She should expect to return to full function and regain full range of elbow motion.
Reduction and casting has equivalent outcomes to those of surgical treatment.
This type of injury is associated with a high rate of complications.
Nerve dysfunction is commonly associated with this injury.
Ulnohumeral instability is the major complication seen with this fracture pattern.

Correct Answer: This type of injury is associated with a high rate of complications.

Explanation:

This is a Bado type 2 (posterior) Monteggia lesion, which is associated with higher rates of complications than other types of Monteggia lesions. The injury is associated with indirect high-energy trauma and less often pathologic causes. Of the four types of Monteggia lesions, the type 2 or posterior type is associated with the worst prognosis. These injuries are best treated surgically with dorsal plating of the ulna and reduction with fixation or arthroplasty of the radial head. The major complications seen with this injury pattern are nonunion and plate failure. Almost all patients have some loss of elbow range of motion. Satisfactory results based on functional scores for this injury are not universal. Neurologic injury and ulnohumeral instability are unusual with this type of injury. Full functional recovery is not expected with nonsurgical management.
(SBQ12TR.101) An otherwise healthy young adult male sustains a transverse radial shaft and ulna fracture. He undergoes definitive surgical fixation with two nonlocking compression plates (LCPs) as shown in Figure A. What is the principle of this fixation technique on bone healing?
Absolute stability with direct healing by callus formation
Relative stability with indirect healing by callus formation
Absolute stability with direct healing by internal remodeling
Relative stability with indirect healing by internal remodeling
Absolute stability with endochondral bone formation
Definitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole

Question 9:

What is the most likely long-term sequela of the injury shown in Figures 47a and 47b?

Options:

Peroneal tendon instability
Ankle joint instability
Subtalar joint arthrosis
Ankle joint arthritis
Entrapment of the flexor hallucis longus tendon

Correct Answer: Subtalar joint arthrosis

Explanation:

Question 10:

Options:

host chondrocytes in the articular cartilage.
subchondral revascularization and fragmentation, without evidence of cartilage degeneration.
an articular surface covered with a pannus of synovial tissue.
radiographically normal thickness of the articular surface, with evidence of cellular debris in the lacuna.
severe degenerative changes in the articular cartilage surface with complete loss of the tidemark.

Correct Answer: radiographically normal thickness of the articular surface, with evidence of cellular debris in the lacuna.

Explanation:

DISCUSSION: Osteoarticular allografts are devoid of host chondrocytes but do contain “mummified” cellular debris left over from donor processing. The cartilage architecture is preserved in the first 2 to 3 years after transplantation. The articular surface is covered with a pannus of fibrocartilage maintaining the joint space radiographically; this pannus later contains islands of fibrocartilage containing host mesenchymal stem cells. Degenerative changes to the joint surface occur earlier and are more severe in joints that are unstable. Only with degenerative changes at the surface is there histologic evidence of subchondral revascularization. Often degenerative changes involving the articular cartilage reach the tidemark, but the tidemark itself remains structurally intact.
REFERENCES: Enneking WF, Campanacci DA: Retrieved human allografts:
A clinicopathological study. J Bone Joint Surg Am 2001;83:971-986.
Enneking WF, Mindell ER: Observations on massive retrieved human allografts.
J Bone Joint Surg Am 1991;73:1123-1142.

Question 11:

Options:

The athlete must wear a functional brace for all athletic activities for 2 years following reconstruction.
The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.
The athlete must wear a functional brace for 2 years following reconstruction for basketball only; other athletic activities such as running and tennis are allowed without the brace.
The athlete must wear a custom-fit functional brace for 2 years following reconstruction because off-the-shelf braces produce inferior results.

Correct Answer: The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.

Explanation:

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 12:

Options:

Ultrasound
CT
Bone scan
Scapular Y-view of the shoulder
Stress views of the shoulder

Correct Answer: Stress views of the shoulder

Explanation:

Question 13:

Options:

Rheumatoid arthritis
Previous anterior cruciate ligament reconstruction with allograft tissue
Malalignment
Chondral defect
Body mass index

Correct Answer: Previous anterior cruciate ligament reconstruction with allograft tissue

Explanation:

Question 14:

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Options:

Correct Answer: C5

Explanation:

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 15:

Options:

Polymorphonuclear leukocytes
Extracellular metal-wear debris
Cement particles within the macrophages
Lymphocytes and plasma cells

Correct Answer: Lymphocytes and plasma cells

Explanation:

Question 16:

Options:

Distal rerouting of the biceps tendon
Glenohumeral fusion with external rotation
External rotation osteotomy of the proximal humerus
Latissimus dorsi and teres major transfer to the posterior rotator cuff
Latissimus dorsi and teres major transfer to the subscapularis

Correct Answer: Latissimus dorsi and teres major transfer to the posterior rotator cuff

Explanation:

Question 17:

Which radiographic abnormality most accurately serves as a predictor of ankle syndesmosis disruption?

Options:

Medial clear space equal to the superior clear space on the anteroposterior (AP) view
Tibiofibular overlap exceeding 6 mm on the AP view
Tibiofibular clear space exceeding 6 mm on AP view
Talocrural angle symmetric to the opposite side

Correct Answer: Tibiofibular clear space exceeding 6 mm on AP view

Explanation:

DISCUSSION
Normal syndesmotic relationships include a tibiofibular clear space smaller than 6 mm on both AP and mortise views. In a 1989 cadaveric study by Harper and Keller, a tibiofibular clear space exceeding 6 mm on both the AP and mortise views was the most reliable predictor of early syndesmotic widening. Tibiofibular overlap is measured 1 cm proximal to the plafond. Normal values exceed 6 mm or 42% of the width of the fibula on the AP view, or 1 mm on the mortise view. Proximal fibula fracture can occur in isolation without syndesmotic injury, frequently after direct trauma. The medial clear space is the distance between the lateral border of the medial malleolus and the medial border of the talus and is measured at the level of the talar dome. In the mortise view with the ankle in neutral dorsiflexion, the medial clear space should be equal to or smaller than the superior clear space between the talar dome and the tibial plafond. ?A normal medial clear space may be present with syndesmotic injury and consequently lacks sensitivity and specificity.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.
View Abstract at PubMed
Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg. 1997 May;5(3):172-181. PubMed PMID: 10797219.
View Abstract at PubMed
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. PubMed PMID: 2613128.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 37 THROUGH 40
A 41-year-old man sustained a twisting injury while running up stairs 4 weeks ago. He was treated in an ankle brace and has been bearing weight since the injury occurred. He has no history of ankle problems, but he now has ankle pain, swelling, and instability. The pain is aggravated by stairs, and the instability is worse on unlevel ground. Radiographs do not show a fracture.

Question 18:

Options:

Non-weight bearing bilateral lower extremities and right upper extremity
Weight bearing as tolerated bilateral lower extremities and right upper extremity
Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

Correct Answer: Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities

Explanation:

Question 19:

Options:

Teratologic hip dislocation
Septic right hip
Congenital coxa vara
Transphyseal fracture of the proximal femur
Postpartum ligamentous laxity

Correct Answer: Transphyseal fracture of the proximal femur

Explanation:

Question 20:

Options:

Will result in improvement in pain but no difference in function or range of motion compared to therapy alone.
Will result in greater improvement in pain and function compared to therapy alone, with equivalent range of motion at one year
Will prevent development of rotator cuff arthropathy in patients with rotator cuff tears.
Will likely have no effect on pain, function or range of motion at one year, compared to therapy alone.
Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Correct Answer: Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Explanation:

Question 21:

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Options:

flexor hallucis longus tendon.
peroneus brevis tendon.
peroneus longus tendon.
calcaneal fibular ligament.

Correct Answer: peroneus longus tendon.

Explanation:

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.
View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.
View Abstract at PubMed

Question 22:

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 23:

During a Lisfranc (tarsometatarsal) amputation of the foot, which of the following is crucial to prevent the patient from having a supinated foot during gait.

Options:

Releasing the posterior tibialis tendon
Preserving the soft-tissue envelope (peroneus brevis, tertius and plantar fascia) around the fifth metatarsal base
Myodesis of the anterior tibialis to the medial and middle cuneiforms
Lengthening of the gastrocsoleus (achilles tendon)
Osteotomy through 1st metatarsal

Correct Answer: Releasing the posterior tibialis tendon

Explanation:

Question 24:

Options:

Abnormal alpha angle and a chondrolabral tear
Acetabular retroversion
Heterotopic ossification
Ankylosing spondylitis
Coxa varum

Correct Answer: Abnormal alpha angle and a chondrolabral tear

Explanation:

Question 25:

Options:

Admission and traction
Open surgical debridement of the lesion
Perform an open biopsy of the lesion
Nonsurgical treatment with antibiotics and immobilization DISCUSSION -Childhood diskitis represents one end of a continuum of spinal infections, from diskitis to vertebral osteomyelitis with soft-tissue abscess. Diskitis is now generally accepted as a bacterial infection involving the disk space and adjacent vertebral end plates. Optimal treatment includes the use of antibiotics. Empiric coverage is directed against Staphylococcus aureus because it has been the most common organism isolated from culture-positive biopsy specimens. Open biopsy is not necessary for patients who exhibit all of these clinical characteristics, but it is indicated for those whose symptoms do not resolve rapidly with treatment or who have atypical presentation.

Correct Answer: Nonsurgical treatment with antibiotics and immobilization DISCUSSION -Childhood diskitis represents one end of a continuum of spinal infections, from diskitis to vertebral osteomyelitis with soft-tissue abscess. Diskitis is now generally accepted as a bacterial infection involving the disk space and adjacent vertebral end plates. Optimal treatment includes the use of antibiotics. Empiric coverage is directed against Staphylococcus aureus because it has been the most common organism isolated from culture-positive biopsy specimens. Open biopsy is not necessary for patients who exhibit all of these clinical characteristics, but it is indicated for those whose symptoms do not resolve rapidly with treatment or who have atypical presentation.

Question 26:

Options:

Gender
Age
Race
Environment

Correct Answer: Race

Explanation:

Question 27:

Options:

20% to 30%
35% to 45%
50% to 60%
80% to 95%
100%

Correct Answer: 80% to 95%

Explanation:

Question 28:

Options:

external electrical stimulation.
external ultrasound stimulation.
implanted electrical stimulation.
closed reduction and percutaneous fixation.
open reduction and internal fixation with bone graft.

Correct Answer: open reduction and internal fixation with bone graft.

Explanation:

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have
shown some healing response with callus formation, but these techniques are not successful
in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions
of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson
NS
, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 29:

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Options:

perpendicular to the shaft of the metatarsal.
parallel with the inclination of the metatarsal.
parallel with the plantar surface of the foot.
45 degrees to the shaft of the metatarsal.
10 degrees to the shaft of the metatarsal.

Correct Answer: parallel with the plantar surface of the foot.

Explanation:

DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment.
REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.

Question 30:

A Canale view best visualizes which of the following structures?

Options:

Posterior facet of the subtalar joint
Lisfranc joint
Talar neck
Sustentaculum tali
Lateral column of the foot

Correct Answer: Talar neck

Explanation:

Question 31:

Options:

less than 10%.
30%.
50%.
70%.
greater than 90%.

Correct Answer: greater than 90%.

Explanation:

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.
J Trauma 1982;22:691-693.

Question 32:

Options:

Unloader brace
Distal femoral osteotomy
Open arthrofibrosis debridement with lateral ligament balancing and polyethylene exchange
Revision TKA of both the femoral and tibial components

Correct Answer: Revision TKA of both the femoral and tibial components

Explanation:

Question 33:

Options:

weight.
gender.
the knee compartment involved.
open or closed growth plates.
limb alignment.

Correct Answer: open or closed growth plates.

Explanation:

Question 34:

Options:

Sling immobilization and rest
Physical therapy for aggressive stretching
Intra-articular corticosteroid injection and stretching program
Manipulation of the shoulder under anesthesia
Arthroscopic subacromial decompression and capsular release

Correct Answer: Intra-articular corticosteroid injection and stretching program

Explanation:

Question 35:

Options:

MRI-arthrogram to evaluate the rotator cuff
Rotator cuff strengthening program
Posterior capsular stretching program
Shoulder arthroscopy with SLAP repair
Shoulder arthroscopy with posterior capsular release

Correct Answer: Posterior capsular stretching program

Explanation:

Question 36:

Options:

Gradual return to play
Physical therapy program
Custom orthosis
Non-weight-bearing cast
Weight-bearing AP radiograph

Correct Answer: Weight-bearing AP radiograph

Explanation:

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return
to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 37:

Cell signaling through the activation of a transmembrane receptor complex formed by serine/threonine kinase receptors occurs with which of the following growth factors?

Options:

Bone morphogenetic protein
Fibroblast growth factors
Insulin-like growth factors
Platelet-derived growth factors
Growth hormone

Correct Answer: Bone morphogenetic protein

Explanation:

Question 38:

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

Options:

Posterior heel
Plantar-lateral foot
Plantar-medial foot
Dorso-lateral foot
Dorso-medial foot

Correct Answer: Dorso-lateral foot

Explanation:

DISCUSSION: The sural nerve runs with the small saphenous vein on the posterior leg just lateral to the Achilles tendon. It is formed by contributions from both the tibial and common peroneal nerves and provides sensation on the dorso-lateral aspect of the foot.
REFERENCES: Aktan Ikiz ZA, Ucerler H, Bilge O: The anatomic features of the sural nerve with an emphasis on its clinical importance. Foot Ankle Int 2005;26:560-567.
Lawrence SJ, Botte MJ: The sural nerve in the foot and ankle: An anatomic study with clinical and surgical implications. Foot Ankle Int 1994;15:490-494.

Question 39:

Survival rates for children with soft-tissue sarcoma other than rhabdomyosarcoma are best correlated with

Options:

size of the tumor.
histologic grade.
histologic subtype.
use of adjuvant chemotherapy.
age of the patient.

Correct Answer: histologic grade.

Explanation:

Question 40:

Options:

patella baja.
nonresurfaced patella.
isolated femoral revision.
noncemented tibial component.
previous use of the quadriceps turn-down technique.

Correct Answer: patella baja.

Question 41:

Options:

revision of all components to ensure patellar tracking.
athroscopic debridement.
arthrotomy and keloid excision.
intra-articular corticosteroid injections.
patellar component revision.

Correct Answer: athroscopic debridement.

Explanation:

Question 42:

Options:

No treatment is required because spontaneous healing is common.
Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
Hyperbaric oxygen treatment is helpful.
Ankle fusion is frequently necessary.

Correct Answer: Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.

Explanation:

Question 43:

Options:

Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement
Open reduction and internal fixation

Correct Answer: Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement

Explanation:

Question 44:

- Which of the following procedures is associated with the highest risk of osteonecrosis of the metatarsal head?

Options:

Distal chevron osteotomy with soft-tissue release
Distal soft-tissue realignment only
Closing wedge osteotomy (Aken) of the proximal phalanx
Proximal first metatarsal osteotomy only
Soft-tissue realignment with a proximal metatarsal osteotomy

Correct Answer: Distal chevron osteotomy with soft-tissue release

Explanation:

Question 45:

Options:

medial and lateral collateral ligaments, radial head, and coronoid.
medial collateral ligament and coronoid.
lateral collateral ligament and radial head.
medial and lateral collateral ligaments.
radial head and coronoid.

Correct Answer: medial and lateral collateral ligaments, radial head, and coronoid.

Explanation:

Question 46:

Options:

Posterior cruciate ligament
Anterior cruciate ligament
Popliteus
Lateral collateral ligament
Medial collateral ligament

Correct Answer: Posterior cruciate ligament

Explanation:

Question 47:

Options:

a lateral patellar restraining brace for practice and competition.
arthroscopic lateral retinacular release.
open medial retinacular plication.
medial tibial tubercle transfer.
Maquet tibial tubercle elevation.

Correct Answer: arthroscopic lateral retinacular release.

Explanation:

Question 48:

Options:

Brodie’s abscess
Hyperparathyroidism
Stress fracture
Enchondroma
Osteoid osteoma

Correct Answer: Osteoid osteoma

Explanation:

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a
radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic
features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 49:

Options:

Surgical hip dislocation (“Berne” approach)
Watson-Jones approach
Smith-Peterson approach
Kocher-Langenbeck approach
Extensile iliofemoral approach

Correct Answer: Surgical hip dislocation (“Berne” approach)

Explanation:

Question 50:

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Options:

aseptic necrosis of the humeral head.
a nondisplaced anatomic neck fracture.
a partial-thickness rotator cuff tear.
a full-thickness rotator cuff tear.
a bony Bankart defect.

Correct Answer: a full-thickness rotator cuff tear.

Explanation:

Question 51:

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 52:

The clinical photograph in Figure 27 shows a palsy of what nerve/associated muscle?

Options:

Long thoracic/rhomboid
Long thoracic/serratus anterior
Long thoracic/supraspinatus
Dorsal scapular/trapezius
Spinal accessory/trapezius

Correct Answer: Long thoracic/serratus anterior

Explanation:

Question 53:

Options:

a soft cervical collar.
a rigid cervical collar.
halo vest immobilization for 3 months.
simple midline (Rogers) wiring.
lateral mass plate fixation at C4-C6.

Correct Answer: lateral mass plate fixation at C4-C6.

Explanation:

Question 54:

Options:

Increase risk for iatrogenic ulnar nerve injury
Provide more construct stiffness than adding a medial pin
Improve construct stiffness in the presence of medial column comminution
Will not affect construct stiffness in the presence of residual distal fragment internal rotation

Correct Answer: Improve construct stiffness in the presence of medial column comminution

Explanation:

Question 55:

Which of the following treatments for osteoporosis is a direct inhibitor of RANK ligand (RANK-L)?

Options:

Romosozumab
Zoledronic acid
Denosumab
Teriparatide
Blosozumab

Correct Answer: Denosumab

Explanation:

Question 56:

Options:

a hard-soled shoe for 4 to 6 weeks.
closed reduction and percutaneous pinning.
burning a hole in the nail for relief of the impending hematoma.
digital block and irrigation and debridement of the wound.
repair of the extensor hallucis longus tendon injury and use of a hard-soled shoe.

Correct Answer: digital block and irrigation and debridement of the wound.

Explanation:

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of
the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 57:

Options:

Use of a hinged knee brace for 6 weeks postoperatively
Use of a continuous passive motion device for 2 weeks postoperatively
Eccentric strengthening starting at week #3
Concentric strengthening starting at week #3
Eccentric strengthening starting at week #12

Correct Answer: Use of a hinged knee brace for 6 weeks postoperatively

Explanation:

Question 58:

Options:

observation.
antibiotic therapy.
irrigation and debridement.
aspiration and compression.
excision.

Correct Answer: aspiration and compression.

Explanation:

Question 59:

Options:

talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.

Correct Answer: reimplantation of the talus.

Explanation:

DISCUSSION: The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
REFERENCES: Smith CS, Nork SE, Sangeorzan BJ: The extruded talus: Results of reimplantation. J Bone Joint Surg Am 2006;88:2418-2424.
Brewster NT, Maffulli N: Reimplantation of the totally extruded talus. J Orthop Trauma 1997;11:42-45.

Question 60:

Options:

Saline lavage and splinting of the tibia and knee immobilizers of both femurs
Betadine dressing and splinting of the tibia with unlocked retrograde nailing of both femurs
Betadine dressing and external fixation of the tibia and knee immobilizers of both femurs
Irrigation and debridement and external fixation of the tibia and external fixation of both femurs
Irrigation and debridement and external fixation of the tibia and unlocked retrograde nailing ofboth femurs

Correct Answer: Irrigation and debridement and external fixation of the tibia and external fixation of both femurs

Question 61:

Options:

Therapeutic footwear/depth-inlay shoes and a custom accommodative foot orthosis
Charcot restraint orthotic walker (CROW)
Percutaneous Achilles tendon lengthening, a total contact cast, and a CROW walker
Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear
Ankle disarticulation (Syme) amputation

Correct Answer: Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear

Explanation:

DISCUSSION: This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear.
REFERENCES: Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.
Pinzur M: Surgical versus accommodative treatment for Charcot arthropathy of the midfoot.
Foot Ankle Int 2004;25:545-549.

Question 62:

What muscle attaches to the site shown by the arrow in Figure 2?

Options:

Teres minor
Teres major
Latissimus dorsi
Pectoralis major
Pectoralis minor

Correct Answer: Latissimus dorsi

Explanation:

Question 63:

Which of the following statements is correct regarding Vitamin D?

Options:

1,25-dihydrocholecalciferol is the best laboratory study to determine a Vitamin D deficiency
hydroxycholecalciferol is the active form of Vitamin D
24,25-dihydroxycholecalciferol is an inactive form of Vitamin D
1,25-dihydrocholecalciferol is converted to 25-hydroxycholecalciferol in the kidney
The half-life of 1,25-dihydrocholecalciferol is longer than 25-hydroxycholecalciferol

Correct Answer: The half-life of 1,25-dihydrocholecalciferol is longer than 25-hydroxycholecalciferol

Explanation:

Question 64:

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Options:

Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss
A net negative change in calcium balance because of a decrease in intestinal absorption and a lesser decrease in urinary calcium loss
An increase of intestinal resorption with an increase of free 1,25-dihydroxyvitamin D
Loss of estrogen stimulating loss of calcium via increased PTH levels and subsequent decreased renal tubular absorption of calcium
No true change in calcium metabolism, but rather a net increased turnover of bone because of a decrease in circulating estrogen

Correct Answer: Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss

Explanation:

DISCUSSION: There is a negative change of calcium balance with a decrease
in intestinal absorption and an increase in urinary calcium loss. The reduction of
intestinal absorption is accompanied by reduced circulating concentrations of total, but
not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 65:

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 66:

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 67:

Contracture of which structure causes hammertoe deformity?

Options:

Extensor digitorum longus tendon
Extensor digitorum brevis tendon
Flexor digitorum longus tendon
Flexor digitorum brevis tendon

Correct Answer: Flexor digitorum longus tendon

Explanation:

DISCUSSION
A patient with a flexible hammertoe deformity has the deformity while standing, but practically no deformity when seated with the foot in equinus. The metatarsophalangeal joint is not involved. The deformity is created by contracture of the flexor digitorum longus tendon.
RECOMMENDED READINGS
Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-44. Review. PubMed PMID: 12690869.
View Abstract at PubMed
Couglin MJ. Lesser toe deformities. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 1. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:363-464.

Question 68:

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Options:

A prosthetic foot which incorporates a multi-axis articulated foot assembly is recommended for which of the following amputees?
Low functioning diabetic who needs to transfer bed to chair
Long distance runner with below knee amputation
Elderly male with above knee amputation
Below knee amputee who needs to regularly walk on uneven ground
year-old male with above knee amputation from osteosarcoma

Correct Answer: Long distance runner with below knee amputation

Explanation:

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 69:

Options:

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

Correct Answer: Bone grafting and compression plating

Explanation:

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

Question 70:

Options:

a program of shoulder strengthening exercises.
decompression of the nerve at the spinoglenoid notch.
decompression of the nerve at the transverse suprascapular ligament.
release of the fascial elements of the muscle tethering the nerve.
arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

Correct Answer: a program of shoulder strengthening exercises.

Explanation:

Question 71:

Figure 37 shows a coronal T2-weighted MRI scan. What is the name of the labeled torn structure?

Options:

Brachialis tendon
Biceps tendon
Flexor/pronator origin
Medial collateral ligament (MCL)
Lateral collateral ligament (LCL)

Correct Answer: Lateral collateral ligament (LCL)

Explanation:

DISCUSSION: The labeled structure is the LCL, and it is avulsed from the lateral humeral epicondyle. This is the most common site of injury for the LCL. The biceps and brachialis tendon insertions are not well visualized in this section. The MCL and flexor/pronator origin
are intact.
REFERENCES: Potter HG, Weiland AJ, Schatz JA, et al: Posterolateral rotatory instability of the elbow: Usefulness of MR imaging in diagnosis. Radiology 1997;204:185-189.
King JC, Spencer EE: Lateral ligamentous instability: Techniques of repair and reconstruction. Techniques in Orthopaedics 2000;8:93-104.

Question 72:

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Options:

Interosseous ligament
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Deltoid ligament
Tibiotalar ligament

Correct Answer: Interosseous ligament

Explanation:

Question 73:

Options:

Varus malreduction of the talar neck
Osteonecrosis of the talar body
Subtalar traumatic arthropathy
Nonunion of the talar neck
Occult infection

Correct Answer: Osteonecrosis of the talar body

Explanation:

Question 74:

A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?

Options:

Flexion distraction
Vertical shear
Extension distraction
Flexion compression
Axial load

Correct Answer: Axial load

Explanation:

DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 75:

The use of radiation therapy is most effective in metastatic bone disease from which of the following tumors?

Options:

Renal cell carcinoma
Adenocarcinoma of the lung
Adenocarcinoma of the colon
Carcinoma of the cervix
Lymphoma

Correct Answer: Lymphoma

Explanation:

Question 76:

Options:

Fibrous dysplasia
Osteosarcoma
Ewing’s sarcoma
Periosteal chondroma
Aneurysmal bone cyst

Correct Answer: Fibrous dysplasia

Explanation:

Question 77:

Options:

Home exercise program
Sling at all times until her pain decreases
Closed manipulation under anesthesia
Arthroscopic rotator cuff repair
Arthroscopic anterior and posterior capsular release

Correct Answer: Home exercise program

Explanation:

Question 78:

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment? Review Topic

Options:

Spica cast immobilization
Rigid reamed nailing of the femur and a short leg cast
Flexible nailing of the femur and tibia
Reamed nails of the femur and tibia
Spanning external fixator

Correct Answer: Flexible nailing of the femur and tibia

Explanation:

Question 79:

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Options:

water debt at the onset of exercise.
sodium debt at the onset of exercise.
potassium debt at the onset of exercise.
ambient temperature.
percentage of lean body mass.

Correct Answer: water debt at the onset of exercise.

Explanation:

Question 80:

During fracture healing, granulation tissue tolerates the greatest strain before failure so that mature bone can eventually bridge the fracture gap during healing. What is the definition of strain?

Options:

Amount of force an object can withstand until plastic deformation is lost
Change in length / original length of an object due to an external force
Relationship of stiffness to time-dependent loading
Force intensity / volume
Force intensity / cross sectional area

Correct Answer: Amount of force an object can withstand until plastic deformation is lost

Explanation:

Question 81:

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Options:

Foam filling of the forefoot void
Custom last shoe of a smaller size
Solid ankle polypropylene ankle-foot orthosis
Silicone partial foot prosthesis with cosmetic toes
Cushioned molded insole and toe filler over a carbon fiber footplate

Correct Answer: Cushioned molded insole and toe filler over a carbon fiber footplate

Explanation:

Question 82:

Options:

Fourth cervical nerve root
Upper trunk of the brachial plexus
Middle trunk of the brachial plexus
Lateral cord of the brachial plexus
Axillary nerve

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 83:

Options:

AP and lateral radiographs of the elbow
Diagnositc arthroscopy
Aspiration of joint fluid
An erythrocyte sedimentation rate and CBC
A diagnostic lidocaine injection

Correct Answer: A diagnostic lidocaine injection

Explanation:

Question 84:

Options:

additional physical therapy for 6 months followed by reassessment.
manipulation under anesthesia.
arthroscopic release combined with the use of an interscalene catheter postoperatively.
open release with Z-plasty lengthening of the subscapularis and capsule.
shoulder hemiarthroplasty.

Correct Answer: open release with Z-plasty lengthening of the subscapularis and capsule.

Explanation:

Question 85:

Which of the following anatomic structures is often difficult to visualize during elbow arthroscopy?

Options:

Ulnar collateral ligament
Olecranon fossa
Radial head
Coronoid process
Anterior superior capsular attachment to the humerus

Correct Answer: Ulnar collateral ligament

Explanation:

Question 86:

Options:

recurrent buckling with a probable meniscal tear.
limitation of motion with a delay in recovery.
a full return to activity with no limitations.
an improvement in overall performance.
an uneventful completion of the soccer season.

Correct Answer: recurrent buckling with a probable meniscal tear.

Explanation:

Question 87:

Options:

Avascular necrosis of the proximal pole of the scaphoid
Dorsal intercalated segment instability (DISI)
Volar intercalated segment instability
Thumb metacarpophalangeal joint hyperextension

Correct Answer: Dorsal intercalated segment instability (DISI)

Explanation:

Question 88:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 89:

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Options:

Before Risser 1 and menarche
After Risser 1 and menarche
Between Risser 1 and menarche
After menarche but before Risser 1
At Risser 2

Correct Answer: Before Risser 1 and menarche

Explanation:

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not
require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am
2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 90:

Options:

anterior midline.
anterolateral.
medial parapatellar.
posteromedial.

Correct Answer: posteromedial.

Explanation:

Question 91:

Options:

Trochanteric bursitis
Femoral component loosening
Iliopsoas tendonitis
Acetabular component loosening

Correct Answer: Iliopsoas tendonitis

Explanation:

Question 92:

Increased hip intracapusular pressures can lead to diminished femoral head perfusion. What leg position has been shown to create the lowest intracapsular hip pressures after femoral neck fracture?

Options:

flexion and internal rotation
extension and external rotation
flexion, abduction, and external rotation
extension, adduction, and internal rotation
there are no differences in hip pressures with any position

Correct Answer: flexion and internal rotation

Explanation:

Question 93:

Options:

When the patient is medically stable for surgery
When the MRI scans show multisegmental high-intensity intramedullary signal changes on T2-weighted sequences
When he reaches a Nurick grade of IV for his preoperative neurologic function
When he reports neck and/or extremity pain that becomes intolerable or not controlled by medication
When he develops bowel or bladder incontinence

Correct Answer: When the patient is medically stable for surgery

Explanation:

Question 94:

Options:

An intra-operative surgical team leader
A surgical checklist
The presence of a senior surgeon
Magnet certification of nursing staff
Exclusion of surgical residents from the operating room team

Correct Answer: An intra-operative surgical team leader

Explanation:

Question 95:

What is the most common mechanism of injury that produces turf toe?

Options:

Valgus stress at the first metatarsophalangeal (MTP) joint
Hyperflexion stress
Hyperextension stress
Varus stress
Axial load

Correct Answer: Hyperextension stress

Explanation:

Question 96:

Options:

Brachiocephalic
Innominate
Subclavian
Axillary
Circumflex scapular

Correct Answer: Axillary

Explanation:

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 97:

Which of the following methods most reliably detects mechanical loosening of the hip?

Options:

Serial planar radiographs
Joint aspiration
Aspiration and arthrogram
Technetium Tc 99m scan
CT scan

Correct Answer: Serial planar radiographs

Explanation:

Question 98:

Options:

Of the following variables, which has the strongest influence on external fixator stiffness?
Pin diameter
Pin spread
Bone quality
Stacking a second fixator bar
Distance from bone to fixator bar

Correct Answer: Of the following variables, which has the strongest influence on external fixator stiffness?

Explanation:

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.
Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?
Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution
Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.
What is the post-amplification product of reverse transcription polymerase chain reaction (RT-PCR)?
RNA
DNA
Protein
Mitochondria
Immunoglobulins
Reverse transcription polymerase chain reaction (RT-PCR) is a variant of polymerase chain reaction (PCR) used in molecular biology to generate many copies of a DNA sequence from fragments of RNA. The RNA strand is first reverse transcribed into its DNA complement, followed by amplification of the resulting DNA using polymerase chain reaction. Polymerase chain reaction amplifies short segments of DNA by using the temperature stable DNA polymerase enzyme.
A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma?
Bone mineral density T-score < -2.5
Low vitamin D levels
Family history of osteoporosis
History of a prior fragility fracture
Ten year history of oral prednisone use
Each of the answer choices is a risk factor for subsequent fragility fracture, but patient history of a prior fragility fracture is the strongest predictor.
Bouxsein et al reviews the proper care, diagnosis, and prevention of fragility fractures. History of a fragility fracture is the greatest predictor of a future fracture from low energy trauma. Appropriate care includes not only treatment of the fracture itself, but also proper evaluation to identify the etiology of the fracture and appropriate intervention to rectify the underlying pathology. Evaluation includes bone densitometry, lab testing of Vitamin D and calcium.
A T-score compares your bone density to the optimal peak bone density for your gender. It is reported as number of standard deviations below the average. A T-score of -1 to -2.5 is considered osteopenia, and a risk for developing osteoporosis. A T- score of less than -2.5 is diagnostic of osteoporosis.
Long-term alendronate (Fosamax) use for osteoporosis has been associated
with which of the following?
Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures
Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with
uterine cancer or a detached retina.
Implants composed of polylactic acid are excreted by what system after they are absorbed?
Hepatic
Renal
Respiratory
Gastrointestinal
Polylactic acid suture and suture anchors are popular bioabsorbable orthopaedic implants. This material undergoes hydrolysis of the ester background in vivo. Resulting lactic acid enters the tricarboxylic acid (Krebs)
cycle and is excreted as carbon dioxide by the lungs. Polyglycolic acid and poly(p- dioxanone) may also be excreted by the kidneys.
A patient sustains a grade III medial collateral ligament injury. One year later, when compared to collagen in an uninjured ligament, an increase is likely in the
gross number of fibers.
proportion of type III fibers.
cross-linking.
mass and diameter of fibers.
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?
Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (ß-catenin) pathway
Parathyroid hormone (PTH) pathway
Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the ß-catenin. The unphosphorylated ß-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, ß- catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/ß- catenin pathway. The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation. BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.
During endochondral ossification of the growth plate, the process that most contributes to the longitudinal growth of long bones is
chondrocyte apoptosis.
chondrocyte hypertrophy.
chondrocyte proliferation.
growth plate matrix synthesis.
The growth plate is divided into 5 distinct zones: reserve, proliferative, maturation, hypertrophy, and vascular invasion. During growth-plate chondrocyte hypertrophy, intracellular volume and an increase in chondrocyte height are responsible for most growth of long bones. Other factors that contribute to bone growth are chondrocyte proliferation and matrix synthesis, but to a lesser degree than chondrocyte hypertrophy. Growth plate chondrocytes undergo programmed cell death (apoptosis) after hypertrophy
takes place.
Bacterial resistance to tetracycline is confirmed by ribosome protection, tetracycline modification, and
altered RNA polymerase.
altered membrane binding protein.
increased drug efflux.
DNA gyrase mutation.
Mutations of bacterial DNA gyrase can decrease the effectiveness of quinolones. Altered membrane-binding protein is observed with resistance to ?
-lactam antibiotics. Tetracyclines are antibiotics that inhibit bacterial growth by stopping protein synthesis. Three specific mechanisms of tetracycline
resistance have been identified: increased tetracycline efflux, ribosome protection, and tetracycline modification. Alteration of RNA polymerase is found in resistance to rifampin.
A 14-year-old boy has failed physical therapy management for Scheuermann kyphosis, and an extension thoracolumbosacral orthosis brace is recommended. The boy and his parents are told that the brace will force his thoracic spine into normal sagittal alignment and put the anterior vertebral bodies of the thoracic segment into tension, which will induce bone growth and normalization of wedge- shaped
vertebrae. What name is associated with this process?
Hooke's law
Kirchhoff's law
Wolff's law
Heuter-Volkmann principle
The Heuter-Volkmann principle shows that bone placed in longitudinal tension will tend to stimulate longitudinal growth, and that compressive longitudinal forces inhibit longitudinal growth, making this response the best choice. Hooke's law relates to stress being proportional to strain and is not directly related to bone growth. Kirchhoff's laws apply to electrical circuit design. Wolff's law states that bone remodels in response to mechanical stress, with the correlate that increased stress causes increased growth, and decreased stress leads to bone loss.
A tendon repair is thought to be weakest during which phase of tendon healing?
Inflammatory
Proliferation
Maturation
Remodeling
Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest
5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth
factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor- beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.
A 4-year-old boy has bilateral genu varum and is in the fifth percentile for height for his age. A younger sister has less severe genu varum. Radiographs reveal physeal cupping and widening on both the distal femur and proximal tibia. Laboratory studies show sodium 145 mEq/L (reference range, 136-142 mEq/L), potassium 4.0 mEq/L (reference range, 3.5-5.0 mEq/L), calcium 9.0 mg/dL (reference range, 8.2-10.2 mg/dL), phosphorous 2 mg/dL (reference range, 4-

Question 99:

Options:

skeletal traction.
immediate application of a cast brace.
a retrograde supracondylar nail.
revision total knee replacement.
resection arthrodesis.

Correct Answer: a retrograde supracondylar nail.

Explanation:

Question 100:

Options:

A locked plate construct (locked screws) or hybrid construct (locked and non-locked screws) is necessary.
Periosteal stripping is performed through two incisions proximal and distal to the fracture.
Bridge plating is performed following direct reduction of the fracture.
AO Type A diaphyseal fractures are best treated with this technique.
Bridge plating with a long working length creates a flexible, axially stable construct.

Correct Answer: A locked plate construct (locked screws) or hybrid construct (locked and non-locked screws) is necessary.

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

Orthopedic Board Review MCQs: Foot, Fracture, Knee, Pediatric, Wrist | Part 207

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 207

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index