Orthopedic Board Review MCQs: Knee, Foot & Ankle | Pt 21

About This Board Review Set

This is Part 21 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 21

This module focuses heavily on: Ankle, Arthroplasty, Foot, Knee.

Sample Questions from This Set

Sample Question 1: A 55-year-old woman is referred for evaluation of a painful knee replacement. She underwent total kneearthroplasty (TKA) more than 1 year ago without perioperative complications but has had consistent pain since the surgery. The patient’s ...

Sample Question 2: Which of the following antibiotics is contraindicated in children?...

Sample Question 3: A newborn has been referred for evaluation of a deformed foot. Prenatal and birth history are unremarkable. Examination reveals a rocker bottom appearance to the foot, and a longitudinal arch cannot be created. A palpable lump is appreciate...

Sample Question 4: Which of the following surgical techniques is associated with an increased incidence of patellar complications after total knee arthroplasty?...

Sample Question 5: A 40-year-old man has a painless mass around his left ankle. He notes minimal growth over the past year. An MRI scan is shown in Figure 73a, and biopsy specimens are shown in Figures 73b and 73c. What is the most likely diagnosis?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 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 2

Which of the following antibiotics is contraindicated in children?

Explanation

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 3

A newborn has been referred for evaluation of a deformed foot. Prenatal and birth history are unremarkable. Examination reveals a rocker bottom appearance to the foot, and a longitudinal arch cannot be created. A palpable lump is appreciated on the plantar medial surface. What is the best course of action?

Explanation

DISCUSSION: The patient has congenital vertical talus. The navicular is irreducibly dorsally dislocated on the talus with the talar head prominent on the plantar medial aspect of the foot. Initial management involves corrective casting for 3 months to stretch the dorsal tendons, skin, and neurovascular structures. Surgical reconstruction is often needed and is indicated when the patient is age 6 to 12 months. Reconstruction requires both bony and soft-tissue procedures.
REFERENCES: Napiontek M: Congenital vertical talus: A retrospective and critical review of 32 feet operated on by peritalar reduction. J Pediatr Orthop 1995;4:179-187.
Oppenheim W, Smith C, Christie W: Congenital vertical talus. Foot Ankle 1985;5:198-204.

Question 4

Which of the following surgical techniques is associated with an increased incidence of patellar complications after total knee arthroplasty?

Explanation

DISCUSSION: Surgical technique in patellar resurfacing has been found to be one of the critical factors in the success or failure of total knee arthroplasty. Theoretically, metal-backed patellar components are an excellent way of evenly distributing joint forces from the polyethylene button to bone (similar to the tibial component). However, despite this theoretical advantage, metal-backed patellae have been associated with a higher failure rate. Some of the observed problems include poor bone ingrowth, peg failure, dissociation of the metal plate and polyethylene button, and component fracture. Because of these factors, all-polyethylene patellae have proved to be the standard if patellar resurfacing is attempted. Medialization of the patellar component, a symmetrically thick patella, and external rotation of the femoral and tibial components improve patellar tracking.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 323-337.
Barrack RL, et al: Resurfacing of the patella in total knee arthroplasty: A prospective, randomized, double-blind study. J Bone Joint Surg Am 1997;79:1121-1131.

Question 5

A 40-year-old man has a painless mass around his left ankle. He notes minimal growth over the past year. An MRI scan is shown in Figure 73a, and biopsy specimens are shown in Figures 73b and 73c. What is the most likely diagnosis?

Explanation

DISCUSSION: The biopsy specimen is a low-power view of a soft-tissue sarcoma with a biphasic pattern of epithelial cells and fibrous spindle cells that are typical of a synovial sarcoma. A deep, painless soft-tissue mass greater than 5 cm in size is suspicious for a sarcoma. The imaging in this patient is indeterminate and the patient requires a biopsy for an accurate diagnosis. The biopsy reveals a tumor with a biphasic appearance consistent with a synovial sarcoma. These tumors are slow growing, occur primarily in the lower extremities, and are found in a younger demographic population compared to malignant fibrous histiocytoma and liposarcoma. They can occur in a biphasic pattern with clumps of epithelial cells and fibrous spindle cells or in a monophasic pattern. Synovial sarcomas stain positively for keratin. Keratin is positive in nearly all biphasic types and in many tumors of the monophasic fibrous type. Sixty percent of these tumors are found in the lower extremity. The area around the knee is the most common location, followed by the ankle and foot. Epithelioid and clear cell sarcomas are found associated with tendon sheaths of the hand and feet and are generally smaller in size. Epithelioid sarcoma may resemble granulomatous inflammation histologically; clear cell sarcoma is composed of nests of clear cells with occasional multinucleated giant cells. Pigmented villonodular synovitis is found within the synovium and is characterized by a villous histologic appearance with hemosiderin-laden macrophages. Malignant fibrous histiocytoma has a storiform histologic pattern with an abundance of pleomorphic cells.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 757.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 227.

Question 6

A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm. Appropriate management should consist of

Explanation

DISCUSSION: An exercise program to strengthen the deltoid and remaining rotator cuff will most likely offer the best results. Revision rotator cuff surgery yields better results in decreasing pain than improving strength and function, and this patient has only minimal pain. Tendon transfers, involving the use of the latissimus dorsi or teres major, have been used when the rotator cuff is deemed irreparable but are not indicated in elderly patients with minimal symptoms.
REFERENCES: Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES: Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am 1992;74:1505-1515.
DeOrio JK, Cofield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am 1984;66:563-567.
Gerber C, Vinh TS, Hertel R, Hess CW: Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff: A preliminary report. Clin Orthop 1988;232:51-61.

Question 7

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered? Review Topic

Explanation

The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following spine fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.

Question 8

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior knee pain, a trace effusion, a 2+ posterior drawer, a grade 1A Lachman, no valgus laxity, and negative dial tests at 30° and 90°. What is the best treatment strategy at this time?

Explanation

Figure 1 is the MRI scan of a 61-year-old man who had left shoulder pain with a massive rotator cuff tear. Active forward elevation was 120°. Arthroscopic examination revealed that the rotator cuff tear was irreparable. The articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment option for pain relief in this patient?
A. Biceps tenotomy
B. Loose body removal
C. Latissimus dorsi transfer
D. Reverse total shoulder arthroplasty

Question 9

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Explanation

DISCUSSION: The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."

Question 10

A unilateral "piano key" sign, indicates

Explanation

EXPLANATION:
The piano key sign is a demonstration of instability at the DRUJ, typically seen after healing from a distal radius fracture with an associated ulnar styloid fracture (as in this case) or other wrist injury. The hand is pushed down against a table top, and the distal radius translates dorsally (with the distal ulna apparently moving volarly). In fact, the distal radius is the mobile segment, while the distal ulna is fixed in space. Treatment involves repair or reconstruction of the foveal insertion of the triangular fibrocartilage complex (TFCC) and distal radioulnar ligaments. This type of instability is also common in malunions of the distal radius or distal one-third of the radial shaft (Galeazzi-type fractures). In malunions, DRUJ instability can be treated with a corrective osteotomy of the distal radius to restore the anatomic relationship between the distal ulna and the distal radius at the DRUJ. Radiocarpal and midcarpal instability do not involve the DRUJ. Disruption of the interosseous membrane (in isolation, with intact distal radioulnar ligaments and an intact TFCC) does not lead to translational instability of the DRUJ. Although hypermobility syndrome may lead to ligamentous laxity, it does not lead to unilateral DRUJ instability.

Question 11

Arthrodesis

Explanation

Long term prospective study involving 67 humeral head replacements for OA &RA. "Based on this experience, we would recommend that humeral head replacement alone be used sparingly in patients
with OA or RA. Certainly in patients who have glenoid bone deficiency precluding placement of a glenoid component…" as is apparent in this radiograph.

Question 12

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

Explanation

DISCUSSION: The smallest pedicle isthmic width is at L1, whereas T12 has the largest pedicle width in the upper lumbar and lower thoracic spine. Although smaller in diameter than T12, both T10 and T11 have larger pedicle widths than L1.
REFERENCE: Ofiram E, Polly DW, Gilbert TJ Jr, et al: Is it safe to place pedicle screws in the lower thoracic spine than in the upper lumbar spine? Spine 2007;32:49-54.

Question 13

-In zone II flexor tendon lacerations, repairing only 1 slip compared to repairing both slips of the flexor digitorum sublimis results in

Explanation

Question 14

What term in statistics defines rejecting the null hypothesis when it is in fact true?

Explanation

Rejecting the null hypothesis when it is true is an example of a type-I error.
Type-I errors, to put it simply, detect an effect that is not present. In contrast, a type-II error fails to detect an effect that is present. In simple studies, the rate of a type-I error is denoted by a (alpha). For a 95% confidence level, the value of alpha is 0.05. This means that there is a 5% probability that we will reject a true null hypothesis.
Illustration A shows the difference between type-I and type-II errors. Incorrect Answers;
not technically considered "errors," but instead are variables that properly constructed studies attempt to avoid. Answer 4: Variance is an estimate of the variability of each individual data point from the mean.

Question 15

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Explanation

DISCUSSION: The resultant spasticity and weakness (paresis) following a cerebrovascular accident leads to muscle imbalance that commonly results in contracture of the shoulder in adduction, internal rotation, and varying degrees of forward flexion. In addition, the elbow is usually flexed and the forearm pronated.
REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 16

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Explanation

DISCUSSION: If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson’s fracture. Patients with this type of injury usually require fusion.
REFERENCES: Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50.
Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 362-363.

Question 17

During right knee anterior cruciate ligament (ACL) reconstruction, after drilling an appropriately positioned and referenced tibial tunnel, the surgeon finds that the transtibial guide is placing the femoral tunnel at 11:30 within the intercondylar notch. Which of the following choices will best enable appropriate graft placement in this clinical scenario? Review Topic

Explanation

Anatomic placement of the femoral tunnel is best achieved in this clinical scenario by drilling the femoral tunnel through the anteromedial portal or via a two-incision technique. Several recent studies have demonstrated the difficulty that may be encountered in restoring true ACL anatomy on the femoral side when placing a femoral tunnel through a transtibial technique. While this is not always the case and this technique may be reasonable and sufficient, it is important for orthopaedic surgeons to critically assess tunnel placement intraoperatively and postoperatively to
minimize errant tunnel placement, demonstrated in the literature as the most common cause of ACL failure and need for revision. In this not uncommon clinical scenario, simply converting to a two-incision ACL technique or drilling through the anteromedial portal with the knee hyperflexed will permit accurate femoral tunnel placement and increase the likelihood of an optimal clinical outcome. Femoral tunnel accuracy with these techniques is enhanced by a lower starting point in the intercondylar notch. Familiarity with these techniques is valuable for surgeons performing ACL reconstruction. Revising the tibial tunnel in this scenario would likely lead to bone compromise of the proximal tibia and may interfere with graft fixation and incorporation. Converting to a double-bundle ACL with a transtibial technique would not correct the vertical femoral tunnel. Hyperflexion of the knee may improve femoral tunnel placement to some extent, but is unlikely to allow anatomic placement of a femoral tunnel when the transtibial guide lies in a clearly excessive vertical position.

Question 18

When performing a Green transfer for cerebral palsy—flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB)—in addition to improving wrist extension, what other motion may be improved if the FCU is routed around the ulna instead of through the interosseous membrane?

Explanation

EXPLANATION:
The typical upper extremity deformity in spastic hemiplegic cerebral palsy consists of shoulder internal rotation, elbow flexion, forearm pronation and wrist flexion, and ulnar deviation. The pronation position of the forearm can make bimanual activities more challenging for the child. The wrist flexion and ulnar deviation deformity interferes with finger function and therefore with grasp and release patterns. By transferring the FCU tendon to the ECRB, the deforming force is released, and central wrist extension is augmented. This transfer can lead to a supination moment when it is routed around the ulna to the ECRB insertion on the dorsum of the wrist. Thumb and finger extension are not affected by an FCU-to-ECRB tendon transfer. Forearm supination, not pronation, is potentially improved with this tendon transfer.

Question 19

Figures 32a and 32b show the radiographs of a 13-year-old right hand-dominant boy who sustained a closed Salter-Harris type II fracture of the proximal humerus during a hockey game. The shoulder has significant swelling, but is neurovascularly intact. What treatment offers the best chance of reestablishing normal shoulder motion?

Explanation

DISCUSSION: The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient’s age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement.
REFERENCES: Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.
Sarwark JF, King EC, Luhmann SJ: Proximal humerus, scapula, and clavicle, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, pp 703-715.

Question 20

An active 55-year-old man who felt a sudden pop in the left heel while playing tennis 6 months ago was diagnosed with an ankle sprain around the time of injury. He now reports calf atrophy and severe weakness with running. Examination reveals a palpable defect in the Achilles tendon and only trace passive ankle flexion when the calf is squeezed. At the time of surgery, an Achilles tendon defect of 6 cm cannot be approximated. Surgical management of the Achilles tendon should include

Explanation

DISCUSSION: Chronic or neglected Achilles tendon ruptures can present a surgical problem. Ideally, end-to-end apposition of tendon should be attempted, but this should be accomplished without placing the foot in marked equinus. A defect of greater than 5 cm requires the use of a tendon transfer either alone or in combination with a V-Y advancement of the gastrocnemius. Because of its proximity to the Achilles tendon and its strength as a plantar flexor, the flexor hallucis longus is an ideal choice for this task. Studies have shown that early active range-of-motion exercises after an Achilles tendon repair is beneficial for tendon healing and improved clinical outcomes.
REFERENCES: Myerson M: Achilles tendon ruptures. Instr Course Lect 1999;48:219-230.
Mandelbaum BR, Myerson MS, Forster R: Achilles tendon ruptures: A new method of repair, early range of motion, and functional rehabilitation. Am J Sports Med 1995;23:392-395.

Question 21

An obtunded 80-year-old man was found alone in his apartment after an apparent fall. A CT scan performed in the emergency department shows that he has an extensile injury of an ankylosed cervical spine. The fracture extends across the ossified C5-C6 disk space and into the lamina of C5. There is 1.5 cm of widening between the C5 and C6 vertebrae anteriorly. The patient's family asks you about the long-term impact of the fracture on his functional capacity and survival. You advise them that patients with fractures of the cervical spine with ankylosing conditions have

Explanation

DISCUSSION
Several studies have found that rates of neurologic deficit and mortality are higher for patients with ankylosing spondylitis and a spinal fracture than for age-matched controls. The 2011 work of Schoenfeld and associates, which directly compared patients with cervical fractures in ankylosed spines to age-and sex-matched controls who also had cervical fractures but no ankylosing condition, demonstrated that those with ankylosing spondylitis were at elevated risk for mortality for up to 2 years after sustaining a fracture. In a study by Westerveld and associates, the rate of neurologic deficit among patients with ankylosing spondylitis and a spinal fracture was 57.1% compared to 12.6% among controls.
RECOMMENDED READINGS
Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J. 2014 May 1;14(5):729-40. doi: 10.1016/j.spinee.2013.06.038. Epub 2013 Aug 27. PubMed PMID: 23992936. View Abstract at PubMed
Schoenfeld AJ, Harris MB, McGuire KJ, Warholic N, Wood KB, Bono CM. Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study. Spine J. 2011 Apr;11(4):257-64. doi: 10.1016/j.spinee.2011.01.018. Epub 2011 Mar 5. PubMed PMID: 21377938. View Abstract at PubMed

Question 22

A 55-year-old woman with a history of untreated idiopathic scoliosis has had neurogenic claudication for the past several months. MRI reveals spinal stenosis at L2-L3, L3-L4, and L4-L5. Radiographs show a 45° lumbar curve from T10 to L4, with a degenerative spondylolisthesis at L4-L5. Laminectomy at the stenotic levels and stabilization of the deformity are planned. Which of the following is NOT considered an absolute indication for extending the fusion to the sacrum, rather than stopping at L5?

Explanation

DISCUSSION: There are several indications for extending adult scoliosis fusions to the sacrum, rather than stopping in the lower lumbar spine. These indications include posterior column deficiencies at L5-S1, such as spondylolysis and laminectomy, and deformities extending to the sacrum, such as fixed tilt of L5-S1 or sagittal imbalance. MRI signal changes in the L5-S1 disk do not preclude stopping the fusion at L5. Some surgeons use diskography or diagnostic facet blocks to evaluate the integrity of the L5-S1 level prior to stopping the fusion at L5. Long scoliosis fusions stopping at L5 have a significant risk of failure, highlighting the importance of careful selection of fusion levels.
REFERENCES: Bradford DS, Tay BK, Hu SS: Adult scoliosis: Surgical indications, operative management, complications, and outcomes. Spine 1999;24:2617-2629.
Bridwell KH: Where to stop the fusion distally in adult scoliosis: L4, L5, or the sacrum? Instr Course Lect 1996;45:101-107.
Edwards CC II, Bridwell KH, Patel A, et al: Long adult deformity fusions to L5 and the sacrum: A matched cohort analysis. Spine 2004;29:1996-2005.

Question 23

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

Explanation

Polytraumatized patients can be classified as stable, unstable, borderline, or in extremis. Management of the borderline patient is controversial because it is unclear which patients can safely undergo early definitive surgical stabilization of fractures, and which patients would benefit from temporizing "damage control" stabilization to allow adequate resuscitation and physiologic stabilization prior to definitive treatment. Although the question of damage control versus early total care is unresolved, there are several clinical parameters that have been suggested for use in deciding who should be treated with early damage control. These include Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with thoracic trauma, multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater. A hemoglobin of 9 g/dL is not included in these suggested parameters.

Question 24

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

Explanation

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

Question 25

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

Explanation

DISCUSSION: The patient has the classic signs of Little Leaguer’s shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic.
REFERENCES: Carson WG Jr, Gasser SI: Little Leaguer’s shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 26

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

Explanation

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

Question 27

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete's shoulder?

Explanation

The goal in the initial phase of shoulder rehabilitation is to improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. In the advanced strengthening and final phase, the goals are to initiate aggressive strengthening drills, enhance power and endurance, perform functional drills, and to gradually initiate throwing activities.

Question 28

Figure 35 shows the radiograph of a 35-year-old weightlifter who has had pain with overhead lifts for the past 7 months. Cortisone injections in the acromioclavicular joint provided only temporary relief. A bone scan reveals increased activity of the acromioclavicular joint. Treatment should now consist of

Explanation

DISCUSSION: Osteolysis of the distal clavicle is common in weightlifters; therefore, distal clavicle excision is the treatment of choice. A subacromial decompression alone would not alleviate the acromioclavicular joint symptoms. Interval closure, biceps degeneration, and superior labrum anterior and posterior repair would limit superior migration but would not explain the abnormal bone scan. Thermal capsular shrinkage does not have a role here.
REFERENCES: Flatow EL, Cordasco FA, McCluskey GM, Bigliani LU: Arthroscopic resection of the distal clavicle via a superior portal: A critical quantitative radiographic assessment of bone removal. Arthroscopy 1990;6:153-154.
Lyons FR, Rockwood CA: Osteolysis of the clavicle, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 541-546.

Question 29

What is the most important genetic element that distinguishes community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) from hospital-acquired MRSA? Review Topic

Explanation

PVL is a cytotoxin that defines CA-MRSA and is not typical of hospital-acquired MRSA. PVL has the ability to lyse white blood cells and cause tissue necrosis, allowing for rapid progression of abscess formation. Beta-lactamase is an enzyme that breaks the beta-lactam bond of penicillin and is present in most strains of Staphylococcus aureus today. Synthetic penicillins such as methicillin are resistant to the effects of beta-lactamase. MRSA and CA-MRSA carry the mecA gene, which
encodes a penicillin-binding protein with a very low affinity for beta-lactam antibiotics, resulting in methicillin resistance. SCCmec mobile genetic units carry the mecA gene with additional genetic elements that together yield the multidrug-resistant strains found in healthcare environments. SCCmec type IV is specific to CA-MRSA and lacks these additional genetic elements, resulting in less multidrug resistance.

Question 30

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy? Review Topic

Explanation

Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.

Question 31

Which of the following statements is true regarding brake travel time after surgical treatment of complex lower extremity trauma?

Explanation

DISCUSSION: Brake travel time (BTT) has been shown to be significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity.
Egol et al used a computerized driving simulator to compare BTT in three groups of patients; 1)control group, 2)long bone lower extremity fracture group, 3)lower extremity articular fracture group. They concluded that BTT was significantly reduced until 6 weeks after initiation of weight bearing in both long bone and articular fractures of the right lower extremity, and that short musculoskeletal functional assessment scores improved with respect to function and other indexes, but did not correlate with improvement in BTT.
An earlier study by Egol et al looked at total brake time as it related to distance traveled by the automobile before braking at 6, 9, and 12 weeks after operative fixation of a right ankle fracture. When compared with controls, braking time was shown to return to normal by 9 weeks post-operatively, and no significant association was found between the functional scores and this normalization.
Giddins et al provide a review of the literature, the law and the views of the major motor insurers related to driving after injury or operations.

Question 32

Trabecular bone is remodeled through the formation of

Explanation

Trabecular bone is remodeled through osteoclast activation that creates a resorption pit known as a Howship lacuna. After the pit is formed, osteoclasts are replaced by osteoblasts that form new bone matrix. The cement line separates new bone formation from resorption. Cutting cones are created in cortical bone remodeling. Haversian canals carry nerves and blood vessels longitudinally in bone, while Volkmann canals connect different Haversian canals.

Question 33

Porous hydroxyapatite is placed into a bone defect. Incorporation of this bone graft substitute is expected to follow which of the following patterns?

Explanation

Porous hydroxyapatite is created via a hydrothermal chemical exchange with phosphate of the calcium carbonate exoskeleton of ocean corals. This process converts the original exoskeleton into an inorganic replica of hydroxyapatite. The porous structure allows neovascularization and new bone is deposited on the macrostructure via appositional bone deposition. The hydroxyapatite does not dissolve and is not removed via creeping substitution. Creeping substitution relies on osteoclastic resorption creating a cutting cone followed by osteoblastic bone formation. The macrostructure of porous hydroxyapatite allows full penetration of osteoblasts and vascularization, not just to the periphery. Inorganic hydroxyapatite does not induce an inflammatory response.

Question 34

Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Explanation

These diseases cause demyelinated regions of the axon and thus have a higher capacitance and lower membrane resistance (opposite of normal) and thus affects an action potential’s saltatory propagation. When an action potential is propagate down a myelinated axon and reaches a demyelinated region its conduction becomes slowed or may even stop. This loss of conduction had effects on behavior.

Question 35

A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. She occasionally takes acetaminophen, but the pain does not limit sport activities. Examination reveals a mild right rib prominence during forward bending. Neurologic examination is normal. Radiographs show a 20-degree right thoracic scoliosis with no congenital anomalies or lytic lesions. Management should consist of Review Topic

Explanation

Mild scoliosis is not a painful condition, but it usually presents during adolescence. Intermittent back pain is reported by 25% to 30% of adolescents whether or not scoliosis is present. Such pain is often attributed to muscle strain from tight muscles, poor posture, or heavy school backpacks. The clinician must distinguish typical pain (mild, intermittent, nonlimiting) from atypical pain. The latter requires more careful examination and imaging studies (bone scan or MRI) to determine the source of pain. The patient’s age and right thoracic curve pattern are typical for idiopathic scoliosis; therefore, imaging of the neuroaxis is not necessary to look for cord syrinx, tethering,
or tumor. Brace treatment is not required for this small curve unless future progression is demonstrated.

Question 36

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 37

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

Explanation

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

Question 38

A 32-year-old woman has left second toe dactylitis (sausage toe). Radiographs show a “pencil in cup” distal interphalangeal joint deformity. Examination reveals that subtalar motion is markedly reduced. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s clinical picture is considered the classic presentation for psoriatic arthritis. The other answers are not applicable for the constellation of findings.
REFERENCES: Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA,

WB Saunders, 1991, pp 1691-1693.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Question 39

A 70-year old woman undergoes revision total knee arthroplasty for tibial component aseptic loosening. She is concerned about recurrent loosening, and tibial stem fixation options during revision are reviewed. Figure below displays a radiograph of the revision technique used for this patient. What is the incidence of intraoperative tibial shaft fracture that is associated with this type of revision surgery?

Explanation

DISCUSSION:
Using press-fit tibial stems during a hybrid revision total knee arthroplasty is associated with a 3% to 5% incidence of intraoperative tibial shaft fracture. Diaphyseal fixation of press-fit stems has the advantage of setting component alignment, dispersing forces on the proximal tibia, and offers excellent clinical results. The disadvantages include proximal and distal tibia anatomic mismatch and tibial shaft fracture. Cipriano and associates reported a tibial shaft fracture incidence of 4.9% in a series of 420 consecutive
knee revisions. All fractures healed with nonsurgical management, and none led to implant loosening. In this patient, it is important to recognize on the radiograph that this technique is a hybrid method of revision total knee arthroplasty, with cementation along the tibial tray and metaphysis and with press-fit fixation of the diaphyseal engaging stem. Then, it is important to know the risk and management of intraoperative diaphyseal tibial fractures. Cemented tibial stems are associated with a low rate of intraoperative fracture, because the implant is typically undersized to allow for an appropriate cement mantle. Option C is incorrect, because this revision is not cemented. Option A underestimates the incidence of fracture,
whereas D overestimates the rate of fracture.

Question 40

Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?

Explanation

DISCUSSION
The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609. View Abstract at PubMed
Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211. View Abstract at PubMed
Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13. View Abstract at PubMed
Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496. View Abstract at PubMed
Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070. View Abstract at PubMed
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.View Abstract at PubMed
Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258. View Abstract at PubMed

Question 41

During a percutaneous plating of a proximal tibia fracture requiring a 13-hole minimally invasive locking plate system, the placement of the distal most screws should be done through a small open incision to avoid injury to what structure?

Explanation

The superficial and deep peroneal nerves are consistently at risk near the distal holes of long locking proximal tibia plates but can be avoided with a small open incision for those screws. The peroneal tendons are more posterior at that level. The saphenous nerve is medial. The peroneal artery runs behind the fibula and is not at risk. The posterior tibial artery is posterior to the tibia.

Question 42

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

Explanation

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

Question 43

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Explanation

DISCUSSION: Cervical laminectomy is an accepted treatment for multilevel cervical spondylotic myelopathy. When the compression is posterior, laminectomy addresses it directly; when the compression is anterior, it is addressed indirectly (the spinal cord floats posteriorly away from the anterior compression). Preexisting kyphosis is a contraindication to laminectomy because the cord is unable to float posteriorly away from the anterior compression, and the risk for increasing kyphosis is significant. Kyphosis after laminectomy is more likely to develop in younger patients who have fewer degenerative changes to stabilize the spine.
REFERENCES: Malone DG, Benzyl EC: Laminotomy and laminectomy for spinal stenosis causing radiculopathy or myelopathy, in Clark CR (ed.): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 817-825.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 44

A 4-month-old infant is referred for evaluation of congenital scoliosis. The child has no congenital heart anomalies, and a renal ultrasound shows that he has one kidney. Examination reveals mild scoliosis and a large hairy patch on the child’s back. Neurologic evaluation is normal for his age. A clinical photograph and radiograph are shown in Figures 19a and 19b. Initial management should consist of Review Topic

Explanation

Congenital anomalies of the spine, including failure of formation and failure of segmentation, are associated with other anomalies in other organ systems that develop at the same time. These include anomalies in the genitourinary system, cardiac anomalies, Sprengel’s deformity, radial hypoplasia, and gastrointestinal anomalies including imperforate anus and trachealesophageal fistula. Spinal dysraphism is the most common associated abnormality. McMaster found an 18% incidence before the common use of MRI. Bradford and associates reported on 16 of 42 patients with congenital spinal anomalies and spinal dysraphism using MRI. Neural axis lesions may be associated with visible midline abnormalities such as a hairy patch or nevus. The child has already had a cardiac and renal work-up, and based on the findings of the hairy patch and congenital vertebral anomalies, MRI of the entire spine is prudent at this time. Spinal fusion is indicated for progressive congenital scoliosis or kyphosis. Physical therapy does not affect the natural history of congenital scoliosis.

Question 45

The above surgery was performed with recombinant human bone morphogenetic protein-2 (rhBMP-2). She reports immediate relief of her leg pain and is discharged home on postoperative day 2. The patient reports new-onset radicular pain and weakness in her leg 1 year later. Figures 22a and 22b are her postoperative CT myelogram images. What is the most likely cause of her pain? 22A B

Explanation

DISCUSSION
Transient thigh pain after lateral, transpsoas interbody fusion is common and generally lasts for less than 3 months. Transpsoas interbody fusion with slip reduction can result in indirect spinal decompression and often obviates the need for a laminectomy for most patients. Complications with this approach are comparable to those experienced with open surgery, but the hospital stay is generally shorter.
Use of BMP in interbody devices has also become common. The images above show heterotopic bone growth into the spinal canal causing nerve compression. This complication is more commonly encountered after posterior lumbar interbody fusions.
RECOMMENDED READINGS
Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements.
Spine (Phila Pa 1976). 2010 Dec 15;35(26 Suppl):S331-7. doi: 10.1097/BRS.0b013e3182022db0. PubMed PMID: 21160397. View Abstract at PubMed Cummock MD, Vanni S, Levi AD, Yu Y, Wang MY. An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine. 2011 Jul;15(1):11-8. doi: 10.3171/2011.2.SPINE10374. Epub 2011 Apr 8. PubMed PMID:

Question 46

A 56-year-old man has had a 2-year history of slowly progressive neck pain and bilateral arm aching. Over the past year, he has noticed intermittent, diffuse numbness in both hands, with decreased grip strength and mild hand clumsiness. He denies any problems with balance. Examination shows a wide-based gait, intrinsic wasting, and a postive Hoffman's sign bilaterally. An MRI scan of the cervical spine is shown in Figure 16. What is the most appropriate treatment? Review Topic

Explanation

The patient has classic symptoms of myelopathy with upper motor neuron signs on examination. His symptoms have been present for years, and are getting worse. The cervical spine MRI scan shows spinal stenosis with multilevel spondylosis causing spinal cord compression at multiple levels. With the longstanding duration of the patient's signs and symptoms, combined with involvement of multiple levels in the cervical spine, posterior multilevel laminectomy and fusion is the best treatment option. Two-level anterior diskectomy and fusion would address the two areas of most severe narrowing, but it would fail to decompress the other stenotic areas which also require decompression. Posterior cervical foraminotomies would only address radicular symptoms, which are not present in this patient, and would not succeed in decompression of the spinal cord. Cervical epidural injections are not indicated for myelopathy symptoms, and may in fact place this patient at risk for neurologic deterioration.

Question 47

The CT scan reveals a nondisplaced greater trochanteric fracture. The patient is now experiencing severe pain. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
This patient presents with significant polyethylene wear, which can lead to both osteolysis and synovitis. However, synovitis usually manifests as a mild to moderate chronic ache, which should explain the discomfort. Although infection should always be ruled out with new-onset pain, no clinical parameters suggest acute hematogenous infection. Similarly, without any mention of back pain or neuropathy, radicular pain from the spine is unlikely. If this patient has a nondisplaced greater trochanteric fracture noted on MR imaging, the optimal immediate mode of treatment is to not rush into surgery despite the mild osteolysis. The patient’s severe pain is likely attributable to the nondisplaced greater trochanteric fracture rather than wear-induced synovitis, which typically presents as a mild to moderate ache. It is recommended to
allow the fracture to heal to avoid fracture displacement. Once the fracture is healed, a revision surgery with liner exchange can be recommended. Based on this clinical scenario, the acetabular component is within what is largely considered the “safe-zone” in THA. Despite this patient’s dislocations, the preferred treatment modality is to revise to a constrained liner. This patient had a well-functioning hip for longer than 15 years. Therefore, conversion to a constrained liner is the best treatment.

Question 48

A 16-year-old football player sustains a direct blow to the anterior aspect of his flexed right knee. Examination reveals a contusion over the anterior tibial tubercle and a small effusion. MRI scans are shown in Figures 33a through 33c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show disruption of the fibers of the PCL. Patients sustaining an isolated acute PCL injury can present with only minimal discomfort and have full range of motion. When examination reveals a contusion over the tibial tubercle and discomfort with the posterior drawer examination, with or without instability, a possible injury to the PCL should be considered. In acute injuries, the reported accuracy of MRI imaging for diagnosing PCL tears ranges from 96% to 100%.
REFERENCES: Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 699-700.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.
Fischer SP, Fox JM, Del Pizzo W, Friedman MJ, Snyder SJ, Ferkel RD: Accuracy of diagnoses from magnetic imaging of the knee: A multi-center analysis of one thousand and fourteen patients. J Bone Joint Surg Am 1991;73:2-10.

Question 49

Figures A-C are images of a 37-year-old man who presents with isolated muscle atrophy due to a compressed nerve. Which of the following sequences correctly describes the pathway of this nerve through the brachial plexus, before it innervates the affected muscles?

Explanation

Figures A-C shows atrophy of teres minor and deltoid due to compression of the axillary nerve. The correct pathway of the axillary nerve within the brachial plexus is, C5-C6 nerve roots; upper trunk, posterior division, posterior cord.
Quadrilateral space syndrome is a condition defined by axillary nerve, +/- posterior humeral circumflex artery compression in the quadrilateral space. It most commonly affects the dominant shoulder in overhead movement athletes (e.g. basketball players) or other throwing athletes. Physical examination may reveal weakness with the arm positioned in abduction and external rotation. In situations of long-standing compression, there may also be atrophy of the teres minor and deltoid muscle.
Chafik et al. dissected thirty-one cadaveric human shoulders to describe the neuromuscular anatomy of teres minor. They showed that the primary nerve branch to teres minor travelled in a fascial sling 44 mm medial to the muscular insertion. This
area may be the potential site of greatest compression and tethering of this nerve in patients with isolated teres minor atrophy.
Friend et al. performed a cadaveric dissection of nine shoulder specimens to look at the anatomical variability in course, length and branching pattern of both the teres minor nerve and the axillary nerve. These were compared to a case-based study of these two male patients with isolated atrophy of teres minor. They concluded that there is no good anatomical predictor of nerve compression outside the quadrilateral space as there is considerable anatomical variation in its origin and course, as well as potential site of compression.
Figure A-C are MRI images that show atrophy of the teres minor muscle and possibly deltoid muscle. The rotator cuff muscles are labeled in Illustration A. The teres minor muscle is labeled in Illustration B. Illustration C shows a diagram of the brachial plexus.
Incorrect
1:
This
describes
the
musculocutaneous
nerve.
3:
This
describes
the
suprascapular
nerve.
4:
This
describes
the
long thoracic
nerve.

Question 50

Figures 10a and 10b show the radiographs of an athletic 9-year-old boy who has activity-related anterior knee pain with intact active knee extension. Examination reveals tenderness to palpation over the inferior pole of the patella. There is no effusion or ligamentous instability. Initial management should consist of

Explanation

DISCUSSION: The radiographs show fragmentation of the inferior pole of the patella. This finding, along with the clinical presentation, is most consistent with Sindig-Larsen-Johansson disease. This is an overuse syndrome commonly seen in boys ages 9 to 11 years. The differential diagnosis includes bipartite patella and patellar sleeve fracture. Like most overuse syndromes, Sindig-Larsen-Johansson disease responds to activity modification and nonsteroidal anti-inflammatory drugs. While symptoms usually resolve with short periods of activity restriction, radiographic findings may persist.
REFERENCES: Stanitski CL: Anterior knee pain syndromes in the adolescent. J Bone Joint Surg Am 1993;75:1407-1416.
Stanitski CL: Anterior knee pain syndromes in the adolescent, in Schafer M (ed): Instructional Course Lectures 43. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1994, pp 211-220.

Question 51

03 A 35 year old man sustains a dislocation of his dominant shoulder in a fall. The shoulder is reduced and placed in a sling, but returns 6 hours later with shoulder dislocated again, despite use of a sling. A CT scan is shown in figure 36. Management should now consist of

Explanation

AM J Sports Med 1998;26:41-45 JBJS Am 1993;75:479-484
back to this question go to explanation

Question 52

What nerve is at greatest risk when developing the superficial plane between the tensor fascia lata and sartorious during the anterior (Smith-Peterson) approach to the hip?

Explanation

DISCUSSION: The lateral femoral cutaneous nerve pierces the fascia between the tensor fascia lata and the sartorius approximately 2.5 cm distal to the anterosuperior iliac spine and is at risk when the interval is defined. The superior gluteal and femoral nerves define the internervous plane between the tensor fascia lata and the sartorius and are not at risk for injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 302-316.
Crenshaw AH (ed): Campbell’s Operative Orthopedics, ed 7. St Louis, MO, CV Mosby, 1987, pp 59-60.

Question 53

The newborn foot deformity seen in Figures 64a and 64b should initially treated with

Explanation

DISCUSSION: Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American AcademAyL-oMfadOenrathCooppayedic Surgeons, 2006, pp 240-241.
Farsetti P, Weinstein SL, Ponseti IV: The Long-term functional and radiographic outcomes of untreated
and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265. Question 65
A 4-year-old girl has been limping for the past 2 months. There is no history of trauma, previous injury, fever, or other systemic complaints. Examination reveals a moderate right knee effusio n with a 10-degree knee flexion contracture. What is the next most appropriate step in evaluation?
Arthroscopy
Antinuclear antibody
MRI
Bone scan
HLA-B27
DISCUSSION: The patient presents with juvenile idiopathic arthritis manifestations. The American College of Rheumatology defines this as one or more joints involved with swelling of 6 weeks or longer. A positive antinuclear antibody test would be diagnostic. Consideration should be made to have the patient see an ophthalmologist for evaluation of possible uveitis. Although the patient could have Lyme disease, that choice is not an option. The presence of an elevated antinuclear antibody by itself should not necessarily be used for diagnosing arthritis; however, the test does have clinical utility as a screening test. The frequency of a positive antinuclear antibody test is greatest in younger girls with oligoarticular disease and carries an increased risk for anterior uveitis. Arthroscopy might be indicated if this patient was presenting with a discoid meniscus, but there is no history of clicking, which is often one of the classic signs of discoid meniscus. MRI would not be used to diagnose juvenile idiopathic arthritis, but
MRI would be useful to help diagnose discoid meniscus. A bone scan would show increased uptake in the patient’s knee but again, this would not help diagnose her condition. HLA-B27 has no role in diagnosing juvenile idiopathic arthritis, especially in females.
REFERENCES: Iesaka K, Kubiak EN, Bong LR, et al: Orthopaedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 2006;35:67-73.
Wright DA: Juvenile idiopathic arthritis, in Morrissey RT, Weinstein SL (eds): Love l and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia PA, Lippincott Williams and Wilkins, 2006, pp 405-438. Question 66
An 18-month-old girl is brought in by her parents because of concerns about intoeing, bowlegs, and tripping and fa ling. Prenatal and birth history are otherwise unremarkable. The child’s growth and
development appear to be normal and she has a normal neurologic exam, a straight spine with no defects, and the hips are stable. Examination reveals hip internal rotation of 40 degrees and hip external rotation of 60 degrees. The thigh-foot angle is internal 30 degrees. Feet are straight and supple. Gait is characterized by intoeing with occasional tripping and falling. Based on these findings, what is the most appropriate action?
No treatment because internal tibial torsion slowly resolves on its own
Immediate treatment with a Denis-Browne bar
Distal tibial osteotomies
Proximal femoral derotational osteotomies
Treatment with twister cables PREFERRED RESPONSE: 1
DISCUSSION: The child has classic internal tibial torsion that is very commonly seen in younger children who are just beginning to walk. The normal outcome is for slow resolution of this problem and it seldom requires any treatment. Treatment with a Denis-Browne bar or with twister cables has not been proven to be effective. Surgical treatment at this point is premature and clearly not indicated.
REFERENCES: Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.
Staheli LT, Corbett M, Wyss C, et al: Lower-extremity rotational problems in children: Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47.

Question 54

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

Explanation

In children, the main route of infection in skeletal TB is through hematogenous spread from a primary source. The mycobacterium is deposited in the end arterials in the vertebral body adjacent to the anterior aspect of the vertebral end plate. Thus, the anterior portion of the vertebral body is most commonly involved. The lower thoracic region is the most common segment; next in decreasing order of frequency are the lumbar, upper thoracic, cervical, and sacral regions.

Question 55

A 38-year-old man sustains a terrible triad injury consisting of an elbow dislocation, comminuted and displaced radial head fracture, and a type I coronoid fracture. Intraoperative findings after radial head replacement and lateral collateral ligament complex repair reveal persistent instability consisting of medial opening on valgus stress and posteromedial subluxation of the ulnohumeral and radiocapitellar joints. What is the best next step?

Explanation

Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which will
normally correct the medial instability. Articulated versus static external fixation can be considered if
restoration of the ligamentous constraint of the medial side of the elbow cannot be accomplished surgically.

Question 56

Figure 1 is the clinical photograph of a 42-year-old woman who has a lesion that has failed prior silver nitrate applications. She experiences frequent bleeding from this lesion. A tissue biopsy performed by a dermatologist revealed capillary hypertrophy with lobular arrangement. Which treatment is most appropriate to minimize recurrence?

Explanation

EXPLANATION:
This lesion is a pyogenic granuloma, which is a common benign vascular lesion that can occur on skin or mucosa. The etiology is unclear, although this lesion tends to occur in areas of physical trauma. Initial treatment with silver nitrate with an average of 1.6 applications has a success rate of 85%. This patient, however, has failed silver nitrate applications. Wide surgical excision (Figures below) is associated with the lowest recurrence rate and offers the benefit of a single procedure. Other options often necessitate repeated procedures to completely eradicate this lesion.

Question 57

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Explanation

Medoff described the radiographic teardrop of the distal radius. This radiographic landmark matches the critical volar ulnar corner of the distal radius. A malreduction of the volar ulnar corner of the distal radius in an intra-articular distal radius fracture leads to volar subluxation of the lunate and the rapid development of posttraumatic arthritis at the distal radioulnar and radiolunate joints. Knowledge of the specific shape and appearance of this radiographic landmark helps the surgeon when he or she is critically analyzing postreduction imaging. The volar portion of the ulnar head may be mistaken for this teardrop sign and should be separately identified as distinct from the distal radius. The radial styloid and Lister tubercle are not part of the volar aspect of the lunate facet.

Question 58

A right-handed 24-year-old professional baseball player injured his left shoulder 6 weeks ago when he dove forward and landed hard with the arm extended. He reports that the shoulder “slipped out” and “went back in.” The shoulder did not need to be reduced. He now reports deep pain in the front of the shoulder when batting on either side and is hesitant to raise his left arm up over his head to catch a ball. Examination reveals no obvious deformities of the shoulder and a somewhat guarded, limited range of motion in all planes. Provocative tests for the rotator cuff and labrum are equivocal. MRI scans are shown in Figures 16a and 16b. What is the best course of action?

Explanation

DISCUSSION: A hard fall on an outstretched arm often results in injury to the glenoid labrum. A significant tear of the anterior/inferior labrum often leads to instability, pain, and mechanical symptoms of the shoulder. The MRI scan shows no obvious labral tear or Hill-Sachs lesion to suggest an anterior dislocation. Recent clinical studies have suggested that early stabilization of initial anterior dislocations may lead to better results than nonsurgical management in young, athletic patients. However, there are no data to support early surgery for anterior labral tears resulting from traumatic subluxation without dislocation. Initial treatment should consist of a short period of rest and immobilization, followed by a physical therapy rehabilitation program designed to restore motion, strength, and dynamic stability to the shoulder. If the athlete cannot return to play following nonsurgical management, surgical repair of the labrum, either through an open or arthroscopic approach, is indicated. There is no role for immediate thermal capsular shift in this setting.
REFERENCES: Abrams JS, Savoie FH III, Tauro JC, et al: Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior and multidirectional. Arthroscopy 2002;18:1-13.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.

Question 59

Which of the following best describes heat stroke? Review Topic

Explanation

Heat stroke consists of hyperthermia (greater than 105.8 degrees F [41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than 102.2 degrees F (39 degrees C) and an absence of central nervous system dysfunction. Hypernatremic heat exhaustion results from inadequate water replacement.

Question 60

Which of the following statements regarding the use of thermal shrinkage during arthroscopic shoulder surgery is most accurate? Review Topic

Explanation

Reports of clinical results at 2- and 5-year follow-up indicate much higher failure rates than traditional stabilization techniques for all common instability patterns. The degree of capsular shrinkage is dependent on the total amount of thermal energy delivered, as well as the rate of delivery. Denatured tissue undergoes a healing response. The capsule typically encountered in revision cases is thin and patulous, rather than thick and fibrotic.

Question 61

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Explanation

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17. http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 62

A 10-year-old child has leg discomfort with activity. A radiograph, bone scan, and biopsy specimen are shown in Figures 1a through 1c. What is the most likely diagnosis?

Explanation

DISCUSSION: The ground glass appearance on the radiograph, the hot bone scan, and histologic findings of bony spicules without osteoblastic rimming in a background of bland fibrous tissue all suggest fibrous dysplasia. Stress-related pain is common with activity because of the dysplastic bone. Parosteal osteosarcomas are surface lesions. Simple cysts, aneurysmal bone cysts, and eosinophilic granuloma are all possible radiographically; however, the histology is most consistent with fibrous dysplasia.
REFERENCES: Harris WH, Dudley HR Jr, Barry RS: The natural history of fibrous dysplasia: An orthopaedic, pathological and roentgenographic study. J Bone Joint Surg Am 1962;44:207.
Campanacci M: Bone and Soft Tissue Tumors. Vienna, Austria, Springer-Verlag, 1990.

Question 63

Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate for which of the following patients? Review Topic

Explanation

Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate in a patient with pseudoparesis of anterior elevation and external rotation, in the setting of shoulder arthritis (narrowing of glenohumeral joint and acetabularization of the acromion).
Combining a latissimus dorsi tendon transfers with reverse total shoulder arthroplasty (R-TSA) helps to restore control of active external rotation. Dysfunction with external rotation can be determined clinically with external rotation lag sign, a positive Hornblower's sign, and radiographically with fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al.
Gerber et al. found that R-TSA with combined lat dorsi transfer yielded minimal improvements in external rotation ROM (13 deg to 19 deg) compared to increases in shoulder ROM in flexion (94 deg to 137 deg) and abduction (87 deg to 145 deg), with this procedure.
Boileau et al. examined 17 consecutive patients treated with reverse shoulder arthroplasty and latissimus dorsi and teres major transfer (L'Episcopo). They found
that external rotation increased from -21 degrees to 13 degrees (+34 degrees ). They recommend transferring both the LD and TM, rather than the LD alone as it results in better active external rotation.
Illustration A is a radiograph showing a right reverse total shoulder replacement. Illustration B shows a cadaveric image of the positioning of the latissimus dorsi tendon transfer prior to implantation of the reverse total shoulder components.
Incorrect Answers

Question 64

A 21-year-old man has had right groin pain for the past year. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 50a through 50e. What is the most likely diagnosis?

Explanation

DISCUSSION: The pathology demonstrates a very cellular chondroid matrix with multinucleated forms, atypia, and myxomatous regions. This is most consistent with a myxoid chondrosarcoma. The radiograph shows a well-circumscribed lesion in the superior and medial aspect of the right acetabulum. The CT and MRI scans confirm these same findings with no evidence of matrix mineralization or significant surrounding edema. Unfortunately, in this location with this appearance, the radiographic differential diagnosis includes all the diagnoses listed.
REFERENCES: Terek RM: Recent advances in the basic science of chondrosarcoma. Orthop Clin North Am 2006;37:9-14.
Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.

Question 65

A 62-year-old woman with a bone mass density (BMD) T-score of -2.0 sustained a subcapital fracture of her hip. She is an avid tennis player, and history reveals no previous fractures. What is the most appropriate follow-up care?

Explanation

DISCUSSION: A DEXA scan is most appropriately used to establish a baseline score. Even if the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone density, such as worsening vision or balance, confusion, or other predispositions to falls. The guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is performed. A recent study showed that antiresorptive therapy following a hip fracture reduces not only the risk of a second fracture but also overall mortality.
REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint Surg Am 2005;87:3-7.

Question 66

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

Explanation

DISCUSSION: The clinical findings indicate venous obstruction without arterial compression, and the venogram reveals occlusion of the subclavian vein, which is most likely the result of thoracic outlet compression. In the developed athlete, scalene muscle hypertrophy (Paget-Schroetter syndrome) causes compression of the subclavian vein. Treatment should consist of thrombolysis followed by decompressive surgery.
REFERENCES: Angle N, Gelabert HA, Farooq MM, et al: Safety and efficacy of early surgical decompression of the thoracic outlet for Paget-Schroetter syndrome. Ann Vasc Surg 2001;15:37-42.
Azakie A, McElhinney DB, Thompson RW, et al: Surgical management of subclavian-vein effort thrombosis as a result of thoracic outlet compression. J Vasc Surg 1998;28:777-786.

Question 67

A 6-year-old girl is referred for the elbow injury seen in Figure 2. What is the most appropriate treatment?

Explanation

DISCUSSION: The patient has a displaced lateral condyle fracture; therefore, simple immobilization for 3 to 8 weeks is likely to result in malunion or nonunion. Closed reduction of such injuries is rarely successful. The fracture is unstable, so fixation is required after open reduction. Because the fixation must cross the physis, smooth pins are indicated for the skeletally immature elbow. Open reduction with fixation has been shown to reduce the risk of delayed union and malunion.
REFERENCES: Beaty JH, Kasser JR: The elbow: Physeal fractures, apophyseal injuries

of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 625-703.
Rutherford A: Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am 1985;67:851-856.
Hasler CC, von Laer L: Prevention of growth disturbances after fractures of the lateral humeral condyle in children. J Pediatr Orthop B 2001;10:123-130.

Question 68

Portions of which of the following normal structures help compose the spiral cord seen in Dupuytren’s contracture?

Explanation

DISCUSSION: The normal fascial components that become diseased and compose the spiral cord include the pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament. Cleland’s ligament lies dorsal and is not involved with spiral cord formation. The intrinsic muscle and tendon, the natatory ligament, and the intermetacarpal ligament are well proximal to the digit and are not involved in spiral cord formation.
REFERENCES: McGrouther D: Dupuytren’s contracture, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone,

1999, vol 1, pp 565-569.
McFarlane R: Patterns of diseased fascia in the fingers in Dupuytren’s contracture.

Plast Reconstr Surg 1974;54:31-44.

Question 69

A 45-year-old woman has had radiating pain in the medial ankle for the past 3 months. Examination reveals a small mass in the retromedial ankle region and a positive Tinel’s sign. An intraoperative photograph and a hematoxylin/eosin biopsy specimen are shown in Figures 24a and 24b. Treatment should consist of

Explanation

DISCUSSION: Neurilemoma is a benign tumor of nerve sheath origin, and peak incidence is in the third through sixth decades. The tumor is well encapsulated on the surface of a peripheral nerve. MRI findings may be significant for a “string sign.” A positive Tinel’s sign in the distribution of the nerve affected may be present. Grossly, the lesion is well encapsulated in a nerve sheath. Microscopically, there are structures referred to as Antoni A (a pattern of spindle cells arranged in intersecting bundles) and Antoni B (areas with less cellularity with loosely arranged cells). These lesions are benign, and treatment should consist of marginal excision. Nerve function may be preserved by careful dissection, excising the lesion parallel to the nerve fascicles so the lesion may be extruded. Recurrence is rare.
REFERENCES: Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1007-1032.
Simon M, Springfield D: Surgery for the Bone and Soft-Tissue Tumors. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 530-531.

Question 70

The patient returns 1 year later to report curling of her toes and numbness on the plantar surface of her foot. What is the most likely cause of this condition?

Explanation

DISCUSSION
Radiographs reveal a Lisfranc fracture dislocation with fractures of the first and second metatarsals. Tenting of skin that is over a bony prominence is an orthopaedic emergency. The fracture dislocation should be reduced without delay. There is no evidence of compartment syndrome of the foot, but this may develop and monitoring is necessary. Toe deformity may develop on a delayed basis because of the subclinical presentation. Nerve irritation is not uncommon with dorsal midfoot surgical incisions. A positive Tinel test result over the midfoot in the distribution of the superficial common peroneal nerve is consistent with a stretch injury to this nerve. CRPS is usually associated with multiple nerve distributions and autonomic nerve findings such as cold hypersensitivity and hyperhidrosis.
RECOMMENDED READINGS
Benirschke SK, Meinberg EG, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. Instr Course Lect. 2013;62:79-91. PubMed PMID: 23395016. View Abstract at PubMed
Schepers T, Oprel PP, Van Lieshout EM. Influence of approach and implant on reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal joint. Foot Ankle Int. 2013 May;34(5):705-10. doi: 10.1177/1071100712468581. Epub 2013 Jan 14. PubMed
PMID: 23637239. View Abstract at PubMed

Question 71

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Explanation

DISCUSSION: The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.
REFERENCES: Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225.
Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Kerr CD, Sybert DR, Albarracin NS: An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases. J Hand Surg Am 1992;17:1028-1030.

Question 72

For halo traction, what is the preferred site for anterior pin placement?

Explanation

DISCUSSION: The safe zone for anterior halo pin insertion is marked laterally by the anterior border of the temporalis muscle (to avoid penetration of this muscle and relative thin cortex of the skull). Medially, the pin should be placed 4.5 cm lateral to the midline to avoid injury to the supraorbital nerve or the frontal sinus. The safe area is marked superiorly by the head equator to avoid cephalad migration of the pin and inferiorly by the supraorbital ridge to prevent displacement or penetration into the orbit.
REFERENCE: Ebraheim NA, Lu J, Biyani A, Brown JA: Anatomic considerations of halo pin placement. Am J Orthop 1996;25:754-756.

Question 73

Nerve conduction velocity is slowed by

Explanation

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no association between hand dominance and nerve conduction velocity.

Question 74

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

Explanation

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

Question 75

Because of the ongoing pain and instability and the demonstration of radiographic instability when the ankle is stressed, what surgical procedure should be performed to restore stability to the ankle joint based on the CT findings?

Explanation

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 76

A 71-year-old woman with coronary artery disease underwent an uncomplicated right total hip arthroplasty for osteoarthritis 12 years ago. Her hip has functioned well until approximately 18 months ago when she noted the spontaneous onset of groin, buttock, and proximal thigh pain that is present at rest and made worse with activity. A radiograph is shown in Figure 15. What is the recommended management at this point?

Explanation

DISCUSSION: The radiograph shows significant osteolysis with loosening of the femoral component. The patient is symptomatic and surgery is indicated because of the extent of osteolysis and the loose femoral component.
Reassurance and follow-up if symptoms worsen places the patient at risk for further bone loss and periprosthetic fracture. Emergent surgery is not required because the symptoms have been present for more than a year; however, urgent revision hip arthroplasty is recommended when the patient is medically cleared. While there is data to suggest that bisphosphonates may slow the progression of osteolysis in animal modes, there is no clear evidence that bisphosphonate treatment prevents the progression of osteolysis in humans. Additionally, this patient has a loose symptomatic femoral component.
REFERENCES: Chiang PP, Burke DW, Freiberg AA, et al: Osteolysis of the pelvis: Evaluation and treatment. Clin Orthop Relat Res 2003;417:164-174.
Dunbar MJ, Blackley HR, Bourne RB: Osteolysis of the femur: Principles of management. Instr Course Lect 2001;50:197-209.
Rubash HE, Dorr LD, Jacobs JJ, et al: Does alendronate inhibit the progression of periprosthetic osteolysis? Trans
Orthop Res Soc 2004;29:1888.
)
Figure 16a Figure 16b

Question 77

A type 2A hangman’s fracture, which has the potential to overdistract with traction, has which of the following hallmark findings?

Explanation

DISCUSSION: Type 2A hangman’s fractures are thought to have a flexion mechanism rather than extension and axial loading. This allows them to rotate around the anterior longitudinal ligament into flexion. Anterior translation of greater than 3 mm and angulation distinguish type 2 fractures from type 1 fractures. Although there is an association between C1 ring fractures and C2 fractures, this does not factor into the classification. If a C2-3 facet dislocation exists in combination with a C2 pars fracture, it is considered a type 3 fracture.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.

Question 78

In the treatment of intra-articular calcaneal fractures, surgical reduction and fixation has been shown to have improved outcomes over nonoperative treatment in all of the following patient groups EXCEPT:

Explanation

DISCUSSION: The referenced study by Buckley et al is a prospective study of intra-articular calcaneus fractures at several trauma centers. They found that overall, the outcomes after nonoperative treatment were not different from those after operative treatment. However, when stratifying groups, women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively. Also, patients who were less than twenty-nine years old, had a Böhler angle of 0 degrees to 14 degrees, a comminuted fracture, or a light workload did better after surgery compared with those who were treated nonoperatively.

Question 79

An 82-year-old woman fell on her right shoulder 2 days ago. She is alert, oriented, and in mild discomfort. Prior to falling, she lived alone and functioned independently. Examination reveals extensive ecchymosis extending to the midhumeral region. Her neurovascular examination is normal. Radiographs are shown in Figures 41a and 41b. What is the most appropriate management?

Explanation

DISCUSSION: The patient has a displaced four-part proximal humerus fracture. Given her age and the presence of osteopenia, a cemented hemiarthroplasty is the treatment of choice. The glenoid is uninjured so a total shoulder arthroplasty is not indicated. Percutaneous pinning in younger individuals with good bone quality may be indicated but not in an 82-year-old woman with osteopenia. Sling immobilization and immediate pendulum exercises will lead to a nonunion. Sling immobilization for 6 weeks followed by active range of motion will result in a nonunion or malunion with unacceptable functional results.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089.
Bigliani LU, Flatow EL, Pollock RG: Fractures of the proximal humerus, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA,

WB Saunders, 1998, pp 352-354.

Question 80

A 28-year-old professional dancer reports a 3-month history of progressive pain in the posterior aspect of the left ankle. Her symptoms are worse when she assumes the en pointe position. Examination reveals tenderness to palpation at the posterolateral aspect of the ankle posterior to the peroneal tendons which is made worse with passive plantar flexion. There is no nodularity, fluctuance, or tenderness of the Achilles tendon. The neurovascular examination is unremarkable. A lateral radiograph and MRI scan are shown in Figures 16a and 16b, respectively. Management should consist of

Explanation

DISCUSSION: The imaging studies reveal findings typical of the os trigonum syndrome. This condition results from inflammation between the os trigonum and the adjacent talus. The symptoms of posterior ankle pain are exacerbated by plantar flexion, which stresses the fibrous union between these two bones. Definitive management of the high-level athlete involves excision of the os trigonum from a medial approach, although arthroscopic excision has also been described. The os trigonum is not an intra-articular structure; therefore, ankle arthroscopy is neither diagnostic nor therapeutic.
REFERENCES: Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057.
Mouhsine E, Crevoisier X, Leyvraz P, et al: Post-traumatic overload or acute syndrome of the os trigonum: A possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 2004;12:250-253.
Wredmark T, Carlstedt CA, Bauer H, et al: Os trigonum syndrome: A clinical entity in ballet dancers. Foot Ankle 1991;11:404-406.

Question 81

A 6-year-old girl has the bilateral foot deformity shown in Figure 1. There is no family history of disease. Examination reveals fixed hindfoot equinus, and muscle function testing shows strong posterior tibial function, fair plus anterior tibial function, poor peroneal function, and strong gastrocnemius function. A Coleman block test shows a correctable hindfoot. Nerve conduction velocity studies show diminished function in the peroneal and ulnar nerves on both sides. Pathologic changes found in a sural nerve biopsy include “onion bulb” formation, and DNA testing confirms the presence of a mutation in the MPZ gene, consistent with hereditary motor sensory neuropathy type III (HMSN-III). What is the best course of action?

Explanation

DISCUSSION: The patient has HMSN-III or Dejerine-Sottas syndrome. This form of HMSN progresses very rapidly and frequently results in severe foot deformity in early childhood. The changes are progressive and are the result of muscle imbalance during growth. Balancing of the foot musculature is essential, particularly during the phases of rapid growth of the foot. However, this cannot be accomplished using the anterior tibial muscle because it is already weak and the transfer will further weaken it. Bony procedures also may be required, and tendon transfers cannot be depended on to correct bony deformity. However, these procedures can be deferred until the foot is closer to adult size. Surgeries that lead to joint arthrodesis, such as triple arthrodesis and some midfoot osteotomies, are contraindicated because the feet may lose protective sensation as the disease progresses. Fusions in insensate feet are less successful than realignment procedures that maintain mobility.
REFERENCES: Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 1989;71:417-422.
Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth. J Bone Joint Surg Br 1989;71:17-20.
Miller GM, Hsu JD, Hoffer MM, Rentfro R: Posterior tibial tendon transfer: A review of the literature and analysis of 74 procedures. J Pediatr Orthop 1982;2:363-370.

Question 82

Figures 39a and 39b show the current radiographs of an 8-year-old girl who has had pain in the left thigh for the past 3 months. She was recently diagnosed with hypothyroidism and started treatment 1 week ago. Examination reveals a mild abductor deficiency limp on the left side. She lacks 30 degrees internal rotation on the left hip compared with the right hip. Management should consist of

Explanation

DISCUSSION: The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip

“pre-slip.” Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Aronson DD, Carlson WE: Slipped capital femoral epiphysis: A prospective study of fixation with a single screw. J Bone Joint Surg Am 1992;74:810-819.

Question 83

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

Explanation

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

2001;26:1522-1527.

Question 84

A 39-year-old woman jammed her long finger playing softball 24 hours ago. She is unable to actively extend the proximal interphalangeal joint; however, when the joint is brought passively into full extension, she is able to maintain that position. Management should consist of

Explanation

Disruption of the central slip of the extensor tendon at the PIP joint with volar migration of the lateral bands will result in the so-called boutonniere deformity, which includes loss of extension at the PIP joint and compensatory hyperextension at the DIP joint. The lesion is most often secondary to closed blunt trauma with acute forceful flexion at the PIP joint. This produces avulsion of the central slip from its insertion on the dorsal base of the middle phalanx with or without fracture and/or laceration of the extensor tendon at its insertion. In closed injuries the characteristic boutonniere deformity may not be apparent at the time of injury and may not be noted until 10 to 21 days after injury. Two diagnostic tests that are useful in early recognition of this lesion are: (1) a 15 deg to 20 deg or greater loss of active extension of the PIP joint when the wrist and MP joint are fully flexed and (2) extravasation of intraarticular radiopaque dye dorsal and distal to the PIP joint. Weak extension against resistance has also been noted to be a helpful diagnostic finding. Treatment in acute cases before fixed contractures have occurred may be achieved by progressively splinting the PIP joint into full extension and at the same time performing active and passive flexion exercises of the DIP joint. In a closed boutonniere deformity operative intervention is indicated under two circumstances. (1) when the central slip has been avulsed with a bone fragment which is lying free over the PIP joint and (2) a long-standing boutonniere deformity in a young person.

Question 85

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Explanation

DISCUSSION: Synovectomy of the knee prior to loss of articular cartilage has been shown to consistently relieve pain in patients with rheumatoid arthritis. Partial knee replacement will not arrest the process of joint destruction. Osteotomy of the hip has not been found to be a successful procedure in patients with rheumatoid arthritis. Hip arthrodesis should not be considered because of the multiarticular involvement in patients with rheumatoid arthritis. Core decompression of the hip has not been shown to save the femoral head because the necrosis appears to occur simultaneously with the inflammatory joint process.
REFERENCES: Granberry WM, Brewer EJ Jr: Early surgery in juvenile rheumatoid arthritis, in Calundruccio RA (ed): Instructional Course Lectures XXIII. St Louis, MO, CV Mosby, 1974, pp 32-37.
Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA: Surgical management of inflammatory arthritis of the adult hip and knee, in Zuckerman JD (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-109.

Question 86

Figures 174a through 174c are the MRI scans of a 16-year-old football player who dislocated his dominant left shoulder 3 weeks ago while landing on his outstretched arm. The dislocation was reduced in the emergency department. He has since had two episodes where he felt like his shoulder slipped partially out of place. Which of the following statements to the athlete and his parents is most accurate regarding treatment options? Review Topic

Explanation

Arthroscopic capsulolabral repair is a reasonable option despite this being a first-time dislocation. The patient has had recurrent instability episodes with two subluxations since his dislocation. Outcome studies have shown up to 90% recurrent instability rates in young, active populations. Capsulolabral repair has the best chance to reduce the risk of recurrent instability. Physical therapy is unlikely to significantly reduce the high likelihood of recurrence. While there is controversy regarding immobilization in internal or external rotation, studies have shown that immobilization may not reduce the risk of recurrent instability. While older studies did show that open repairs had lower recurrence rates than arthroscopic repairs, more recent studies have shown similar rates for arthroscopic capsulolabral plication with modern suture anchor techniques and no glenoid bone loss or engaging Hill-Sachs lesion.

Question 87

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the

Explanation

DISCUSSION: Posterolateral rotatory instability (PLRI) of the elbow represents a three-dimensional injury pattern of rotational displacement of the ulna from the trochlea and the radius from the capitellum. The ulna supinates (externally rotates) past its normal limit and the radiocapitellar joint subluxates posterolaterally, permitting the coronoid process to slide beneath the trochlea. In cadaver studies, the lateral ulnar collateral ligament has been shown to be the essential lesion responsible for PLRI. The medial collateral ligament (of which the anterior bundle is the most important) is the primary restraint to valgus instability. The posterolateral capsule and radial collateral ligament may be disrupted in a complete posterolateral dislocation but are not essential injuries for PLRI. The primary function of the annular ligament is to stabilize the proximal radioulnar joint.
REFERENCES: O’Driscoll SW, Jupiter JB, King GJW, Hotchkiss RN, Morrey BF: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738.
Olsen BS, Sojbjerg JO, Dalstra M, Sneppen O: Kinematics of the lateral constraints of the elbow. J Shoulder Elbow Surg 1996;5:333-341.
O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxations and dislocation: A spectrum of instability. Clin Orthop 1992;280:186-197.

Question 88

A 21-year-old man has had posterior neck discomfort for the past 6 months. Radiographs, an MRI scan, and a photomicrograph of the biopsy specimen are shown in Figures 17a through 17d. What is the most likely diagnosis?

Explanation

DISCUSSION: Forty percent of osteoblastomas occur in the spine, and they can become large and locally aggressive lesions. They generally occur in the posterior elements but can occur in the ribs and transverse processes. Microscopic analysis of the lesion will reveal hyperchromatic osteoblasts separated by incompletely mineralized bars of bone. Recommended treatment is en bloc excision. Fibrous dysplasia, giant cell tumor, and hemangioma can have similar radiographic appearances; therefore, biopsy may be required to differentiate them from more aggressive lesions. Osteochondromas are characterized by an osteocartilaginous growth arising from the cortex.
REFERENCES: Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery. Philadelphia, PA, JB Lippincott, 1991,

vol 2, pp 1143-1174.
Enneking WF: Musculoskeletal Tumor Surgery. New York, NY, Churchill Livingstone, 1983, pp 1043-1053.

Question 89

An 8-year-old girl was treated for a Salter-Harris type I fracture of the right distal femur 2 years ago. She has symmetric knee flexion, extension, and frontal alignment to her contralateral knee. She has a 1-cm limb-length discrepancy of the femur. She has always been in the 50th percentile for height and her skeletal age matches her chronologic age. She has a complete physeal closure of the right distal femur. What is the expected limb-length discrepancy at maturity? Review Topic

Explanation

The child has a near complete central physeal arrest of the distal femur. She will develop worsening limb-length discrepancy. She is growing at the average rate for the population. The distal femoral physis grows roughly at a rate of 9 mm/year. Girls finish their growth roughly at 14 years. Thus, at maturity, the uninjured side will be

Question 90

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

Explanation

Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.

Question 91

A 57-year-old woman with diabetes mellitus has purulent drainage from a lateral incision after undergoing open reduction and internal fixation of a displaced ankle fracture 10 days ago. Examination reveals moderate erythema and a foul odor coming from the wound. Cultures are obtained. What is the next most appropriate step in management?

Explanation

DISCUSSION: Early postoperative wound infections after open reduction and internal fixation should be treated with aggressive debridement and maintenance of stability of the fracture. If infection persists following healing of the fracture, the hardware should be removed.
REFERENCES: Carragee EJ, Csongradi JJ, Bleck EE: Early complications in the operative treatment of ankle fractures: Influence of delay before operation. J Bone Joint Surg Br 1991;73:79-82.
Blotter RH, Connolly E, Wasan A, Chapman MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999;20:687-694.

Question 92

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

Explanation

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

Question 93

03 A patient with carpometacarpal joint arthritis of the thumb undergoes trapezium excision and interposition arthroplasty. One year after treatment, radiographs reveal that there has been 25% subsidence of the thumb metacarpal compared with its preoperative height. This degree of subsidence will have what effect on the surgical outcome?

Explanation

Yang and Weiland, from New York studied subsidence after trapezium excision and interposition arthroplasty. They compared preoperative and postoperative x-rays at rest as well as with maximal lateral key pinch stress. Lateral key
pinch stress causes a large amount of axial compressive force through the CMC joint. They also compared preoperative and postoperative functional measurements, including key pinch strength, tipto-tip pinch strength, grip strength, and thumb ROM. Their findings were that postoperatively the first metacarpal subsided 21% at rest (p=0.001). and it subsided another 10.5% during maximal lateral key pinch. Even with this degree of subsidence, the patients experienced increases in pinch strength and grip strength. Also, all patients except for one who had bony impingement reported that they were subjectively much better and more functional.
Lin et. al. also studied trapezium excision and interposition arthroplasty and found no significant differences between results in patients with varying degrees of subsidence. Thus, subsidence does not affect the results of interposition arthroplasty for basal thumb arthritis.
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Question 94

What type of cementless femoral fixation results in the highest rate of distal femoral osteolysis?

Explanation

DISCUSSION: Despite the relatively few problems with porous-coated cementless stems, stress shielding and thigh pain do occur. One design feature of proximally coated stems that has been associated with a higher incidence of distal osteolysis is the presence of noncircumferential proximal porous coating. Tapered, modular with sleeve, and hydroxyapatite proximally porous-coated stems have all performed well. Fully porous-coated straight stems have a high survivorship rate as well.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 175-180.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.
Emerson RH Jr, Sanders SB, Head WC, Higgins L: Effect of circumferential plasma-spray porous coating on the rate of femoral osteolysis after total hip arthroplasty. J Bone Joint Surg Am 1999;81:1291-1298.

Question 95

A 30-year-old man who underwent an anterior lumbar diskectomy and fusion at L4-5 and L5-S1 through an anterior retroperitoneal approach 1 month ago now reports he is unable to obtain and maintain an erection. The most likely cause of this condition is

Explanation

DISCUSSION: Sexual dysfunction is a common condition after extensive anterior lumbar surgical dissection. Erectile dysfunction usually is nonorganic but may be related to parasympathetic injury. The parasympathetic nerves are deep in the pelvis at the level of S2-3 and S3-4 and usually are not involved in the surgical field for anterior L4-5 and L5-S1 procedures. Retrograde ejaculation is the result of injury to the sympathetic chain on the anterior surface of the major vessels crossing the L4-5 level and at the L5-S1 interspace. Erectile function and orgasm are not affected by sympathetic injury. The pudendal nerve is primarily a somatic nerve and is not located in the surgical field.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Johnson RM, McGuire EJ: Urogenital complications of anterior approaches to the lumbar spine. Clin Orthop 1981;154:114-118.

Question 96

Osteolysis after total knee arthroplasty can be minimized through prosthetic design features such as

Explanation

DISCUSSION: The incidence of osteolysis is minimal in studies reporting the use of all polyethylene or monolithic metal-backed tibial components. Osteolysis has been reported in patients with total knee arthroplasties using cementless implants with modular components. Micromotion between the tibial tray and the polyethylene results in backside wear, leading to osteolysis. Osteolysis also has been reported in cemented posterior cruciate-substituting modular components. O’Rourke and associates reported a 16% incidence of osteolysis in patients with a posterior stabilized implant because of the use of modular polyethylene and the subsequent abrasive wear. Oxidation of the polyethylene that is the result of the method of sterilization and shelf life has also been implicated in the high incidence of osteolysis, along with patient factors such as activity level and weight.
REFERENCE: O’Rourke M, Callaghan J, Goetz D, Sullivan P, Johnson R: Osteolysis associated with a cemented modular posterior cruciate substituting total knee design. J Bone Joint Surgery Am 2002;84:1362-1371.

Question 97

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Explanation

EXPLANATION:
Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.

Question 98

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

Explanation

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

Question 99

A positive Froment sign indicates weakness of which of the following muscles?

Explanation

DISCUSSION: Thumb adduction is powered by the adductor pollicis (ulnar nerve). Testing involves having the patient forcibly hold a piece of paper between the thumb and radial side of the index proximal phalanx. When this muscle is weak or nonfunctioning, the thumb interphalangeal joint flexes with this maneuver, resulting in a positive Froment sign. The paper is held by action of the thumb flexion (flexor pollicis longus and flexor pollicis brevis; median innervated).
REFERENCE: Burton RI: The Hand: Examination and Diagnosis. Chicago, IL, American Society for Surgery of the Hand, 1978, pp 26-27.

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

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 2:

Which of the following antibiotics is contraindicated in children?

Options:

Penicillin
Cephalexin
Tetracycline
Erythromycin
Ampicillin

Correct Answer: Tetracycline

Explanation:

DISCUSSION: The tetracycline family of medications can stain teeth and bone in skeletally immature patients and as a result should be avoided in those patients. The remaining antibiotics have no known specific contraindication to use in children.
REFERENCE: Trumble TE (ed): Hand Surgery Update 3: Hand, Elbow, & Shoulder. Rosemont, IL, American Society for Surgery of the Hand, 2003, pp 433-457.

Question 3:

Options:

Parental education and reassurance
Serial casting of the forefoot
Complete peritalar release
Lengthening of the Achilles tendon and soft-tissue balancing
Reverse last shoes

Correct Answer: Serial casting of the forefoot

Explanation:

Question 4:

Which of the following surgical techniques is associated with an increased incidence of patellar complications after total knee arthroplasty?

Options:

Medialization of the patellar component
Symmetric patellar osteotomy
Use of metal-backed patellar components
Maintaining a patellar thickness of 12 to 15 mm
External rotation of the femoral component

Correct Answer: Use of metal-backed patellar components

Explanation:

Question 5:

Options:

Epithelioid sarcoma
Clear cell sarcoma
Pigmented villonodular synovitis
Malignant fibrous histiocytoma
Synovial sarcoma

Correct Answer: Synovial sarcoma

Explanation:

DISCUSSION: The biopsy specimen is a low-power view of a soft-tissue sarcoma with a biphasic pattern of epithelial cells and fibrous spindle cells that are typical of a synovial sarcoma. A deep, painless soft-tissue mass greater than 5 cm in size is suspicious for a sarcoma. The imaging in this patient is indeterminate and the patient requires a biopsy for an accurate diagnosis. The biopsy reveals a tumor with a biphasic appearance consistent with a synovial sarcoma. These tumors are slow growing, occur primarily in the lower extremities, and are found in a younger demographic population compared to malignant fibrous histiocytoma and liposarcoma. They can occur in a biphasic pattern with clumps of epithelial cells and fibrous spindle cells or in a monophasic pattern. Synovial sarcomas stain positively for keratin. Keratin is positive in nearly all biphasic types and in many tumors of the monophasic fibrous type. Sixty percent of these tumors are found in the lower extremity. The area around the knee is the most common location, followed by the ankle and foot. Epithelioid and clear cell sarcomas are found associated with tendon sheaths of the hand and feet and are generally smaller in size. Epithelioid sarcoma may resemble granulomatous inflammation histologically; clear cell sarcoma is composed of nests of clear cells with occasional multinucleated giant cells. Pigmented villonodular synovitis is found within the synovium and is characterized by a villous histologic appearance with hemosiderin-laden macrophages. Malignant fibrous histiocytoma has a storiform histologic pattern with an abundance of pleomorphic cells.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 757.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 227.

Question 6:

Options:

an exercise program.
revision rotator cuff repair using local tissue transposition.
revision rotator cuff repair using allograft.
latissimus dorsi transfer.
combined latissimus dorsi and teres major transfer.

Correct Answer: an exercise program.

Explanation:

Question 7:

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered? Review Topic

Options:

Fractures of the lower extremities
Paroxysmal hypertension
Infection
Epidural hematoma
Gastrointestinal bleeding

Correct Answer: Epidural hematoma

Explanation:

Question 8:

Options:

Physical therapy with a focus on quadriceps strengthening
Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
PCL reconstruction
PCL and posterolateral corner reconstruction This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II injury to the PCL. In patients with isolated PCL injuries, such as this scenario, the best initial option is nonsurgical treatment and return to play as symptoms subside and strength improves. Physical therapy and delayed PCL reconstruction is not the answer because this patient can likely be treated without surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that time.

Correct Answer: Physical therapy with a focus on quadriceps strengthening

Explanation:

Question 9:

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Options:

Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Terers minor and teres major
Teres major and lattisimus

Correct Answer: Supraspinatus and infraspinatus

Explanation:

Question 10:

A unilateral "piano key" sign, indicates

Options:

distal radioulnar joint (DRUJ) instability.
interosseous membrane disruption.
midcarpal instability.
physiologic motion of hypermobility syndrome.

Correct Answer: distal radioulnar joint (DRUJ) instability.

Explanation:

Question 11:

Arthrodesis

Options:

Repair of the rotator cuff
Replacement of the humeral head
Resection arthroplasty
Total shoulder arthroplasty

Correct Answer: Resection arthroplasty

Explanation:

Question 12:

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

Options:

Correct Answer: L1

Explanation:

DISCUSSION: The smallest pedicle isthmic width is at L1, whereas T12 has the largest pedicle width in the upper lumbar and lower thoracic spine. Although smaller in diameter than T12, both T10 and T11 have larger pedicle widths than L1.
REFERENCE: Ofiram E, Polly DW, Gilbert TJ Jr, et al: Is it safe to place pedicle screws in the lower thoracic spine than in the upper lumbar spine? Spine 2007;32:49-54.

Question 13:

-In zone II flexor tendon lacerations, repairing only 1 slip compared to repairing both slips of the flexor digitorum sublimis results in

Options:

a higher rupture rate.
profundus bowstringing.
improved tendon gliding.
improved passive range of motion.
proximal interphalangeal joint hyperextension.

Correct Answer: improved tendon gliding.

Question 14:

What term in statistics defines rejecting the null hypothesis when it is in fact true?

Options:

Type-I error
Type-II error
Confounding error
Variance
Negative likelihood ratio

Correct Answer: Negative likelihood ratio

Explanation:

Question 15:

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Options:

External rotation, abduction, and extension
External rotation, adduction, and flexion
Internal rotation, abduction, and flexion
Internal rotation, adduction, and extension
Internal rotation, adduction, and flexion

Correct Answer: Internal rotation, adduction, and flexion

Explanation:

Question 16:

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Options:

Jefferson’s fracture
C1-C2 rotational instability
Transverse ligament rupture
Normal finding
Basilar invagination

Correct Answer: Transverse ligament rupture

Explanation:

Question 17:

Options:

Revise the tibial tunnel to be more oblique.
Revise the tibial tunnel to be more posterior.
Convert to a transtibial double-bundle ACL.
Prepare the femoral tunnel via an anteromedial portal or two-incision technique.
Hyperflex the knee and place the femoral tunnel with the transtibial guide.

Correct Answer: Prepare the femoral tunnel via an anteromedial portal or two-incision technique.

Explanation:

Question 18:

Options:

Thumb extension
Forearm supination
Finger extension
Forearm pronation

Correct Answer: Forearm supination

Explanation:

EXPLANATION:
The typical upper extremity deformity in spastic hemiplegic cerebral palsy consists of shoulder internal rotation, elbow flexion, forearm pronation and wrist flexion, and ulnar deviation. The pronation position of the forearm can make bimanual activities more challenging for the child. The wrist flexion and ulnar deviation deformity interferes with finger function and therefore with grasp and release patterns. By transferring the FCU tendon to the ECRB, the deforming force is released, and central wrist extension is augmented. This transfer can lead to a supination moment when it is routed around the ulna to the ECRB insertion on the dorsum of the wrist. Thumb and finger extension are not affected by an FCU-to-ECRB
tendon transfer. Forearm supination, not pronation, is potentially improved with this tendon transfer.

Question 19:

Options:

Closed reduction and application of a shoulder spica cast in the outpatient setting
Closed reduction under fluoroscopy and application of a shoulder spica cast in the operating room
No active reduction and placement of the upper extremity in a shoulder immobilizer
Closed or open reduction and percutaneous pin stabilization
Open reduction and internal fixation

Correct Answer: Closed or open reduction and percutaneous pin stabilization

Explanation:

DISCUSSION: The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient’s age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement.
REFERENCES: Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.
Sarwark JF, King EC, Luhmann SJ: Proximal humerus, scapula, and clavicle, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, pp 703-715.

Question 20:

Options:

a local fascia turndown flap, followed by immobilization in a plantar flexed short leg cast for 12 weeks.
multiple nonabsorbable sutures to bridge the gap and immobilization in a plantar flexed short leg cast for 12 weeks.
a pull out wire and strict immobilization for 12 weeks.
closure of the paratenon with a tight running suture, followed by rehabilitation.
release of the flexor hallucis longus tendon at the Knot of Henry, followed by transfer through the calcaneus either alone or in combination with a V-Y advancement of the gastrocnemius.

Correct Answer: release of the flexor hallucis longus tendon at the Knot of Henry, followed by transfer through the calcaneus either alone or in combination with a V-Y advancement of the gastrocnemius.

Explanation:

Question 21:

Options:

An unknown prognosis until they can participate in an examination.
Higher rates of neurologic deficit and mortality than other same-age people.
Higher rates of neurologic deficit than other same-age people, but comparable mortality rates.
Similar rates of neurologic deficit and mortality as other same-age people.

Correct Answer: Higher rates of neurologic deficit and mortality than other same-age people.

Explanation:

DISCUSSION
Several studies have found that rates of neurologic deficit and mortality are higher for patients with ankylosing spondylitis and a spinal fracture than for age-matched controls. The 2011 work of Schoenfeld and associates, which directly compared patients with cervical fractures in ankylosed spines to age-and sex-matched controls who also had cervical fractures but no ankylosing condition, demonstrated that those with ankylosing spondylitis were at elevated risk for mortality for up to 2 years after sustaining a fracture. In a study by Westerveld and associates, the rate of neurologic deficit among patients with ankylosing spondylitis and a spinal fracture was 57.1% compared to 12.6% among controls.
RECOMMENDED READINGS
Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J. 2014 May 1;14(5):729-40. doi: 10.1016/j.spinee.2013.06.038. Epub 2013 Aug 27. PubMed PMID: 23992936.
View
Abstract at PubMed
Schoenfeld AJ, Harris MB, McGuire KJ, Warholic N, Wood KB, Bono CM. Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study. Spine J. 2011 Apr;11(4):257-64. doi: 10.1016/j.spinee.2011.01.018. Epub 2011 Mar 5. PubMed PMID: 21377938.
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Abstract at PubMed

Question 22:

Options:

Advanced degenerative disk disease with facet arthrosis at L5-S1
Decreased T2 signal in the L5-S1 disk with normal facet joints
Previous laminectomy at L5-S1
Fixed tilt of L5 with severe unilateral facet arthrosis
Spondylolysis bilaterally at L5

Correct Answer: Decreased T2 signal in the L5-S1 disk with normal facet joints

Explanation:

Question 23:

Options:

Normothermia
Hemoglobin of less than 9 g/dL
Unilateral lung contusion evident on CT only
Injury severity score of greater than 40 without thoracic injury
Injury Severity Score of less than 18 with a pulmonary contusion

Correct Answer: Injury severity score of greater than 40 without thoracic injury

Explanation:

Question 24:

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

Options:

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

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

Explanation:

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

Question 25:

Options:

referral to a pitching coach to improve throwing mechanics.
a weight-training program that concentrates on rotator cuff strengthening.
rest until symptoms have resolved, followed by a gradual return to pitching.
a metabolic work-up.
cessation of pitching until the physis is closed.

Correct Answer: rest until symptoms have resolved, followed by a gradual return to pitching.

Explanation:

Question 26:

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

Options:

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

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

Explanation:

Question 27:

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete's shoulder?

Options:

Improve flexibility
Strengthen muscles
Enhance power and endurance
Regain neuromuscular control
Perform functional drills

Correct Answer: Improve flexibility

Explanation:

Question 28:

Options:

rotator cuff interval closure.
distal clavicle excision.
superior labrum anterior and posterior repair.
biceps tenodesis.
thermal capsulorrhaphy.

Correct Answer: distal clavicle excision.

Explanation:

Question 29:

What is the most important genetic element that distinguishes community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) from hospital-acquired MRSA? Review Topic

Options:

Beta-lactamase
Penicillin-binding protein 2a
Panton-Valentine leukocidin (PVL)
Staphylococcus cassette chromosome (SCCmec) type I

Correct Answer: Panton-Valentine leukocidin (PVL)

Explanation:

PVL is a cytotoxin that defines CA-MRSA and is not typical of hospital-acquired MRSA. PVL has the ability to lyse white blood cells and cause tissue necrosis, allowing for rapid progression of abscess formation. Beta-lactamase is an enzyme that breaks the beta-lactam bond of penicillin and is present in most strains of
Staphylococcus aureus
today. Synthetic penicillins such as methicillin are resistant to the effects of beta-lactamase. MRSA and CA-MRSA carry the mecA gene, which
encodes a penicillin-binding protein with a very low affinity for beta-lactam antibiotics, resulting in methicillin resistance. SCCmec mobile genetic units carry the mecA gene with additional genetic elements that together yield the multidrug-resistant strains found in healthcare environments. SCCmec type IV is specific to CA-MRSA and lacks these additional genetic elements, resulting in less multidrug resistance.

Question 30:

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy? Review Topic

Options:

Space available for the cord of less than 8 mm
Ossification of the posterior longitudinal ligament
Fixed cervical kyphosis
Previous posterior surgery
Concomitant cervical radiculopathy

Correct Answer: Fixed cervical kyphosis

Explanation:

Question 31:

Which of the following statements is true regarding brake travel time after surgical treatment of complex lower extremity trauma?

Options:

Brake travel time is significantly reduced until 6 weeks after patient begins weight bearing
Return of normal brake travel time takes longer after long bone fracture compared to articular fractures
Normal brake travel time correlates with improved short musculoskeletal functional assessment scores
Brake travel time is significantly reduced until 8 weeks after patient begins weight bearing
Brake travel time returns to normal when weight bearing begins

Correct Answer: Brake travel time is significantly reduced until 6 weeks after patient begins weight bearing

Explanation:

Question 32:

Trabecular bone is remodeled through the formation of

Options:

cutting cones.
Haversian canals.
Volkmann canals.
Howship lacunae.

Correct Answer: Howship lacunae.

Explanation:

Question 33:

Porous hydroxyapatite is placed into a bone defect. Incorporation of this bone graft substitute is expected to follow which of the following patterns?

Options:

Neovascularization and appositional new bone growth
Creeping substitution
Inflammatory response with sequestration
Dissolution of the graft material and osteoblastic bone formation
Bridging bone formation without incorporation of the graft

Correct Answer: Neovascularization and appositional new bone growth

Explanation:

Question 34:

- Demyelination diseases as multiple sclerosis and Guillain-Barre $ create neurologic symptoms by

Options:

decreasing initiation of action potentials.
increasing action potential amplitude.
blocking the opening of gated sodium channels.
decreasing the number of functional motor units.
slowing or stopping action potential propagation through the axon.

Correct Answer: slowing or stopping action potential propagation through the axon.

Explanation:

Question 35:

Options:

back muscle stretching and reduced weight in the backpack.
consultation with a pain management specialist.
MRI of the thoracic spine.
a technetium Tc 99m bone scan.
a thoracolumbosacral orthosis.

Correct Answer: back muscle stretching and reduced weight in the backpack.

Explanation:

Question 36:

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 37:

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

Options:

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

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

Explanation:

Question 38:

Options:

Rheumatoid arthritis
Lyme disease
Psoriatic arthritis
Crohn’s disease arthropathy
Gout

Correct Answer: Psoriatic arthritis

Explanation:

DISCUSSION: The patient’s clinical picture is considered the classic presentation for psoriatic arthritis. The other answers are not applicable for the constellation of findings.
REFERENCES: Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA,
WB Saunders, 1991, pp 1691-1693.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.

Question 39:

Options:

0% to 1% with press-fit tibial stems B. 3% to 5% with press-fit tibial stems C. 3% to 5% with cemented tibial stems
More than 5% with press-fit tibial stems

Correct Answer: More than 5% with press-fit tibial stems

Explanation:

Question 40:

Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?

Options:

Implant removal, irrigation and debridement, and resection arthroplasty
Implant removal, irrigation and debridement, and rTSA
Implant removal, irrigation and debridement, and revision hemiarthroplasty
Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Correct Answer: Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Explanation:

DISCUSSION
The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609.
View Abstract at PubMed
Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211.
View Abstract at PubMed
Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13.
View Abstract at PubMed
Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496.
View Abstract at PubMed
Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070.
View Abstract at PubMed
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.
View Abstract at PubMed
Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258.
View Abstract at PubMed

Question 41:

Options:

Superficial peroneal nerve
Saphenous nerve
Posterior tibial artery
Peroneal artery
Peroneal tendons

Correct Answer: Superficial peroneal nerve

Explanation:

Question 42:

Options:

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

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

Explanation:

Question 43:

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Options:

Multilevel disease with spinal cord compression
Anterior spinal cord compression
Posterior spinal cord compression
Cervical kyphosis
Ossification of the posterior longitudinal ligament

Correct Answer: Cervical kyphosis

Explanation:

Question 44:

Options:

referral to a plastic surgeon to remove the hairy patch.
MRI of the entire spine.
physical therapy and repeat evaluation and radiographs in 1 year.
anterior and posterior fusion of the anomalous regions of the spine to prevent deformity.
voiding cystourethrography.

Correct Answer: MRI of the entire spine.

Explanation:

Question 45:

Options:

Excessive retraction of the traversing nerve root
Bony overgrowth from the use of BMP protein in the disk space
Osteomyelitis with compression of the nerve roots
Inadequate decompression after surgery

Correct Answer: Bony overgrowth from the use of BMP protein in the disk space

Explanation:

DISCUSSION
Transient thigh pain after lateral, transpsoas interbody fusion is common and generally lasts for less than 3 months. Transpsoas interbody fusion with slip reduction can result in indirect spinal decompression and often obviates the need for a laminectomy for most patients. Complications with this approach are comparable to those experienced with open surgery, but the hospital stay is generally shorter.
Use of BMP in interbody devices has also become common. The images above show heterotopic bone growth into the spinal canal causing nerve compression. This complication is more commonly encountered after posterior lumbar interbody fusions.
RECOMMENDED READINGS
Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements.
Spine (Phila Pa 1976). 2010 Dec 15;35(26 Suppl):S331-7. doi: 10.1097/BRS.0b013e3182022db0. PubMed PMID: 21160397.
View Abstract at PubMed
Cummock MD, Vanni S, Levi AD, Yu Y, Wang MY. An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion. J Neurosurg Spine. 2011 Jul;15(1):11-8. doi: 10.3171/2011.2.SPINE10374. Epub 2011 Apr 8. PubMed PMID:

Question 46:

Options:

Anterior diskectomy without fusion at C4-C5
Epidural injections
Anterior diskectomy and fusion at C4-C5 and C5-C6
Multilevel laminectomy and fusion
Multilevel posterior foraminotomies

Correct Answer: Multilevel laminectomy and fusion

Explanation:

Question 47:

The CT scan reveals a nondisplaced greater trochanteric fracture. The patient is now experiencing severe pain. What is the most appropriate treatment at this time?

Options:

Liner exchange
Revision of the entire acetabular component
Revision of both the femoral and acetabular components
Partial weight-bearing activity for 4 to 6 weeks

Correct Answer: Partial weight-bearing activity for 4 to 6 weeks

Explanation:

Question 48:

Options:

Partial tear of the patellar tendon
Osteochondral fracture of the femur
Anterior cruciate ligament (ACL) tear
Posterior cruciate ligament (PCL) tear
Patella fracture

Correct Answer: Posterior cruciate ligament (PCL) tear

Explanation:

Question 49:

Options:

C5-C7 nerve roots; upper/middle trunks; anterior division; lateral cord
C5-C6 nerve roots; upper trunk; posterior division; posterior cord
C5-C6 nerve roots; upper trunk
C5-C7 nerve roots
C8-T1 nerve root; lower trunk; anterior division; medial cord

Correct Answer: C8-T1 nerve root; lower trunk; anterior division; medial cord

Explanation:

Question 50:

Options:

long leg cast immobilization for 6 weeks.
open reduction and internal fixation.
activity restrictions and nonsteroidal anti-inflammatory drugs.
cessation of sports for 6 to 18 months.
diagnostic arthroscopy.

Correct Answer: activity restrictions and nonsteroidal anti-inflammatory drugs.

Explanation:

Question 51:

Options:

replacement of the sling with a modified spica cast
open reduction and internal fixation
percutaneous pin fixation
arthroscopic labral repair
arthroscopy and removal of the loose fragment back answer Question 125.03

Correct Answer: open reduction and internal fixation

Explanation:

AM J Sports Med 1998;26:41-45 JBJS Am 1993;75:479-484
back to this question go to explanation

Question 52:

What nerve is at greatest risk when developing the superficial plane between the tensor fascia lata and sartorious during the anterior (Smith-Peterson) approach to the hip?

Options:

Lateral femoral cutaneous
Superior gluteal
Inferior gluteal
Obturator
Femoral

Correct Answer: Lateral femoral cutaneous

Explanation:

Question 53:

The newborn foot deformity seen in Figures 64a and 64b should initially treated with

Options:

observation with possible stretching.
serial casting.
medial surgical release.
posterior medial surgical release.
dynamic ankle-foot orthosis.

Correct Answer: serial casting.

Explanation:

DISCUSSION: Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academ
A
y
L-
o
M
f
ad
O
en
r
a
th
C
o
o
p
p
a
y
edic Surgeons, 2006, pp 240-241.
Farsetti P, Weinstein SL, Ponseti IV: The Long-term functional and radiographic outcomes of untreated
and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265. Question 65
A 4-year-old girl has been limping for the past 2 months. There is no history of trauma, previous injury, fever, or other systemic complaints. Examination reveals a moderate right knee effusio n with a 10-degree knee flexion contracture. What is the next most appropriate step in evaluation?
Arthroscopy
Antinuclear antibody
MRI
Bone scan
HLA-B27
DISCUSSION: The patient presents with juvenile idiopathic arthritis manifestations. The American College of Rheumatology defines this as one or more joints involved with swelling of 6 weeks or longer. A positive antinuclear antibody test would be diagnostic. Consideration should be made to have the patient see an ophthalmologist for evaluation of possible uveitis. Although the patient could have Lyme disease, that choice is not an option. The presence of an elevated antinuclear antibody by itself should not necessarily be used for diagnosing arthritis; however, the test does have clinical utility as a screening test. The frequency of a positive antinuclear antibody test is greatest in younger girls with oligoarticular disease and carries an increased risk for anterior uveitis. Arthroscopy might be indicated if this patient was presenting with a discoid meniscus, but there is no history of clicking, which is often one of the classic signs of discoid meniscus. MRI would not be used to diagnose juvenile idiopathic arthritis, but
MRI would be useful to help diagnose discoid meniscus. A bone scan would show increased uptake in the patient’s knee but again, this would not help diagnose her condition. HLA-B27 has no role in diagnosing juvenile idiopathic arthritis, especially in females.
REFERENCES: Iesaka K, Kubiak EN, Bong LR, et al: Orthopaedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 2006;35:67-73.
Wright DA: Juvenile idiopathic arthritis, in Morrissey RT, Weinstein SL (eds): Love
l
and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia PA, Lippincott Williams and Wilkins, 2006, pp 405-438. Question 66
An 18-month-old girl is brought in by her parents because of concerns about intoeing, bowlegs, and tripping and fa
l
ing. Prenatal and birth history are otherwise unremarkable. The child’s growth and
development appear to be normal and she has a normal neurologic exam, a straight spine with no defects, and the hips are stable. Examination reveals hip internal rotation of 40 degrees and hip external rotation of 60 degrees. The thigh-foot angle is internal 30 degrees. Feet are straight and supple. Gait is characterized by intoeing with occasional tripping and falling. Based on these findings, what is the most appropriate action?
No treatment because internal tibial torsion slowly resolves on its own
Immediate treatment with a Denis-Browne bar
Distal tibial osteotomies
Proximal femoral derotational osteotomies
Treatment with twister cables PREFERRED RESPONSE: 1
DISCUSSION: The child has classic internal tibial torsion that is very commonly seen in younger children who are just beginning to walk. The normal outcome is for slow resolution of this problem and it seldom requires any treatment. Treatment with a Denis-Browne bar or with twister cables has not been proven to be effective. Surgical treatment at this point is premature and clearly not indicated.
REFERENCES: Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.
Staheli LT, Corbett M, Wyss C, et al: Lower-extremity rotational problems in children: Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47.

Question 54:

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

Options:

Anterior aspect of the lower thoracic region
Anterior aspect of the cervical spine
Posterior elements of the lower thoracic region
Posterior elements of the cervical spine
Transverse process of the lower lumbar spine

Correct Answer: Anterior aspect of the lower thoracic region

Explanation:

Question 55:

Options:

Medial collateral ligament repair or reconstruction
Reconstruction of the radial collateral ligament
Resection of the type I coronoid fracture and capsular repair to the remaining coronoid
Open reduction and buttress plating of the coronoid fracture

Correct Answer: Medial collateral ligament repair or reconstruction

Explanation:

Question 56:

Options:

Sclerotherapy
Shave excision with cautery
Cryotherapy
Wide surgical excision

Correct Answer: Wide surgical excision

Explanation:

EXPLANATION:
This lesion is a
pyogenic granuloma
, which is a common benign vascular lesion that can occur on skin or mucosa. The etiology is unclear, although this lesion tends to occur in areas of physical trauma. Initial treatment with silver nitrate with an average of 1.6 applications has a success rate of 85%. This patient, however, has failed silver nitrate applications. Wide surgical excision (Figures below) is associated with the lowest recurrence rate and offers the benefit of a single procedure. Other options often necessitate repeated procedures to completely eradicate this lesion.

Question 57:

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Options:

Ulnar head
Volar ulnar corner
Radial styloid
Lister tubercle

Correct Answer: Volar ulnar corner

Explanation:

Question 58:

Options:

Physical therapy
Arthroscopic labral repair
Arthroscopic subscapularis repair
Arthroscopic thermal capsular shift
Open Bankart repair

Correct Answer: Physical therapy

Explanation:

Question 59:

Which of the following best describes heat stroke? Review Topic

Options:

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

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

Explanation:

Question 60:

Which of the following statements regarding the use of thermal shrinkage during arthroscopic shoulder surgery is most accurate? Review Topic

Options:

The amount of shrinkage is fixed for a given peak temperature, irrespective of the time of application.
Denatured capsular tissue does not undergo a healing response.
The capsule is typically found to be thick and fibrotic in revision cases following thermal shrinkage.
Patients with good results at 1 year are unlikely to develop recurrent instability in the future.
High failure rates have been reported in its use for anterior, posterior, and multidirectional instability.

Correct Answer: High failure rates have been reported in its use for anterior, posterior, and multidirectional instability.

Explanation:

Question 61:

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Options:

Open reduction and internal fixation with absolute stability
Open reduction and internal fixation with relative stability
Closed reduction with casting
Reamed locked intramedullary nailing
External fixation

Correct Answer: Open reduction and internal fixation with absolute stability

Explanation:

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17.
http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 62:

A 10-year-old child has leg discomfort with activity. A radiograph, bone scan, and biopsy specimen are shown in Figures 1a through 1c. What is the most likely diagnosis?

Options:

Parosteal osteosarcoma
Unicameral bone cyst
Aneurysmal bone cyst
Eosinophilic granuloma
Fibrous dysplasia

Correct Answer: Fibrous dysplasia

Explanation:

Question 63:

Reverse total shoulder arthroplasty combined with latissimus dorsi transfer would be most appropriate for which of the following patients? Review Topic

Options:

year-old male with post-traumatic shoulder arthritis after a four-part proximal humerus fracture with no motor dysfunction
year-old male with grade 4 shoulder arthritis with severe deltoid muscle dysfunction secondary to a stroke
year-old female with significant rotator cuff arthropathy, a negative Hornblower sign and less than 5 degrees of external rotation lag
year-old female with pseudoparesis of anterior elevation and external rotation, narrowing of gleno-humeral joint and acetabularization of the acromion
year-old male with grade 4 shoulder arthritis and an isolated supraspinatus tear

Correct Answer: year-old male with grade 4 shoulder arthritis and an isolated supraspinatus tear

Explanation:

Question 64:

A 21-year-old man has had right groin pain for the past year. A radiograph, CT scan, MRI scans, and a biopsy specimen are shown in Figures 50a through 50e. What is the most likely diagnosis?

Options:

Chondrosarcoma
Osteoblastoma
Chondroblastoma
Giant cell tumor of bone
Subchondral cyst

Correct Answer: Chondrosarcoma

Explanation:

DISCUSSION: The pathology demonstrates a very cellular chondroid matrix with multinucleated forms, atypia, and myxomatous regions. This is most consistent with a myxoid chondrosarcoma. The radiograph shows a well-circumscribed lesion in the superior and medial aspect of the right acetabulum. The CT and MRI scans confirm these same findings with no evidence of matrix mineralization or significant surrounding edema. Unfortunately, in this location with this appearance, the radiographic differential diagnosis includes all the diagnoses listed.
REFERENCES: Terek RM: Recent advances in the basic science of chondrosarcoma. Orthop Clin North Am 2006;37:9-14.
Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.

Question 65:

Options:

Antiresorptive bisphosphonate medication
A repeat dual-energy x-ray absorptiometry scan (DEXA) and treatment if the T-score is less than -2.5
A repeat DEXA scan and treatment if the T-score is greater than -1.5
No treatment since the BMD is not in osteoporotic range
(PTH) taraparatide hormone followed by surgery

Correct Answer: Antiresorptive bisphosphonate medication

Explanation:

DISCUSSION: A DEXA scan is most appropriately used to establish a baseline score. Even if the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone density, such as worsening vision or balance, confusion, or other predispositions to falls. The guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is performed. A recent study showed that antiresorptive therapy following a hip fracture reduces not only the risk of a second fracture but also overall mortality.
REFERENCE: Gardner MJ, Brophy RH, Demetrakopoulos D, et al: Interventions to improve osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint Surg Am 2005;87:3-7.

Question 66:

Options:

Intimal tearing of the subclavian artery
Compression of the subclavian vein by scalene muscle hypertrophy
Postural compression of the neurovascular bundle between the clavicle and the first rib
A congenital cervical rib
Arterial thrombosis induced by repeated overhead activities

Correct Answer: Compression of the subclavian vein by scalene muscle hypertrophy

Explanation:

Question 67:

A 6-year-old girl is referred for the elbow injury seen in Figure 2. What is the most appropriate treatment?

Options:

Immobilization in a long arm cast for 3 weeks
Immobilization in a long arm cast for 8 weeks
Open reduction and immobilization in a long-arm cast for 3 weeks
Open reduction and internal fixation with smooth pins
Open reduction and internal fixation with a screw

Correct Answer: Open reduction and internal fixation with smooth pins

Explanation:

DISCUSSION: The patient has a displaced lateral condyle fracture; therefore, simple immobilization for 3 to 8 weeks is likely to result in malunion or nonunion. Closed reduction of such injuries is rarely successful. The fracture is unstable, so fixation is required after open reduction. Because the fixation must cross the physis, smooth pins are indicated for the skeletally immature elbow. Open reduction with fixation has been shown to reduce the risk of delayed union and malunion.
REFERENCES: Beaty JH, Kasser JR: The elbow: Physeal fractures, apophyseal injuries
of the distal humerus, avascular necrosis of the trochlea, and T-condylar fractures, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 625-703.
Rutherford A: Fractures of the lateral humeral condyle in children. J Bone Joint Surg Am 1985;67:851-856.
Hasler CC, von Laer L: Prevention of growth disturbances after fractures of the lateral humeral condyle in children. J Pediatr Orthop B 2001;10:123-130.

Question 68:

Portions of which of the following normal structures help compose the spiral cord seen in Dupuytren’s contracture?

Options:

Lateral digital sheet and Grayson’s ligament
Lateral digital sheet and Cleland’s ligament
Lateral digital sheet and the transverse intermetacarpal ligament
Pretendinous band and Cleland’s ligament
Intrinsic muscle and the natatory ligament

Correct Answer: Lateral digital sheet and Grayson’s ligament

Explanation:

DISCUSSION: The normal fascial components that become diseased and compose the spiral cord include the pretendinous band, spiral band, lateral digital sheet, and Grayson’s ligament. Cleland’s ligament lies dorsal and is not involved with spiral cord formation. The intrinsic muscle and tendon, the natatory ligament, and the intermetacarpal ligament are well proximal to the digit and are not involved in spiral cord formation.
REFERENCES: McGrouther D: Dupuytren’s contracture, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone,
1999, vol 1, pp 565-569.
McFarlane R: Patterns of diseased fascia in the fingers in Dupuytren’s contracture.
Plast Reconstr Surg 1974;54:31-44.

Question 69:

Options:

chemotherapy.
radiation therapy.
marginal excision.
wide excision.
above-knee amputation.

Correct Answer: marginal excision.

Explanation:

Question 70:

The patient returns 1 year later to report curling of her toes and numbness on the plantar surface of her foot. What is the most likely cause of this condition?

Options:

CRPS
Plantar fasciitis
Plantar fibromatosis
Subclinical compartment syndrome

Correct Answer: Subclinical compartment syndrome

Explanation:

DISCUSSION
Radiographs reveal a Lisfranc fracture dislocation with fractures of the first and second metatarsals. Tenting of skin that is over a bony prominence is an orthopaedic emergency. The fracture dislocation should be reduced without delay. There is no evidence of compartment syndrome of the foot, but this may develop and monitoring is necessary. Toe deformity may develop on a delayed basis because of the subclinical presentation. Nerve irritation is not uncommon with dorsal midfoot surgical incisions. A positive Tinel test result over the midfoot in the distribution of the superficial common peroneal nerve is consistent with a stretch injury to this nerve. CRPS is usually associated with multiple nerve distributions and autonomic nerve findings such as cold hypersensitivity and hyperhidrosis.
RECOMMENDED READINGS
Benirschke SK, Meinberg EG, Anderson SA, Jones CB, Cole PA. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. Instr Course Lect. 2013;62:79-91. PubMed PMID: 23395016.
View Abstract at PubMed
Schepers T, Oprel PP, Van Lieshout EM. Influence of approach and implant on reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal joint. Foot Ankle Int. 2013 May;34(5):705-10. doi: 10.1177/1071100712468581. Epub 2013 Jan 14. PubMed
PMID: 23637239.
View Abstract at PubMed

Question 71:

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Options:

fibrosis and edema.
polymorphonuclear cells.
negatively birefringent crystals.
macrophages and lymphocytes.
fibrinous degeneration of collagen fibers.

Correct Answer: fibrosis and edema.

Explanation:

Question 72:

For halo traction, what is the preferred site for anterior pin placement?

Options:

Below the head equator, above the supraorbital ridge, and 3.5 cm lateral to the midline
Below the head equator, above the supraorbital ridge, and 4.5 cm lateral to the midline
Below the head equator, below the supraorbital ridge, and 4.5 cm lateral to the midline
Above the head equator, above the supraorbital ridge, and 3.5 cm lateral to the midline
Above the head equator, above the supraorbital ridge, and 4.5 cm lateral to the midline

Correct Answer: Below the head equator, above the supraorbital ridge, and 4.5 cm lateral to the midline

Explanation:

Question 73:

Nerve conduction velocity is slowed by

Options:

increased skin temperature.
increased perineural blood flow.
external compression.
hand dominance.

Correct Answer: external compression.

Explanation:

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no
association between hand dominance and nerve conduction velocity.

Question 74:

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

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 75:

Options:

Brostrom procedure
Syndesmosis repair or stabilization
Allograft lateral ligament reconstruction
Excision of loose body/fracture fragment
Repair of the SPR with possible fibular groove deepening

Correct Answer: Syndesmosis repair or stabilization

Explanation:

DISCUSSION FOR QUESTIONS 107 AND 108:
The fracture at the insertion of the AITFL into the fibula represents a syndesmosis injury. In some cases, a direct repair of the fracture will stabilize the syndesmosis, but in most cases this injury should most likely be reinforced by placing a screw or suture tensioning device across the syndesmosis for additional support.A Brostrom or allograft reconstruction is indicated for an ankle sprain involving the ATFL or CFL.Simply excising the fragment will leave the patient with an incompetent syndesmosis. Repairing the SPR with or without a groove deepening procedure is indicated if there is evidence of subluxated or dislocated peroneal tendons, which is not demonstrated on the CT scans. The bone has been avulsed off the fibula by the portion of the AITFL that attaches to the fibula, therefore indicating that there is a syndesmosis injury. Allograft lateral ligament reconstruction and excision of loose body/fracture fragment are incorrect procedures based on location. The deltoid is a medial structure and this fracture is lateral. The ATFL and CFL attach at the inferior margin of the fibula near the lateral process of the talus and calcaneus. A SPR avulsion would present as an avulsion off the lateral wall of the fibula, not superior and not into the syndesmotic space as shown on the CT scans.

Question 76:

Options:

Immediate admission to the hospital and emergent revision hip arthroplasty
Reassurance and follow-up if symptoms worsen
Repeat radiographs in 1 month
Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared
A prescription for alendronate and reevaluation in 1 year

Correct Answer: Protected weight bearing with urgent revision hip arthroplasty when the patient is medically cleared

Explanation:

Question 77:

A type 2A hangman’s fracture, which has the potential to overdistract with traction, has which of the following hallmark findings?

Options:

Anterior translation of greater than 3 mm
Severe angulation with minimal translation
Extension at the fracture site
Associated C1 ring fracture
Associated C2-3 facet dislocation

Correct Answer: Severe angulation with minimal translation

Explanation:

Question 78:

Options:

Sedentary job
Sanders IIb fractures
Women
Younger age (<29 years old)
Previous calcaneus fracture

Correct Answer: Sedentary job

Explanation:

Question 79:

Options:

Surgical fixation with percutaneous pins
Surgical fixation with a hemiarthroplasty with tuberosity repair
Surgical fixation with a total shoulder arthroplasty
Sling immobilization for 6 weeks followed by active range of motion
Sling immobilization with daily pendulum exercises

Correct Answer: Surgical fixation with a hemiarthroplasty with tuberosity repair

Explanation:

DISCUSSION: The patient has a displaced four-part proximal humerus fracture. Given her age and the presence of osteopenia, a cemented hemiarthroplasty is the treatment of choice. The glenoid is uninjured so a total shoulder arthroplasty is not indicated. Percutaneous pinning in younger individuals with good bone quality may be indicated but not in an 82-year-old woman with osteopenia. Sling immobilization and immediate pendulum exercises will lead to a nonunion. Sling immobilization for 6 weeks followed by active range of motion will result in a nonunion or malunion with unacceptable functional results.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089.
Bigliani LU, Flatow EL, Pollock RG: Fractures of the proximal humerus, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA,
WB Saunders, 1998, pp 352-354.

Question 80:

Options:

a short leg cast with the ankle in slight plantar flexion.
a corticosteroid injection into the retrocalcaneal bursa.
excision of the os trigonum.
excision of the superior tuberosity of the calcaneus.
ankle arthroscopy with loose body removal.

Correct Answer: excision of the os trigonum.

Explanation:

Question 81:

Options:

Triple arthrodesis
Midfoot closing wedge resection osteotomy
Calcaneal and metatarsal osteotomies
Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening
Serial casting

Correct Answer: Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening

Explanation:

Question 82:

Options:

abductor muscle strengthening.
a left 1-½ hip spica cast.
closed reduction and pinning of the left hip.
symptomatic treatment with crutch walking and nonsteroidal anti-inflammatory drugs.
in situ pinning of both hips.

Correct Answer: in situ pinning of both hips.

Explanation:

DISCUSSION: The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip
“pre-slip.” Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Aronson DD, Carlson WE: Slipped capital femoral epiphysis: A prospective study of fixation with a single screw. J Bone Joint Surg Am 1992;74:810-819.

Question 83:

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

Options:

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

Correct Answer: Macrophage infiltration and phagocytosis

Explanation:

Question 84:

- A 39-year-old woman jammed her long finger playing softball 24 hours ago. She is unable to actively extend the proximal interphalangeal joint; however, when the joint is brought passively into full extension, she is able to maintain that position. Management should consist of

Options:

Open repair of the central slip of the extensor mechanism
Open repair of the terminal tendon of the extensor mechanism
Closed splinting with the proximal interphalangeal joint
Closed splinting with the proximal interphalangeal joint in 30 degrees of flexion
Closed splinting with the proximal interphalangeal joint in 45 degrees of flexion

Correct Answer: Closed splinting with the proximal interphalangeal joint

Explanation:

Question 85:

Which of the following procedures is considered most appropriate in patients with rheumatoid arthritis?

Options:

Hip arthrodesis
Osteotomy of the hip
Core decompression of the hip
Synovectomy of the knee
Unicondylar knee arthroplasty

Correct Answer: Synovectomy of the knee

Explanation:

Question 86:

Options:

Physical therapy should allow him to return to football with recurrent dislocations unlikely.
Immobilization of his shoulder in an external rotation brace will eliminate the chance of further dislocations.
Arthroscopic capsulolabral repair is a reasonable option if he wishes to undergo this procedure, despite this being a first-time dislocation.
Arthroscopic capsular and labral repair will likely fail in this situation.
Open repair definitely provides a better outcome.

Correct Answer: Arthroscopic capsulolabral repair is a reasonable option if he wishes to undergo this procedure, despite this being a first-time dislocation.

Explanation:

Question 87:

The essential lesion responsible for posterolateral rotatory instability of the elbow is disruption of the

Options:

lateral ulnar collateral ligament.
medial collateral ligament.
radial collateral ligament.
annular ligament.
posterolateral capsule.

Correct Answer: lateral ulnar collateral ligament.

Explanation:

Question 88:

Options:

Fibrous dysplasia
Osteochondroma
Osteoblastoma
Giant cell tumor
Hemangioma

Correct Answer: Osteoblastoma

Explanation:

DISCUSSION: Forty percent of osteoblastomas occur in the spine, and they can become large and locally aggressive lesions. They generally occur in the posterior elements but can occur in the ribs and transverse processes. Microscopic analysis of the lesion will reveal hyperchromatic osteoblasts separated by incompletely mineralized bars of bone. Recommended treatment is en bloc excision. Fibrous dysplasia, giant cell tumor, and hemangioma can have similar radiographic appearances; therefore, biopsy may be required to differentiate them from more aggressive lesions. Osteochondromas are characterized by an osteocartilaginous growth arising from the cortex.
REFERENCES: Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery. Philadelphia, PA, JB Lippincott, 1991,
vol 2, pp 1143-1174.
Enneking WF: Musculoskeletal Tumor Surgery. New York, NY, Churchill Livingstone, 1983, pp 1043-1053.

Question 89:

Options:

3 cm
6 cm
10 cm
14 cm
18 cm

Correct Answer: 6 cm

Explanation:

Question 90:

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

Options:

progressive increase in lumbar lordosis.
load transfer to the superior adjacent vertebra.
normalization of load transfer with working kyphosis.
reduced strain at the occipito-cervical junction.
reduced strain at the apex of the deformity.

Correct Answer: load transfer to the superior adjacent vertebra.

Explanation:

Question 91:

Options:

Oral cephalosporin
IV cephalexin and dressing changes
Betadine dressing and a short leg cast
Debridement of the wound and removal of the hardware
Debridement of the wound and maintenance of the hardware

Correct Answer: Debridement of the wound and maintenance of the hardware

Explanation:

Question 92:

Options:

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

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

Explanation:

Question 93:

Options:

Will not affect functional outcome
Will result in diminished thumb motion
Will result in diminished pinch strength
Will result in diminished grip strength
Will result in moderate activity-related pain back answer Question 61.03

Correct Answer: Will not affect functional outcome

Explanation:

Question 94:

What type of cementless femoral fixation results in the highest rate of distal femoral osteolysis?

Options:

Tapered circumferential proximally porous-coated stem
Hydroxyapatite-coated tapered circumferential proximally porous-coated stem
Straight circumferential fully porous-coated stem
Straight modular circumferential proximally porous-coated sleeve and distal fluted stem
Noncircumferential proximally porous-coated stem

Correct Answer: Noncircumferential proximally porous-coated stem

Explanation:

Question 95:

Options:

disruption of the sympathetic nerves during anterior lumbar exposure.
traction on the parasympathetic nerve at the L4-5 level.
not related to the surgical dissection.
injury to the pudendal nerves in the anterior sacral region during dissection at the L5-S1 level.
sexual dysfunction secondary to retrograde ejaculation.

Correct Answer: not related to the surgical dissection.

Explanation:

Question 96:

Osteolysis after total knee arthroplasty can be minimized through prosthetic design features such as

Options:

modular polyethylene inserts.
use of tibial posts on the tibial insert.
monolithic metal-backed tibial components.
metal-backed patellar components.
cementless tibial implants.

Correct Answer: monolithic metal-backed tibial components.

Explanation:

Question 97:

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Options:

Long-arm thumb spica casting
Bracing and bone stimulation
Scaphoid excision with intercarpal fusion
Bone grafting with screw placement

Correct Answer: Bone grafting with screw placement

Explanation:

Question 98:

Options:

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

Correct Answer: Type of surgery, age, and BMI

Explanation:

Question 99:

A positive Froment sign indicates weakness of which of the following muscles?

Options:

First dorsal interosseous
Adductor pollicis
Opponens pollicis
Flexor pollicis brevis
Abductor pollicis longus

Correct Answer: Adductor pollicis

Explanation:

Question 100:

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

Options:

Plain radiographs
CT scan
MRI
Arthrogram

Correct Answer: Plain radiographs

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

Orthopedic Board Review MCQs: Knee, Foot, Ankle & Arthroplasty | Part 21

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 21

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index