Orthopedic Board Review MCQs: Hip & Shoulder Part 227

About This Board Review Set

This is Part 227 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 227

This module focuses heavily on: Arthroplasty, Hip, Infection, Shoulder.

Sample Questions from This Set

Sample Question 1: A 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her...

Sample Question 2: -The concept of an “effective joint space” surrounding a prosthetic hip replacement refers to the...

Sample Question 3: What is the most common complication associated with scalene regional anesthesia for shoulder procedures?...

Sample Question 4: Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?...

Sample Question 5: A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynami...

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 43-year-old bus driver sustains a hyperextension injury to her arm and shoulder 4 months after undergoing an open Bankart repair. Examination reveals increased external rotation, anterior shoulder pain, and internal rotation weakness. Her examination also reveals the findings shown in Figure 44. What is the most likely diagnosis?

Explanation

DISCUSSION: An isolated tear of the subscapularis tendon has been noted as early as 1835 by Smith. In Gerber and associates’ 1991 report of 16 men with an average age of 51 years, isolated subscapularis tendon rupture was often caused by a violent hyperextension injury. All patients reported pain anteriorly along with night pain. They also noted pain and weakness of the arm. The lift-off test is performed by having the patient lift the palm of the hand away from the small of the back. The patient must have sufficient internal rotation to allow this test to be performed. A subscapularis rupture is likely if the patient cannot perform the lift-off test.
REFERENCES: Hertel R, Ballmer FT, Lombert SM, Gerber C: Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5:307-313.
Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 2

The concept of an “effective joint space” surrounding a prosthetic hip replacement refers to the

Explanation

The term “effective joint space” was initiated in the article that this question was referenced from. It is defined as all the regions that are accessible to joint fluid. The significance of the effective joint space is that patterns of joint fluid flow (preferential flow) will determine the concentration and pattern of particulate wear debris. Where there is wear debris there is the potential for lytic and linear bone loss secondary to macrophage concentrations.

Question 3

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Explanation

DISCUSSION: Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although parathesias lasting up to 2 weeks have been reported in up to 3% of patients.
REFERENCES: Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779.
Conn RA, Colfield RH, Byer DE, Lindstromberg JW: Interscalene block anesthesia for shoulder surgery. Clin Orthop 1987;216:94-98.

Question 4

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Explanation

Figure A is an AP radiograph demonstrating a displaced femoral neck fracture. Active older patients who present with a displaced femoral neck fracture should be treated with total hip arthroplasty (THA).
Displaced femoral neck fractures can present a challenge to treat. In younger patients with good bone stock a closed vs. open reduction and internal fixation should be attempted. For active older patients a total hip arthroplasty is the best option, especially if there is pre-existing arthritis in the injured hip. THA provides the best function with the least pain and less need for repeat surgery (compared to hemiarthroplasty). For low-demand or debilitated patients, for patients older than age 80, or for those who can not reliably follow hip precautions a hemiarthroplasty provides the lowest risk of dislocation, and thus would be the treatment of choice.
Macaulay et al. present a prospective randomized trial of patients with femoral neck fractures treated with THA vs hemiarthroplasty. They found that functional outcomes and patient satisfaction were higher in the THA group without significant increased risk of complications. Inclusion criteria required patients to be over age 50, be a community ambulator, and were excluded for presence of dementia.
Abboud et al. retrospectively reviewed patients treated with THA for osteoarthritis and compared them to patients treated with THA for a femoral neck fracture. They found no significant difference between the two groups for outcomes or complications.
Figure A is an AP radiograph demonstrating a displaced femoral neck fracture.
Incorrect Answers:

Question 5

A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynamic computed tomographic (CT) was obtained and shown in Figure A. Panel (a) shows an axial image with maximal rotation to the left. Panel (b) shows an axial image with maximal rotation to the right. What is the most appropriate next step in management? Review Topic

Explanation

Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
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Question 6

Figure 37 shows the clinical photograph of a 1-day-old infant who weighed 10.25 lb at birth. Examination reveals an absent right Moro reflex and limited active motion of the right shoulder, elbow, and wrist, but flexion of the fingers. Passive range of motion of the shoulder and elbow is normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s right upper extremity is held in the “head waiter’s” posture with the shoulder internally rotated, the elbow extended, and the wrist in flexion. The Erb type of obstetrical brachial plexus palsy involves the C5 and C6 nerve root, and occasionally, as in this child, the C7 nerve root. Obstetrical palsy is a traction injury, and is associated with a high birth weight, shoulder dystocia, cephalopelvic disproportion, or the use of forceps. Erb palsy is four times more common than injury to the entire plexus or injury to the C8 and T1 nerve roots. It results from the shoulder being depressed while the head and neck are laterally rotated, extended, and tilted in the opposite direction. Most patients recover wrist extension and elbow flexion. Patients with residual weakness of shoulder external rotation and abduction will benefit from release of the pectoralis major, latissimus dorsi, and teres major, with transfer of the latissimus dorsi and the teres major to the posterosuperior aspect of the rotator cuff. Recent studies using arthrograms and CT scans have shown a higher incidence of posterior glenoid deficiency and posterior subluxation than that observed with plain radiographs. The posterior subluxation or dislocation can be effectively reduced by tendon release and transfer procedures.
REFERENCES: Hoffer MM, Phipps GJ: Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:997-1001.
Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667.
Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:668-677.

Question 7

A patient who underwent total knee arthroplasty 6 years ago now reports knee pain for the past 3 days following dental surgery. Cultures of the aspirate are positive for Staphylococcus epidermidis. Management should consist of

Explanation

DISCUSSION: The patient has an early prosthesis infection as a result of hematogenous seeding from dental surgery. Irrigation and debridement with polyethylene exchange and IV antibiotics have been successful in early postoperative infections; it is less likely to be effective for a late hematogenous infection. Immediate total component exchange also may be effective, but it should be reserved for failure of irrigation and debridement.
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.
Goldman RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.

Question 8

A 24-year-old dancer reports posterior ankle pain when in the “en pointe” position. Examination reveals posteromedial tenderness, no pain reproduction with passive forced planter flexion, and pain with motion of the hallux. What is the most likely diagnosis?

Explanation

DISCUSSION: Flexor hallucis longus tendinitis is a common cause of posterior ankle pain in dancers. It tends to be more posteromedial and is characterized by a clicking or catching sensation posteromedially with motion of the great toe. A painful os trigonum typically causes more posterolateral ankle pain and may occur after an ankle sprain or plantar flexion injury where there may be a fracture of the os trigonum.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 249-261.
Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.

Question 9

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

Explanation

DISCUSSION: The artery of the tarsal canal is a branch of the posterior tibial artery. Among the branches of the artery of the tarsal canal is the deltoid artery. This arterial complex supplies the medial one third of the talar body. Disruption of this artery may lead to osteonecrosis of the medial body and subsequent collapse into varus. This is most commonly seen with talar body fractures but may be seen in Hawkins type 3 talar neck fractures. The artery of the tarsal sinus arises from the dorsalis pedis, lateral malleolar, and perforating peroneal arteries. The peroneal artery anastomoses with the calcaneal branches of the posterior tibial artery to form a plexus of vessels that supplies the posterior tubercle of the talus. Disruption of this artery would not result in collapse of the medial body, and thus would not lead to a varus deformity.
REFERENCES: Halibruton RA, Sullivan CR, Kelly PJ, et al: The extra-osseous and intra-osseous blood supply of the talus. J Bone Joint Surg Am 1958;40:1115.
Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.

Question 10

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

Explanation

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

Question 11

Figures 4a through 4c show the radiographs of a 43-year-old woman who sustained a twisting injury to her right ankle. She has ankle pain and tenderness medially and laterally. To help determine the optimal treatment, an external rotation stress radiograph of the ankle is obtained. This test is designed to evaluate the integrity of what structure?

Explanation

DISCUSSION: In the presence of a supination external rotation-type fracture of the distal fibula (Weber type B), stability of the ankle is best assessed by performing an external rotation stress AP view of the ankle. This test is used to assess the integrity of the deltoid ligament. The presence of a deltoid ligament rupture results in instability and generally is best managed surgically. The gravity stress test can also be used.
REFERENCES: Egol KA, Amirtharajah M, Tejwani NC, et al: Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004;86:2393-2398.
McConnell T, Creevy W, Tornetta P III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86:2171-2178.
Schock HJ, Pinzur M, Manion L, et al: The use of the gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89:1055-1059.

Question 12

A 7-year-old patient has had a painless limp for several months. Examination reveals pain and spasm with internal rotation, and abduction is limited to 10° on the involved side. Management consists of 1 week of bed rest and traction, followed by an arthrogram. A maximum abduction/internal rotation view is shown in Figure 40a, and abduction and adduction views are shown in Figures 40b and 40c. The studies are most consistent with

Explanation

DISCUSSION: The radiographs show classic hinge abduction. The diagnostic feature is the failure of the lateral epiphysis to slide under the acetabular edge with abduction, and the abduction view shows medial dye pooling because of distraction of the hip joint. Persistent hinge abduction has been shown to prevent femoral head remodeling by the acetabulum. Radiographic changes are characteristic of severe involvement with Legg-Calve-Perthes disease. The Catterall classification cannot be well applied without a lateral radiograph, but this degree of involvement would likely be considered a grade III or IV. Because the lateral pillar is involved, this condition would be classified as type C using the Herring lateral pillar classification scheme.
REFERENCE: Reinker KA: Early diagnosis and treatment of hinge abduction in Legg-Perthes disease. J Pediatr Orthop 1996;16:3-9.

Question 13

..A 60-year-old woman has a proximal femur fracture. A permeative, lytic defect is recognized at the fracture site. Appropriate imaging studies are performed and show no other lesions. What is the next treatment step?

Explanation

CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9

Question 14

One of the serious potential complications of repair of distal biceps tendon ruptures is limited pronation and supination as a result of synostosis. What surgical approach and technique presents the highest risk for development of this complication?

Explanation

DISCUSSION: The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture. However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.
REFERENCE: Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, p 342.

Question 15

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of

Explanation

This question refers to plantar fascitis. Heel spurs are noted in approximately 50% of the cases of subcalcaneal pain syndrome. In this patient, diagnosis should rule out lumbar radiculopathy since the symptoms are bilateral.
The most common site for heel pain is where the plantar fascia and intrinsic muscles arise from the medial calcaneal tuberosity on the anteromedial aspect of the heel.
First line treatment is NSAID’s, Physical therapy involving heel cord stretching and an orthosis. Second line therapy after these treatments are unsuccessful involve steroid injection and plaster immobilization. Surgical intervention should be the very last choice in the options given.

Question 16

When using a two-incision approach for open reduction and internal fixation of a Hawkins III talar fracture-dislocation involving the talar neck and body, what anatomic structure must be preserved to optimize outcome?

Explanation

DISCUSSION: A Hawkins III fracture-dislocation generally presents with posteromedial displacement with the deltoid ligament intact. Therefore, the only remaining blood supply is the deltoid branch of the artery of the tarsal canal originating from the posterior tibial artery. Often, the medial malleolus is fractured, assisting in reduction and visualization of fracture reduction. If the medial malleolus is intact, a medial malleolus osteotomy allows visualization of the reduction without compromising the last remaining blood supply to the talus.
REFERENCES: Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.
Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.

Question 17

A 32-year-old man underwent a total medial meniscectomy 2 years ago. He now reports pain and recurrent swelling for the past 3 months. Work-up includes full standing hip-knee-ankle radiographs, standing AP radiographs of both knees in full extension, an axial view of the patellofemoral joint, and a 45-degree flexion AP radiograph. Contraindication to meniscus allograft transplantation includes which of the following? Review Topic

Explanation

Flattening of the femoral condyles indicates the onset of significant arthritis of the joint and is a contraindication to meniscus allograft transplantation. Criteria to proceed with allograft transplantation includes prior total meniscectomy, age of 50 years or younger, BMI of less than 30, clinical symptoms of pain in the involved tibiofemoral compartment, 2 mm or more of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph, ligamentous stability, normal alignment, and no radiographic evidence of advanced arthrosis. Recurrent effusions are associated with chronic meniscus deficiency, and is one criteria for meniscal transplantation. High tibial osteotomy is often considered in conjunction with meniscal transplantation to correct tibiofemoral malalignment.

Question 18

In a longitudinal study of children with spastic diplegia, analysis of long-term function will most likely reveal

Explanation

DISCUSSION: In a longitudinal study of 18 patients with spastic diplegia over a period of 32 months, three-dimensional gait analysis revealed a deterioration of gait stability with increases in double support time and decreases in single support time. Kinematic data also identified a loss of excursion about the knee, ankle, and pelvis. Interestingly, the static examination of the children showed a decrease in the popliteal angle over time. The authors concluded that ambulatory ability tends to worsen over time in children with spastic diplegia.
REFERENCE: Johnson DC, Damiano DL, Abel MF: The evolution of gait in childhood and adolescent cerebral palsy. J Pediatr Orthop 1997;17:392-396.

Question 19

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Explanation

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 20

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?

Explanation

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.
Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 21

Figure 33 shows the CT scan of a 40-year-old man who injured his left shoulder while skiing. What structure is attached to the bony fragment?

Explanation

DISCUSSION: The scan reveals a bony Bankart lesion. The anterior band of the inferior glenohumeral ligament is the major restraint to anterior translation of the humeral head and is usually injured with anterior shoulder dislocations. It inserts onto the glenoid labrum at the anteroinferior aspect of the glenoid rim. The labrum most frequently avulses from the glenoid (Bankart lesion), but occasionally the bony attachment is avulsed.
REFERENCES: O’Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18:449-456.
Warner JP: The gross anatomy of the joint surfaces, ligaments, labrum and capsule, in Matsen FA, Fu FF, Hawkins RJ (eds): The Shoulder: A Balance of Mobility and Stability. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1992, pp 7-28.

Question 22

Locked lateral plate fixation of the proximal tibia is most appropriate for what Schatzker type fracture?

Explanation

Locked lateral plate fixation of the proximal tibia has proven effective for bicondylar fractures (Schatzker types V and VI). The laterally based plate provides support for the lateral condyle fracture and locked proximal screws support the medial fragment from varus collapse. A medial antiglide plate can be used in conjunction with the locked plate. Lateral locked plate fixation has not been shown to have advantages for pure lateral fractures (Schatzker types I, II, and III) that require buttress plating or support of depressed articular components. Pure medial fractures (Schatzker type IV) are best treated with medial fixation.

Question 23

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Staphylococcus aureus. What is the next most appropriate step in management?

Explanation

DISCUSSION: The overriding factor determining treatment in this case is the appearance of the surgical wound. Based on MacPhearson’s work, this “C” wound is best managed with two-stage exchange. The functional outcome is markedly diminished following a knee arthrodesis compared to revision knee arthroplasty.
REFERENCES: Harwin SF: The diagnosis and management of infected total knee replacement. Seminars Arthroplasty 2002;13:9-22.
Goldmann RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.
Morrey BF, Westholm F, Schoifet S, Rand JA, Bryan RS: Long-term results of various treatment options for an infected total knee arthroplasty. Clin Orthop 1989;248:120-128.

Question 24

Figures 43a and 43b show the radiographs of an 8-year-old boy who was referred by his gym teacher because of an awkward running pattern. The patient denies any pain in his hips. Examination reveals a mild Trendelenberg gait and decreased internal rotation of the left hip to 25 degrees compared to 40 degrees on the right. What is the most likely diagnosis?

Explanation

The referenced article is a current concept review on the treatment of Legg-Calve-Perthes Disease and does not specifically mention diagnosis. Self limited non-inflammatory deformity of the weight-bearing portion of the femur, likely due to osteonecrosis. Usually seen in 4-8 year old males with delayed skeletal maturity. Family history, low birth weight, and abnormal birth presentation.
Symptoms include-pain, effusion (from synovitis), and a limp, decreased ROM especially Abduction internal rotation. Trendelenburg stance is common.
The key in this question is the age, decreased ROM, Trendelenburg gait. The prognosis is directly related to the age at presentation, after 8 years old the prognosis is poor. SCFE(Slipped Capital Femoral Epiphysis)-Usually seen in obese adolescent boys with a family history. African American more common. Often related to endocrine abnormalities, presenting with externally rotated gait, decreased internal rotation, thigh atrophy, with hip or knee pain, symptoms vary with the acuteness of the slip.
Hypothyroidism is often a finding with patients presenting with SCFE and chondrolysis is a known complication of SCFE.

Question 25

03 An 18 year old female Olympic basketball player is seeking advice on how to prevent future ACL injury. What recommendations can be made based on available scientific data?

Explanation

The reference article is a landmark in Female-ACL Injuryliterature. Hewett et al, “Plyometric Training in Female Athletes.” Am. J. Sports Med 1996, 24(6) pg 765-773. The conclusion: “This training may have significant effect on knee stabilization and prevention of serious knee injury among female athletes.”
In researching this answer I searched Ovid, looked in sports texts and looked online for “derotation brace.” Every article mentioned “derotation brace” with “the ACL-deficient knee.” I could not find any mention of prophylactic ACL injury prevention with derotation brace.
Prophylactic surgery and oral contraceptive prescription would never be correct answers. As with “derotation brace”, they are buzzwordsin the femaleACL injury literature and you could pick them as an answer if you didn’t have enough knowledge of the subject. It’s hypothesized that estrogen levels may have a role in when females injure there ACLs.
Finally, notchplasty relates to resecting part of the lateral femoral condyle during ACL reconstruction for both visualization of graft placement and to prevent impingement on the graft.
back to this question next question Figure 7 shows the clinical photograph of the knee of a chronic

Question 26

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

Explanation

The ZPA is located on the posterior (ulnar) margin of the limb bud. It expresses Shh protein. When tissue from ZPA is added to the anterior (radial) margin of the limb bud, ulnar dimelia, or mirror hand duplication, occurs.
The ZPA controls AP (radioulnar) growth. The signaling molecule is Shh, which is dose dependent. Higher Shh doses lead to posterior (ulnar) digits ulnar sided polydactyly. The extent of duplication is dose dependent (higher dose = more replication). Reduced Shh leads to loss of digits. Posterior elements (little finger/ulna) are formed EARLY prior to anterior elements which are formed LATE (radius/thumb). Disruption of AP patterning will result in loss of later forming elements (radius/thumb).
Al-Qattan et al. reviewed embryology of the upper limb. They summarized that embryology of the upper limb can be viewed in 2 distinct ways: the steps of limb development and the way that the limb is patterned along its 3 spatial axes. Cell signaling plays a major role in regulating growth and patterning of the vertebrate limbs. Signaling cell dysfunction results in congenital differences according to the affected signaling axis.
Illustration A shows an experiment to create ulnar dimelia by adding ZPA tissue to the anterior limb bud. The video shows development of the limb.
Incorrect Answers:

Question 27

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Explanation

Anabolic steroids have many effects on the body. Increased muscle mass occurs specifically through increased production of messenger RNA. HDL levels usually decrease but do not affect muscle. Also, steroids act to change the effects of cortisol to decrease catabolism.

Question 28

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

Explanation

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

Question 29

A 51-year-old woman with no preoperative neurologic deficit is undergoing elective anterior cervical diskectomy and fusion (ACDF) with plating and fusion for a C5-6 disk herniation with right-sided neck pain. Thirty minutes into the surgery the neurophysiologic monitoring shows a rapid drop and then loss of amplitude in the right cortical somatosensory-evoked potential waveform. All other waveforms remained normal and unchanged, including right-sided cervical (subcortical) and peripheral (Erb’s point), and those from the left-sided upper extremity and both lower extremities. What is the most likely cause of the change? Review Topic

Explanation

The change noted is focal and confined to the cortex, sparing the opposite side, both lower extremities, and the subcortical waveforms, making all the choices unlikely with the exception of carotid compression with focal cortical ischemia. This may be associated with poor collateral flow from the opposite hemisphere due to an incomplete circle of Willis.

Question 30

Figure 1 shows the radiograph obtained from a 67-year-old man recently diagnosed with osteoarthritis, 8 years after receiving a left metal-on-metal total hip arthroplasty (THA). The acetabular component has a modular cobalt alloy acetabular liner. The patient states that he did very well postoperatively, but for the last 6 months has noted worsening pain and swelling in his left hip. Serum metal ion testing reveals a chromium level of 12.4 ng/mL, compared with a normal level of less than 0.3 ng/mL, and a cobalt level of 11.8 ng/mL, compared with a normal level less than 0.7 ng/mL. An MRI with metal artefact reduction sequence (MARS) was performed and is shown in Figure 2. What is the most appropriate management at this time?

Explanation

DISCUSSION:
Metal-on-metal THA was initially introduced in the 1990s, with the proposed advantages of decreased wear and improved stability. However, catastrophic adverse local tissue reactions associated with their use has raised numerous concerns. The work-up of a patient with a prior metal-on-metal total hip arthroplasty involves a thorough history and physical examination; blood analysis, including the erythrocyte sedimentation rate, C-reactive protein, and metal ion levels; and secondary imaging, including ultrasonography, CT, and MRI. In a patient with clinical symptoms, elevated metal ion levels, and a large fluid collection seen on MRI, the most appropriate treatment would be removal of the metal-on-metal bearing. Given the presence of an adverse reaction involving cobalt and chromium, a revision ceramic head may be most appropriate to avoid the potential of trunnion-associated corrosion.

Question 31

What is the most common diagnosis in a patient older than age 40 years with a destructive bony lesion?

Explanation

DISCUSSION: The most common destructive lesions in a patient older than age 40 years are, in decreasing incidence, metastatic carcinoma, multiple myeloma, lymphoma, and chondrosarcoma. Osteosarcoma is found primarily in younger patients.
REFERENCE: CA, January/February 2000, vol 50, no. 1 (Cancer Statistics).

Question 32

Figure 1 is the MR image of a 36-year-old athlete who is tackled from behind and falls forward onto his left knee. He has pain, swelling, and stiffness. Examination includes a moderate effusion, positive quadriceps active test, and normal Lachman test finding. This patient elects nonsurgical treatment and later experiences persistent instability. Examination reveals an asymmetric Dial test finding and a varus thrust during ambulation. Which osteotomy and correction appropriately addresses this chronic instability pattern?

Explanation

The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, one major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading. The scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag. Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used.
Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 33

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following? Review Topic

Explanation

The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.

Question 34

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 35

A B Figures 90a and 90b are MR images of a 34-year-old man who is referred to your office by his primary care physician after failing 4 months of nonsurgical treatment that included epidural steroids for severe right arm pain occurring in a C6 distribution. He also has associated paresthesias in this region. The patient is weak in elbow flexion and wrist extension. What are his likely outcomes if he is treated with a posterior foraminotomy instead of anterior cervical diskectomy and fusion (ACDF)?

Explanation

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617. View Abstract at PubMed Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 36

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Explanation

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.

J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 37

A 70-year-old woman has a 3-year history of gradually increasing diffuse and global right knee pain. Her main issues are difficulty with stairs, stiffness with prolonged sitting, and swelling. She has taken NSAIDs and has received intra-articular steroid injections, all with decreasing efficacy. Her right knee examination reveals a range of motion of 15° to 80° with a fixed deformity to varus and valgus stress. Her symptoms are no longer manageable nonsurgically. Radiographs reveal a 30-degree mechanical axis deformity. The deformity shown in Figure below is predominantly associated with

Explanation

DISCUSSION:
In the setting of valgus deformities, TKA poses different challenges than those encountered when varus deformities are present. Most valgus alignment is attributable to a deformity of the distal femur rather than of the proximal tibia, as seen in varus knees. One of the major anatomical differences is a hypoplastic lateral femoral condyle which, when not recognized and used as a rotational reference point, can lead to internal rotation of the femoral component. This malrotation in turn leads to patellofemoral maltracking
or instability, which is a common complication associated with primary TKA.

Question 38

A 14-year-old boy sustained a femoral neck fracture in a fall from a tree and underwent open reduction and internal fixation 6 months ago. Follow-up examination now reveals an antalgic Trendelenburg gait and painful range of motion. A radiograph is shown in Figure 23, and a CT scan shows a nonunion. Treatment should consist of

Explanation

DISCUSSION: The coxa vara deformity and fracture nonunion should be treated simultaneously; therefore, the treatment of choice is curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation. In addition, valgus osteotomy will convert the shear forces across the nonunion to compression, aiding in healing of the nonunion. None of the other procedures addresses both issues, and hip fusion is inappropriate under these conditions.
REFERENCES: Lam SF: Fractures of the neck of the femur in children. J Bone Joint Surg Am 1971;53:1165-1179.
Canale ST, Beaty JH: Pelvic and hip fractures, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1109-1193.

Question 39

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

Explanation

DISCUSSION: Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation. Incision and drainage may result in a bacterial infection. Marsupialization is used in the treatment of a chronic paronychia. Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns.
REFERENCES: Fowler JR: Viral Infections. Hand Clin 1989;5:613-627.
Jebsen PL: Infections of the fingertip: Paronychias and felons. Hand Clin 1998;14:547-555.

Question 40

What is the most common MRI appearance of a malignant soft-tissue sarcoma?

Explanation

DISCUSSION: The classic MRI appearance of a soft-tissue sarcoma is a well-defined heterogeneous mass deep to the fascia. MRI has greatly enhanced our ability to identify and characterize soft-tissue masses. In many patients, MRI is diagnostic and may obviate the need for biopsy. In other patients, it may indicate with high probability that the mass is malignant and consideration for referral can be made. A common misconception is that sarcomas are infiltrative; therefore, physicians mistakenly exclude the diagnosis of a sarcoma based on a well-defined mass seen on MRI. However, sarcomas grow centrifugally with balloon-like expansion compressing surrounding normal tissue; as such, they appear well defined. Many benign soft-tissue masses such as lipomas are similarly well defined. However, MRI is especially useful in identifying fat. Lipomas appear to be homogeneous masses with fat signal characteristics on all sequences. Ill-defined soft-tissue masses include infection, trauma, and desmoid tumors. Heterogeneity is not unique to malignant tumors but is a characteristic of soft-tissue sarcomas.
REFERENCES: Bancroft LW, Peterson JJ, Kransdorf MJ, Nomikos GC, Murphey MD: Soft tissue tumors of the lower extremities. Radiol Clin North Am 2002;40:991-1011.
Berquist TH, Ehman RL, King BF, et al: Value of MR imaging in differentiating benign from malignant soft-tissue masses: Study of 95 lesions. Am J Roentgenol 1990;155:1251-1255.
Crim JR, Seegar LL, Yao L, et al: Diagnosis of soft tissue masses with MR imaging: Can benign masses be differentiated from malignant ones? Radiology 1992;185:581-586.

Question 41

A 6-year-old girl sustains an ankle injury after falling on roller blades. An AP radiograph is shown in Figure 68. Treatment should consist of which of the following?

Explanation

DISCUSSION: The child has a Salter-Harris type IV injury involving both the growth plate and the articular surface of the ankle. This injury pattern has a high risk of physeal arrest; open reduction and internal fixation is indicated to realign the physis and joint surface. The best method of fixation to avoid growth arrest is one that does not cross the physis. This is usually achieved by an epiphyseal screw or pins parallel to the physis. If the metaphyseal fragment were large enough, a transverse metaphyseal screw could be used. The incidence of growth arrest following physeal ankle injuries is high and longterm follow- up is indicated.
REFERENCES: Cass JR, Peterson HA: Salter-Harris type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg Am 1983;65:1059-1070. Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibia physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.

Question 42

A 27-year-old professional baseball pitcher who underwent arthroscopic olecranon debridement continues to have medial-sided elbow pain during late cocking. Physical examination reveals laxity and pain with valgus stress testing. What is the most likely cause of his pain? Review Topic

Explanation

Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.

Question 43

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Explanation

DISCUSSION: The acetabular quadrants are defined by two lines: one drawn from the anterosuperior iliac spine to the posterior fovea, forming acetabular halves, and a second drawn perpendicular to the first at the midpoint of the acetabulum, forming four quadrants. The anterior quadrants should be avoided because improper screw placement may injure the external iliac artery and vein, as well as the obturator nerve, artery, and vein. These structures lie close to the pelvic bone, with little protective interposition of soft tissue.
REFERENCES: Wasielewski RC, Cooperstein LA, Kruger MP, et al: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-508.
Keating EM, Ritter MA, Faris PM: Structures at risk from medially placed acetabular screws.

J Bone Joint Surg Am 1990;72:509-511.

Question 44

Figures 35a and 35b show the radiographs of a 7-year-old patient who has progressive deformity of the right thigh accompanied by a dull persistent pain radiating to the knee. Examination reveals an obvious bulge in the right thigh, with flexion of the hip beyond 50° only if the hip is allowed to externally rotate. Management should consist of

Explanation

DISCUSSION: The patient has radiographic signs of osteogenesis imperfecta, including osteopenia, mild acetabular protrusio, cortical thinning, and bowing associated with anterior stress fracturing. The treatment of choice is correction of the bow with osteotomies, followed by intramedullary fixation to prevent further deformity. Biphosphonates, such as pamidronate, may be useful in increasing bone density and preventing fractures. Large multicenter studies on biphosphonate efficacy are currently in progress.
REFERENCES: Zionts LE, Ebramzadeh E, Stott NS: Complications in the use of the Bailey-Dubow extensible nail. Clin Orthop 1998;348:186-195.
Luhmann SJ, Sheridan JJ, Capelli AM, Schoenecker PL: Management of lower-extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: A 20-year experience. J Pediatr Orthop 1998;18:88-94.
Glorieux FH, Bishop NJ, Plotkin H, Chabot G, Lanoue G, Travers R: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1988;339:947-952.

Question 45

A 32-year-old professional skydiver lands awkwardly during a jump. He presents to the emergency room with bilateral knee injuries. Following successful closed reduction of both extremities, both feet are warm and pulses are present. Bedside doppler assessment is performed and the results are seen in Figure A. What would be the most appropriate next step in treatment?

Explanation

The ankle-brachial index (ABI) of left and right limbs are 0.78 and 0.96 respectively. CT angiography (or conventional angiography) of the left lower extremity is indicated because of abnormal ABI <0.9. It is sufficient to observe the right lower extremity (ABI >0.9).
Injury to the popliteal artery is present in 10-40% of knee dislocations (KD). ABI
<0.9 has sensitivity of 87% and specificity of 97% for the diagnosis of arterial disruption. Delayed recognition of an occlusive injury (>8 hours) is likely to result in above knee amputation.
Stannard et al. examined the role of selective arteriography based on serial physical examination. They found arterial injury in 7% (9 out of 134 knees), and abnormal physical findings in 10 patients, with only 1 false positive. They recommend arteriography for patients with decreased pulses, color or temperature, expanding knee hematoma, or an abnormal physical examination prior to presentation in the emergency department.
Mills et al. reviewed the value of ABI for diagnosing arterial injury after knee dislocation. They found that of the 29% with ABI <0.9, all required surgery for arterial injury. Of the remaining patients with ABI >0.9, none had vascular injury. They concluded ABI >0.9 has negative predictive value of 100%.
Nicandri et al. reviewed an algorithm for selective angiography. They recommend the following: (1) Intact pulses and ABI >0.9, observation for 24 hours. (2) Asymmetric pulses or ABI <0.9, arteriogram. (3) Hard signs of vascular injury (absent distal pulses, distal ischemia, active hemorrhage, expanding pulsatile hematoma), surgical exploration.
Figure A is a table showing systolic pressure readings at different sites. To calculate the ABI, the highest measured arterial pressure in the ankle or foot is divided by the higher brachial arterial pressure from both upper extremities.
Incorrect Answers:

Question 46

Which of the following associated type acetabular fracture patterns is defined based on the fact that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the sacroiliac joint?

Explanation

DISCUSSION: There are 5 simple and 5 associated fracture types according to the classification system created by Judet and Letournel. The key feature which distinguishes both column fractures from other associated types is that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the SI joint. Although the transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures all show involvement of the anterior and posterior columns, they are not “both columns” because a portion of the articular surface remains in its normal position, attached to intact ilium. The intact ilium is responsible for the "spur sign" noted most prominently on the obturator oblique radiograph.

Question 47

Figure 7 shows the CT scan of a 25-year-old soccer player who has had posterior ankle pain with plantar flexion for the past 2 years. Immobilization has failed to provide relief. He is ambulatory. Management should consist of

Explanation

DISCUSSION: An os trigonum is usually asymptomatic, but this accessory bone has been associated with persistent posterior ankle pain, which has been described as os trigonum syndrome. This usually affects athletes and ballerinas. Forced plantar flexion leads to impingement of the os trigonum against the posterior tibial plafond, and flexor hallucis tendinitis may develop. It may be difficult to differentiate a fractured trigonal process from the os trigonum. MRI may reveal bone marrow edema that may aid in the diagnosis of os trigonum syndrome. Steroid injections may lead to tendon rupture. The results of excision of a symptomatic os trigonum through a posteromedial or lateral approach are favorable, with a rapid return to full function. The main complication of this procedure is sural nerve injury with a lateral approach.
REFERENCES: Hedrick MR, McBryde AM: Posterior ankle impingement. Foot Ankle Int 1994;15:2-8.
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.

Question 48

Persistent symptoms and decreased function following distal clavicle resection, coracoacromial ligament transfer, and augmentation (modified Weaver-Dunn) are most likely related to Review Topic

Explanation

Although multiple studies have reported good clinical results with the modified Weaver-Dunn reconstruction, others have suggested that the reconstruction does not restore the native stability to the acromioclavicular joint. In particular, persistent horizontal (anterior to posterior) instability may cause persistent symptoms following reconstruction. Anatomic repair and reconstruction techniques that preserve the distal clavicle may offer patients less risk of horizontal instability.

Question 49

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Explanation

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:

OrthoCash 2020

Question 50

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

Explanation

DISCUSSION: The most common location of chondrosarcoma is the pelvis (30%), followed by the proximal femur (20%) and shoulder girdle (15%). Chondrosarcoma rarely affects the spine or hand.
REFERENCES: Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.
Simon M, Springfield D, et al: Chondrosarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 276.

Question 51

The Cotton test evaluates which of the following structures?

Explanation

DISCUSSION: The inferior tibiofibular syndesmosis is a fibrous articulation consisting of four ligaments; the elasticity of these ligaments permits axial, vertical, anterior, posterior, and mediolateral motion at the ankle syndesmosis during weight bearing. Nielson et al reported that the level of the fibular fracture does not correlate reliably with the integrity or extent of the interosseous membrane (IOM) tears identified on MRI in operative ankle fractures. Therefore, one cannot consistently estimate the integrity of the IOM and subsequent need for transsyndesmotic fixation based solely on the level of the fibular fracture. This supports the need for intraoperative stress testing (ie, external rotation stress or Cotton test) of the ankle syndesmosis in all operative ankle fractures. The study by Leeds et al noted a correlation between syndesmosis reduction (initial and final) and outcomes (radiographic and clinical). Of note, the Cotton test was originally described around 1910 by Frederic J. Cotton as the "talar glide test" evaluating the medial/lateral translation of the talus in the mortise. A positive result, indicating disruption of the deltoid ligament or ankle syndesmosis, was defined as translation of greater than 1mm.

Question 52

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Explanation

Radiographic assessment of the pelvis is an essential part of the initial evaluation of trauma patients. In addition to an AP radiograph, 40-degree caudal (inlet) and 40-degree cephalad (outlet) views are obtained. The caudal/inlet view is useful for detecting the integrity of the pelvic ring because it shows the sacroiliac joints and the sacrum, which can help detect either sacroiliac dislocations or sacral fractures and their displacement in the anterior-posterior plane. The outlet view detects superior or inferior displacement and sagittal plane flexion or rotation of the pelvis. A lateral radiograph of the sacrum identifies transverse fractures of the sacrum and coccyx and the degree of their displacement. A lateral view should be obtained in instances of bilateral sacral fractures and U-shaped sacral fractures in which there are bilateral vertical fractures through the sacral foramina that connect with a transverse fracture line between the second or third sacral segments. Some patients with these fractures have sacral fracture-dislocations with spinopelvic dissociation and a high incidence of neurologic injuries. The lateral view discloses the extent of displacement of the upper sacral segment (usually S2 forward on S3) and the resultant kyphotic deformity.

Question 53

Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?

Explanation

DISCUSSION: According to a recent study, cemented pegged glenoid components had fewer radiolucent lines initially and at 2-year follow-up when compared to a cemented keeled design. Curve-backed designs have also shown fewer radiolucent lines when compared to flat-backed designs. Oversizing the glenoid can lead to impaired rotator cuff function and decreased range of motion. An off-centered glenoid can lead to early loosening.
REFERENCES: Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg 2005;14:252-257.
Szabo I, Buscayret F, Edwards TB, et al: Radiographic comparison of flat-back and convex-back glenoid components in total shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:636-642.
Mileti J, Boardman ND III, Sperling JW, et al: Radiographic analysis of polyethylene glenoid components using modern cementing techniques. J Shoulder Elbow Surg 2004;13:492-498.

Question 54

Figures 5a and 5b show the radiographs of an 11-year-old boy who felt a pop and immediate pain in his right knee as he was driving off his right leg to jam a basketball. Examination reveals that the knee is flexed, and the patient is unable to actively extend it or bear weight on that side. There is also a large effusion. Management should include

Explanation

DISCUSSION: Fractures through the cartilage on the inferior pole of the patella, the so-called sleeve fracture, are often difficult to diagnose because of the paucity of ossified bone visible on the radiographs. If the fracture is missed and the fragments are widely displaced, the patella may heal in an elongated configuration that may result in compromise of the extensor mechanism function. The treatment of choice is open reduction and internal fixation using a tension band wire technique to achieve close approximation of the fragments and restore full active knee extension.
REFERENCES: Heckman JD, Alkire CC: Distal patellar pole fractures: A proposed common mechanism of injury. Am J Sports Med 1984;12:424-428.
Tolo VT: Fractures and dislocations around the knee, in Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children. Philadelphia, Pa, WB Saunders, 1994, vol 3, pp 380-382.

Question 55

A year-old man who underwent right total knee replacement surgery 2 and a half years ago has had knee pain since surgery. The pain is diffuse, constant, and made worse with activity. He notes warmth and swelling in his knee. Examination shows a well-healed incision, no erythema, moderate warmth, synovitis, and an effusion. The knee is stable, and has an arc of flexion between 3° and 120°. Radiographs show well-fixed and well-aligned implants. What is the most appropriate initial treatment?

Explanation

DISCUSSION:
This patient's history and physical findings are concerning for deep infection. Inflammatory markers, including ESR and CRP, should be obtained first. If the levels are elevated, knee aspiration should be performed for the synovial cell count and culture. A bone scan is not indicated in an initial investigation for deep infection; it is rarely helpful and is not cost effective. CT to assess implant rotation is an appropriate investigation for knee pain when the clinical scenario is not suspicious for a deep infection
and when infection has been excluded.

Question 56

The spread of malignant cells to the vertebrae is often through

Explanation

DISCUSSION: In 1940, Batson described a valveless plexus of veins that extend from the dural venous sinuses of the skull to the sacrum. This system permits retrograde blood flow and enables tumor cells to enter vertebral bodies at multiple levels. Increased intra-abdominal pressure will enhance this retrograde blood flow.
REFERENCE: Batson OV: The function of the vertebral veins and their role in the spread of metastases. Ann Surg 1940;112:138-149.

Question 57

Figure 43 shows the lateral radiograph of a 12-year-old boy with mild osteogenesis imperfecta who injured his left elbow after pushing his brother. Treatment should consist of

Explanation

DISCUSSION: The patient has a displaced fracture of the apophysis of the olecranon for which most authorities recommend surgical treatment. In older children, stability of the reduction may be achieved by the use of two parallel medullary Kirschner wires and a figure-of-8 tension band loop of either stainless steel wire or absorbable suture. The use of an absorbable suture does not require removal of the implant. Absorbable suture alone is best used in very young patients who have this type of injury. An intramedullary screw would pose an unnecessary risk of future growth disturbance.
A displaced, isolated fracture of the apophysis of the olecranon is an unusual injury in a child. It has been suggested by several authors that children who have osteogenesis imperfecta may be especially prone to this injury. One study reported seven of these fractures occurring in five children who had the mild form of osteogenesis imperfecta (Sillence type IA). The authors of this study suggest that the diagnosis of osteogenesis imperfecta be considered in any child who has a displaced fracture of the apophysis of the olecranon, especially when the injury is associated with relatively minor trauma.
REFERENCES: Stott NS, Zionts LE: Displaced fractures of the apophysis of the olecranon in children who have osteogenesis imperfecta. J Bone Joint Surg Am 1993;75:1026-1033.
Gaddy BC, Strecker WB, Schoenecker PL: Surgical treatment of displaced olecranon fractures in children. J Pediatr Orthop 1997;17:321-324.
Dormans JP, Rang M: Fractures of the olecranon and radial neck in children. Orthop Clin North Am 1990;21:257-268.

Question 58

A 14-year-old girl reports a 3-week history of anterior thigh pain and a palpable mass after sustaining a soccer-related injury. Examination reveals a tender, firm mass in the midportion of the rectus femoris. MRI scans are shown in Figures 39a through 39c. What is the most appropriate management?

Explanation

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T₁-weighted MRI scan, the defined fluid signal on the T₂-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 59

A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Explanation

This patient has a tension pneumothorax and needs immediate decompression to convert it to a simple pneumothorax until definitive treatment with a chest tube can be performed. The other choices are inappropriate.

Question 60

Figures 1 and 2 display the radiographs obtained from a woman who had volar plating of the distal radius 8 months earlier. Two days ago, she noticed she could not actively extend her thumb. What is the most appropriate treatment that would restore active thumb extension?

Explanation

EXPLANATION:
Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through view, are useful for avoiding this complication.

Question 61

You are interested in learning a new technique for minimally invasive total knee arthroplasty. The Keyhole Genuflex system seems appealing to you because the instrumentation comes with wireless controls. What is an acceptable arrangement to learn more about this system?

Explanation

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

Question 62

A 10-year-old boy is struck by a car and sustains open left tibia and fibula fractures with bone protruding through a 7-cm laceration, multiple deep and superficial abrasions over the anterior leg, and road gravel is present in the wounds. His foot is warm and well-perfused with normal sensation and he has no pain with passive range of motion of the toes. Optimal treatment should consist of Review Topic

Explanation

The patient has a grade 2 open fracture and therefore needs wound debridement as a first step, followed by fracture stabilization preferably with an external fixator. A reamed intramedullary nail is not indicated in a 10-year-old child with open growth plates. Submuscular plating is not needed in an open fracture and there is no mention of fracture debridement. Percutaneous Kirschner wires will not provide adequate fracture stabilization, nor will a short leg cast. Flexible nailing should be considered as another form of fixation.

Question 63

A 13-year-old gymnast presents with ongoing knee pain for the past few months. She tried conservative measures including kinesiotaping, physical therapy and rest. On physical exam, she has normal valgus alignment, negative patellar tilt and discomfort with resisted open chain knee extension. A representative radiographs are shown in Figure A-C. What is the most likely clinical diagnosis? Review Topic

Explanation

Based on history, physical examination and radiographic findings this patient has patellofemoral syndrome
Evaluation of a patient with patellofemoral pain requires a physical examination and plain radiographs. Appropriate examination of all structures around the knee is critical to rule out other diagnoses. An MRI is useful for evaluating intra-articular or intra-osseous lesions, if clinical suspicion is suggestive of this. Treatment is predominantly conservative, with focus on low impact exercises that maximize aerobic conditioning.
Earl et al. review the epidemiology, etiology and management of patellofemoral syndrome. They note that there is no clear cause of this issue, although issues related to the quadriceps and dynamic malalignment may be contributory.
Outerbridge et al. describe overuse injuries in the young athletic patient. They provide an overview of diagnosis and management specific to this patient population.
Figures A, B and C show AP, lateral and merchant radiographs of a normal knee in a skeletally immature individual. No osseous abnormalities are identified.
Incorrect

Question 64

Which of the following conditions is most likely inherited as an autosomal dominant trait?

Explanation

Postaxial polydactyly involves polydactyly of the little finger, preaxial polydactyly usually involves the thumb or the index finger. Postaxial polydactyly is further divided into Type A, in which the well formed extra digit artier with the fifth or an extra metacarpal and Type B, a small extra digit that is poorly formed and often is little more than a skin tag. Postaxial polydactyly is inherited as an autosomal dominant trait with marked penetrance.

Question 65

A 55-year-old woman with a 15-year history of systemic lupus erythematosus has had left shoulder pain for the past 3 months. She reports that the pain has grown progressively worse over the past few months, and her shoulder function is severely limited. She is presently being treated with azathioprine and has used corticosteroids in the past. AP and axillary radiographs are shown in Figures 19a and 19b, and MRI scans are shown in Figures 19c and 19d. Which of the following forms of management will yield the most predictable pain relief and return of shoulder function?

Explanation

DISCUSSION: Prosthetic shoulder arthroplasty has been shown to provide predictable results for treating stage III and stage IV osteonecrosis of the humeral head. The decision to resurface the glenoid (total shoulder arthroplasty versus humeral hemiarthroplasty) usually is made based on the radiographic and intraoperative appearance of the glenoid. Core decompression of the humeral head has been reported to be effective for earlier stages (pre collapse) but would not be appropriate for a patient with stage IV disease.
REFERENCES: Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182.
L’Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361.
Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.

Question 66

In a retroperitoneal approach to the lumbar spine, what nerve is commonly found on the psoas muscle?

Explanation

DISCUSSION: The genitofemoral nerve and the sympathetic plexus consistently lie on the ventral surface of the psoas muscle. The ilioinguinal and iliohypogastric nerves are the most superior branches of the lumbar plexus and emerge along the upper lateral border of the psoas muscle traveling toward the quadratus lumborum. Both the obturator and femoral nerves are deep and lateral to the psoas muscle.
REFERENCES: Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer-Verlag, 1983, p 107.
Johnson R, Murphy M, Southwick W: Surgical approaches to the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1559.
Gray’s Anatomy. New York, NY, Bounty Books, 1977, pp 1226-1227.

Question 67

Figures 21a and 21b show the radiographs of a 12-year-old patient with an L4-level myelomeningocele who has scoliosis that has been slowly progressing for the past several years. There has been no loss of motor function. An MRI scan shows no syringomyelia or increased hydrocephalus. Management should consist of

Explanation

DISCUSSION: Scoliosis is a common occurrence in children with myelomeningocele, with the incidence increasing as the neurologic level moves cephalad. The rate of pseudarthrosis for isolated anterior or posterior fusions has been reported as high as 75%. The combination of anterior and posterior fusions with some type of instrumentation has been shown to decrease the rate of pseudarthrosis to 20%. Brace treatment in smaller curves can be used as a temporizing measure to delay surgery, but as with idiopathic scoliosis, the brace is ineffective for larger curves. Observation is not indicated with a curve of this magnitude.
REFERENCES: Ward WT, Wenger DR, Roach JW: Surgical correction of myelomeningocele scoliosis: A critical appraisal of various spinal instrumentation systems. J Pediatr Orthop 1989;9:262-268.
Muller EB, Nordwall A: Brace treatment of scoliosis in children with myelomeningocele. Spine 1994;19:151-155.

Question 68

During particle-induced osteolysis around implants, what cell secretes most of the interleukin-6 (IL-6)?

Explanation

DISCUSSION: During osteolysis, IL-6 is secreted by fibroblasts in the membrane surrounding the prosthesis. IL-6 also can be secreted by osteoblasts in other settings, but they are not the predominant source of IL-6 in particle-induced osteolysis. The remaining cells are not major sources of IL-6.
REFERENCE: Bukata SV, Gelinas J, Wei X, et al: PGE2 and IL-6 production by fibroblasts in response to titanium wear debris particles is mediated through a Cox-2 dependent pathway. J Orthop Res 2004;22:6-12.

Question 69

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of

Explanation

DISCUSSION: Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed.
REFERENCES: Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.
Sangeorzan BJ, Veith RG, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle 1990;10:193-200.

Question 70

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

Explanation

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

Question 71

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Explanation

Type I collagen fibers are most responsible for the tensile strength of a peripheral nerve. Type I collagen is the most abundant collagen of the human body which forms large, eosinophilic fibers known as collagen fibers. It is present in scar tissue, the end product when tissue heals by repair, as well as tendons, ligaments, the endomysium of myofibrils, the organic part of bone, the dermis, the dentin and organ capsules.
The COL1A1 gene produces a component of type I collagen, called the pro-alpha1(I) chain. This chain combines with another pro-alpha1(I) chain and also with a pro-alpha2(I) chain (produced by the COL1A2 gene) to make a molecule of type I procollagen. These triple-stranded, rope-like procollagen molecules must be processed by enzymes outside the cell. Once these molecules are processed, they arrange themselves into long, thin fibrils that cross-link to one another in the spaces around cells. The cross-links result in the formation of very strong mature type I collagen fibers.
Wong et al. provide a review of the basic science behind nerve healing and the recovery after nerve repair. They note the importance of minimizing additional surgical insult and careful handling of nerve tissue during repair to optimize outcomes.
Pertici et al. noted that autologous nerve implantation to bridge a long nerve gap presents the greatest regenerative performance in spite of substantial drawbacks. They were able to show improved nerve guided regrowth with a type I collagen matrix conduit as compared to a conduit made of a mix of type I and type III collagen.
Illustration A shows a diagram of type I collagen, showing the rope-like characteristics behind the tensile strength.
Incorrect Answers:

Question 72

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

Explanation

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

Question 73

A 19-year-old linebacker for a collegiate football team has had two episodes of bilateral arm tingling and weakness after tackling; the symptoms resolved after 30 minutes of rest. Three follow-up neurologic examinations have been normal. Cervical spine CT and MRI scans are shown in Figures 13a through 13c. What is the next best step in management? Review Topic

Explanation

Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.

Question 74

Figure 3a shows the preoperative radiograph of a 5-year-old girl who achieved complete correction with valgus osteotomies. Figure 3b shows a radiograph obtained 2 years later. What is the cause of the recurrent deformity on the right side?

Explanation

DISCUSSION: Although inadequate correction, obesity, patient age of older than 5 years and an increased metaphyseal-diaphyseal angle are all associated with a poorer outcome, the radiographs show a growth arrest of the medial tibial physis. If not recognized and treated with early surgery, progressive genu varum will occur with continued growth of the lateral physis. In addition to repeat osteotomy, options for treating the arrest include physeal bar resection or, as necessary, completion of the growth arrest by epiphyseodesis of the lateral physes, followed by a limb equalization procedure at a later date.
REFERENCES: Brooks WC, Gross RH: Genu varum in children: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:326-335.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

pp 840-950.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1068-1073.

Question 75

What is a risk factor for interdigital neuroma?

Explanation

DISCUSSION
The only proven risk factor for development of an interdigital neuroma is female gender, which likely is related to the use of fashionable shoes that force plantar flexion of the metatarsal heads and secondary hyperdorsiflexion of the metatarsophalangeal joints. The other factors listed have not been proven to cause interdigital neuroma, as well as mediolateral compression of the forefoot.
RECOMMENDED READINGS
Hill KJ. Peripheral nerve disorder. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:307-327.
Schon LC, Mann RA. Diseases of the nerves. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:613-686.

Question 76

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Explanation

DISCUSSION: Surgical margins are classified according to the plane of dissection in relation to the tumor. An intralesional procedure is where the plane of dissection passes through the tumor. A marginal resection involves a resection where the plane of dissection is through the reactive zone of the tumor. A wide resection is through completely normal tissue outside of the reactive zone. A radical resection removes all of the muscles and/or bone of the compartment that are involved by the tumor.
REFERENCE: Enneking WF, Spanier SS, Goodman MA: A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop 1980;153:106-120.

Question 77

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

Explanation

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

Question 78

Which wear mechanism is most likely responsible for the wear damage on the modular tibial insert retrieval shown in Figure 82?

Explanation

DISCUSSION
The figure shows the top side of a retrieved tibial liner. Pitting and delamination, which are associated with fatigue wear, are noted. Creep is deformation without wear. Adhesive and abrasive wear is associated with removal of material on the back side of modular tibial components.
CLINICAL SITUATION FOR QUESTIONS 83 THROUGH 87
A bilateral cemented total knee arthroplasty (TKA) was performed on an otherwise healthy 63-year-old woman. The surgery and immediate postsurgical course were uneventful. Two days after surgery, while in physical therapy at the hospital, the patient’s oxygen saturation is noted at 92%.

Question 79

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

Explanation

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

Question 80

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Explanation

DISCUSSION: Afferent pain fibers to the lumbar facet joints arise from the medial branch nerves originating from the next two cephalad levels. Therefore, innervation of the L3-L4 facet joint arises from the L2 and L3 medial branch nerves. This effect should be taken into account when considering a medial branch block or facet denervation. The medial branch nerve arises from the dorsal ramus of the exiting nerve root.
REFERENCES: Nade SL, Bell E, Wyke BD: The innervation of the lumbar spinal joint and its significance. J Bone Joint Surg Br 1980;62:255-261
Kornick C, Kramarich SS, Lamer TJ, et al: Complications of lumbar facet radiofrequency denervation. Spine 2004;29:1352-1354.

Question 81

Amphotericin exerts antifungal activity by

Explanation

Antifungals such as amphotericin and nystatin bind to sterols in the cell membrane and disrupt its integrity, allowing diffusion of macromolecules and causing cell death. Sulfonamides and trimethopim mimic the metabolite substrate and block synthesis of metabolites such as folic acid. Rifampin inhibits bacterial RNA polymerase, blocking synthesis of RNA. Tetracycline, chloramphenicol, and clindamycin bind to ribosomes and block bacterial growth by inhibiting protein synthesis.

Question 82

Figures below demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. A further work-up reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MRI with MARS. Revision THA is recommended. The most common complication following revision of a failed metal-on- metal hip arthroplasty is

Explanation

THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cellcounts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Question 83

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Explanation

DISCUSSION: Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or “floating toe.” Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy.
REFERENCES: Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int

2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.

Question 84

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

Explanation

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

Figure 59a Figure 59b

Question 85

..Approximately what percentage of the time does an unknown primary cancer get identified as part of a full metastatic work-up that includes radiographs; blood tests; a CT scan of the chest, abdomen and pelvis; whole-body bone scan; and biopsy of the metastatic focus?

Explanation

CLINICAL SITUATION FOR QUESTIONS 20 THROUGH 23
Figures 20a and 20b are the radiographs of an 83-year-old active, independent, and healthy woman who has experienced 2 months of right lower thigh and knee pain. Her pain increased progressively over the course of several weeks. While exiting a car she “bumped” her knee against the door, felt a “crack,” and developed excruciating pain. She could no longer ambulate and was brought to the hospital.

Question 86

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

Explanation

The MRI scan reveals a partial patellar tendon rupture in conjunction with chronic patellar tendinitis. Mild and moderate patellar tendinitis may be treated nonsurgically with rest, stretching, strengthening, and anti-inflammatory drugs. Severe tendinopathy or extensor mechanism disruption is best treated surgically with tendon debridement and repair.

Question 87

A 46-year-old woman who was involved in a motor vehicle accident reports a 4-month history of right-sided lower back pain and pain radiating into the right thigh. The patient underwent an extensive 3-month course of physical therapy and now is dependent on narcotic medication for pain control. Epidural injection therapy has failed to improve her symptoms. Examination is significant for weakness of hip flexion in the seated position and for decreased sensation to light touch in the medial anterior thigh region. Straight leg raise is negative, but the femoral stretch test reproduces anterior thigh pain. A CT myelogram image, at L3-L4, is shown in Figure 3. What is the most appropriate management at this time?

Explanation

DISCUSSION: The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms.
REFERENCES: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.
Yorimitsu E, Chiba K, Toyama Y, et al: Long-term outcomes of standard discectomy for lumbar disc herniation: A follow-up study of more than 10 years. Spine 2001;26:652-657.

Question 88

A 21-year-old football player reports increasing pain and a deformity involving his chest after colliding with another player during a scrimmage. Imaging studies confirm an anterior sternoclavicular dislocation. Management should consist of

Explanation

DISCUSSION: For the patient with an anterior sternoclavicular dislocation, the most appropriate initial treatment should be symptomatic. Surgical options are usually contraindicated because the incidence of intraoperative and postoperative complications is high. A deformity from an anterior sternoclavicular dislocation is usually well tolerated. Return to play is allowed when symptoms resolve.
REFERENCES: Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 477-525.
Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.

Question 89

A 58-year-old woman is seen in the emergency department after falling at home. History reveals that she underwent right total knee arthroplasty 2 years ago. Radiographs are shown in Figures 56a and 56b. What is the most appropriate treatment?

Explanation

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 90

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

Explanation

DISCUSSION: Documenting the status of recovery at this time is appropriate; therefore, repeat EMG studies should be conducted to check for early signs of reinnervation. Timing of nerve exploration in this setting is debated, with authors suggesting exploration if there is no sign of recovery at 6 to 9 months.
REFERENCES: Perlmutter GS: Axillary nerve injury. Clin Orthop 1999;368:28-36.
Artico M, Salvati M, D’Andrea V, et al: Isolated lesions of the axillary nerves: Surgical treatment and outcome in twelve cases. Neurosurgery 1991;29:697-700.
Vissar CP, Coene LN, Brand R, et al: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery: A prospective clinical and EMG study. J Bone Joint Surg Br 1999;81:679-685.
Pasila M, Jarma H, Kiviluoto O, et al: Early complications of primary shoulder dislocations. Acta Orthop Scand 1978;49:260-263.

Question 91

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 92

If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be

Explanation

DISCUSSION
The treatment of thoracolumbar burst fractures has evolved over the years. In the absence of a neurologic deficit or a posterior ligamentous complex injury, nonsurgical treatment is as effective as surgery. The degree of spinal canal compromise is not a risk factor for neurologic symptoms. Similarly, although kyphosis may be a marker of more significant injury, the degree of kyphosis does not correlate with chronic pain. In the setting of a burst fracture, MRI can be used to evaluate the integrity of the posterior ligamentous complex. Polytrauma may be considered a relative indication for surgical intervention in the setting of a stable burst fracture.
RECOMMENDED READINGS
Rechtine GR 2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S22-7; discussion S36. Review. PubMed PMID: 16685232. View Abstract at PubMed
Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine (Phila Pa 1976). 1999 Feb 15;24(4):412-5. PubMed PMID: 10065527. View Abstract at PubMed
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024. View Abstract at PubMed
Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. doi: 10.1016/j.spinee.2012.10.041. Review. PubMed PMID: 24332321.View Abstract at PubMed

Question 93

Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?

Explanation

DISCUSSION: The obturator internus originates on the obturator membrane and adjacent bone, including the quadrilateral plate, and exits the lesser sciatic notch to insert on the posterior medial greater trochanter. The structure labeled C is the pectineus, B is the sartorius, and D is the gluteus medius.
REFERENCES: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 145-150, 324.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Wilkins, 1978, plate 4-46.

Question 94

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Explanation

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons

Figure 3Id Figure 31e

Question 95

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Explanation

DISCUSSION: Of the incomplete spinal cord injuries, Brown-Sequard syndrome has the best prognosis for ambulation. Central cord syndrome has a variable recovery. Anterior cord syndrome has the worst prognosis, with motor recovery rare below the level of the injury.
REFERENCES: Apple DF: Spinal cord injury rehabilitation, in Herkowitz HN, Garfin SR, Balderston RA, Eismont FJ, Bell GR, Wiesel SW (eds): Rothman-Simeone The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, pp 1130-1131.
Northrup BE: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 544-545.

Question 96

Figure 1 is the MR image of a high school soccer player who sustained a right knee injury during a game while making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a "clunk" within the knee. What is the most likely biomechanical basis for the "clunk"?

Explanation

This patient sustained an isolated anterior cruciate ligament (ACL) injury based upon the mechanism described and examination findings. The finding that produces the “clunk” is the pivot-shift maneuver, which is positive in a knee with an incompetent ACL. With an ACL-deficient knee in full extension and internal rotation, the lateral tibial plateau subluxates anteriorly. As the knee is flexed, the lateral tibial plateau slides posteriorly into a reduced position, causing an audible clunk. Response D correctly describes the pathomechanics that result in the audible clunk heard during the pivot-shift maneuver. Responses A and B are incorrect because they describe the medial tibial plateau, which is not part of the pathomechanics of the pivot shift. Response C is incorrect because in extension, the lateral tibial plateau is subluxated, not reduced.

Question 97

A 40-year-old man underwent an ankle arthroscopy 6 months ago for a talus osteochondral defect. He continues to have pain and burning on the lateral portal but states that the pain is now more superficial than his original pain. Examination reveals that he has shooting pain to his medial foot and ankle when his lateral portal is tapped. A previous injection around the lateral portal gave him relief for about 2 weeks. What treatment will best eliminate his pain?

Explanation

DISCUSSION: The patient clearly has entrapment of the superficial peroneal nerve in the lateral portal. It is most likely only the medial branch by examination. If the nerve is in good condition, it can simply be released. If the nerve is cut or severely thinned, it is better excised and buried. The sural nerve most likely would be caught in a posterior-lateral portal.
REFERENCES: Jobe MT, Wright PE: Peripheral nerve injuries, in Canale ST (ed): Campbell’s Operative Orthopaedics. St Louis, MO, Mosby, 1998, pp 3839-3844.
Saito A, Kikuchi S: Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves. Foot Ankle Int 1998;19:748-752.

Question 98

A 63-year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coated titanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 years but has now had two dislocations and reports pain and weakness around the left hip. She denies any fevers, chills, or constitutional symptoms. On examination, the patient walks well without any signs of an antalgic or Trendelenburg gait. Her abductor mechanism demonstrates good strength. Her erythrocyte sedimentation rate and C-reactive protein level are normal. On radiographs, all components appear well fixed and in good alignment. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Trunnionosis is a recently recognized complication following total hip arthroplasty and can occur when a cobalt alloy femoral head is used on a titanium alloy or cobalt alloy femoral stem. Patients often present with pain or swelling around the hip but at times can present with instability. Certain femoral stem designs have been associated with increased reports of trunnionosis. In a patient with a cobalt alloy femoral head who presents with instability, swelling, and weakness around the hip, the potential for trunnionosis and
an adverse local tissue reaction should be considered.

Question 99

Figures 43a and 43b show the T 1 - and T 2 -weighted MRI scans of a 78-year-old woman who reports the sudden atraumatic onset of well-localized medial knee pain. Pain is worse at night and also occurs with weight-bearing activity. What is the most likely diagnosis?

Explanation

DISCUSSION: Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone of the medial tibial plateau. The diagnosis is more easily established with a bone scan where increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic involvement of the medial compartment, uptake is over both the medial femoral condyle and the medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing accompanying the weight-bearing pain.
REFERENCES: Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-424.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am 1995;77:596-601.

Question 100

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment?

Explanation

DISCUSSION: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Superior labrum anterior and posterior lesion, type III
Isolated traumatic dislocation
Axillary nerve disruption
Subscapularis rupture
Internal impingement

Correct Answer: Subscapularis rupture

Explanation:

Question 2:

- The concept of an “effective joint space” surrounding a prosthetic hip replacement refers to the

Options:

Extent of bone penetrated by reaming, prosthetic components, or acrylic cement
Periprosthetic regions that are accessible to joint fluid and particulate wear debris
Enveloping pseudocapsular scar tissue that develops around a prosthetic hip following surgical capsulectomy
Soft tissue and bone that are potentially contaminated with bacteria in the setting of a prosthetic joint infection
Potential intrapelvic joint space communication created by acetabular fixation screws or intrapelvic extruded acrylic cement

Correct Answer: Periprosthetic regions that are accessible to joint fluid and particulate wear debris

Explanation:

Question 3:

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Options:

Cardiovascular collapse
Block failure
Seizure secondary to intravascular injection
Phrenic nerve injury
Laryngeal nerve injury

Correct Answer: Block failure

Explanation:

Question 4:

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Options:

year-old female golf instructor
year-old female with Parkinsons dementia
year-old male household ambulator
year-old male alcoholic with hepatic encephalopathy
year-old male laborer

Correct Answer: year-old female with Parkinsons dementia

Explanation:

Question 5:

Options:

No further treatment
Closed reduction under conscious sedation
Closed reduction under general anesthesia in the operating room with neurologic monitoring
Occipitocervical fusion
Posterior atlantoaxial fusion

Correct Answer: No further treatment

Explanation:

The clinical presentation is consistent with chronic torticollis caused by Atlantoaxial rotatory displacement (AARD). Because both halter traction and halo traction were attempted and failed, the next most appropriate next step in management is posterior atlantoaxial fusion.
Common causes of Atlantoaxial rotatory displacement (AARD) include infection, trauma, and recent neck surgery. Diagnosis is challenging and is best confirmed with dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are acute (less than 7 days) then initial treatment with a soft collar and anti-inflammatory medications is indicated. If the condition has been present for more than a week, more aggressive treatment with halter traction (present 1 week to 1 month) or halo traction (present for 1-3 months) is indicated. If nonoperative modalities fail, the condition has been present for > 3 months, or the patient has neurologic deficits, then posterior C1-C2 fusion is indicated.
Copley et al discuss the evaluation and treatment of various congenital and traumatic conditions of the pediatric cervical spine. They report that the underlying mechanism of Atlantoaxial rotatory displacement (AARD) is inflammation and spasm which can be caused by infection, prior surgery, trauma, and rheumatoid arthritis.
Subach et al reviewed at 20 children with atlantoaxial rotatory subluxation. They found that of the 20 patients treated overall, conservative management failed in 6 (30%), and they required posterior fusion because of recurrence of the atlantoaxial rotatory subluxation or unsuccessful reduction. The major factor predicting the failure of conservative management was the duration of subluxation before initial reduction. Patients with long-standing subluxation were more likely to experience recurrence and require surgery.
Figure A shows an asymmetric placed odontoid within the ring of C1. There is an increased distance from the odontoid to the right arch of C1 which is fixed and minimally changes with maximal rotation to the left. This radiographic finding is indicative of fixed subluxation. Illustration A further demonstrates this.
Incorrect
(SBQ12SP.1) A 65-year-old female with a history of breast cancer presents with bilateral buttock and leg pain that is worse with walking and improves with sitting. In addition, she reports that she feels unsteady on her feet and requires holding the railing when going up and down stairs. On physical exam she is unable to complete a tandem gait and has hip flexion weakness, ankle dorsiflexion weakness, and ankle plantar flexion weakness. Her reflex exam shows 3+ bilateral patellar reflexes. Radiographs and an MRI are shown in Figure A and B. What is the next most appropriate step in management.
Review
Topic
Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 6:

Options:

Pseudoparalysis secondary to fracture of the proximal humerus
Cervical myelomeningocele
Erb palsy
Arthrogryposis
Cerebral palsy and spastic hemiplegia

Correct Answer: Erb palsy

Explanation:

Question 7:

Options:

IV antibiotics.
arthroscopic irrigation and debridement, following by IV antibiotics.
irrigation and debridement, polyethylene exchange, and IV antibiotics.
one-stage component removal and reimplantation, followed by IV antibiotics.
two-stage component removal and reimplantation, with IV antibiotics in the interim period.

Correct Answer: irrigation and debridement, polyethylene exchange, and IV antibiotics.

Explanation:

Question 8:

Options:

Painful os trigonum
Posterior ankle soft-tissue impingement
Stricture in the knot of Henry
Flexor digitorum longus tendinitis
Flexor hallucis longus tendinitis

Correct Answer: Flexor hallucis longus tendinitis

Explanation:

Question 9:

Varus deformity after talar fractures is often seen due to collapse of the medial cortex. What artery supplies this portion of the talus?

Options:

Artery of the tarsal sinus
Artery of the tarsal canal
Peroneal
Perforating branch of the dorsalis pedis artery
Lateral malleolar

Correct Answer: Artery of the tarsal canal

Explanation:

Question 10:

Options:

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

Correct Answer: ACL tear and medial meniscal tear

Explanation:

Question 11:

Options:

Posterior talofibular ligament
Distal tibiofibular syndesmosis
Anterior talofibular ligament
Deltoid ligament
Calcaneofibular ligament

Correct Answer: Deltoid ligament

Explanation:

DISCUSSION: In the presence of a supination external rotation-type fracture of the distal fibula (Weber type B), stability of the ankle is best assessed by performing an external rotation stress AP view of the ankle. This test is used to assess the integrity of the deltoid ligament. The presence of a deltoid ligament rupture results in instability and generally is best managed surgically. The gravity stress test can also be used.
REFERENCES: Egol KA, Amirtharajah M, Tejwani NC, et al: Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures. J Bone Joint Surg Am 2004;86:2393-2398.
McConnell T, Creevy W, Tornetta P III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86:2171-2178.
Schock HJ, Pinzur M, Manion L, et al: The use of the gravity or manual-stress radiographs in the assessment of supination-external rotation fractures of the ankle. J Bone Joint Surg Br 2007;89:1055-1059.

Question 12:

Options:

Catterall II involvement.
tubercular synovitis.
Herring type A involvement.
hinge abduction.
osteochondritis dissecans.

Correct Answer: hinge abduction.

Explanation:

Question 13:

Options:

Cephalomedullary nail
Standard antegrade intramedullary nail
Resection and arthroplasty reconstruction
Open biopsy DISCUSSION.. In this patient, tissue diagnosis should be obtained prior to any surgical intervention to avoid unnecessary contamination in the event the lesion is a sarcoma. Open biopsy will yield the diagnosis in the majority of cases. The specific choice for surgical treatment of a proximal femur pathologic fracture is controversial, but it would typically involve either a cephalomedullary nail or resection/reconstruction. A simple antegrade femoral nail rarely is sufficient in this setting.

Correct Answer: Open biopsy DISCUSSION.. In this patient, tissue diagnosis should be obtained prior to any surgical intervention to avoid unnecessary contamination in the event the lesion is a sarcoma. Open biopsy will yield the diagnosis in the majority of cases. The specific choice for surgical treatment of a proximal femur pathologic fracture is controversial, but it would typically involve either a cephalomedullary nail or resection/reconstruction. A simple antegrade femoral nail rarely is sufficient in this setting.

Explanation:

CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9

Question 14:

Options:

Single incision, anterior approach with fixation through drill holes in the radius
Single incision, anterior approach with suture anchor fixation to the radius
Single incision, anterior approach through a drill hole in the radius with sutures tied over bolster or button on the posterior forearm
Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes
Dual incision, limited anterior and posterior muscle-splitting approach (supinator and extensor muscles) with attachment through drill holes

Correct Answer: Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes

Explanation:

Question 15:

Options:

steroid injection
stretching of the heel cord
surgical release of the plantar fascia
application of a short leg cast for 6 to 8 weeks
wearing dorsiflexion night splints

Correct Answer: stretching of the heel cord

Explanation:

Question 16:

Options:

Deltoid branch of the artery of the tarsal canal
Dorsalis pedis artery
Tarsal sinus artery
Perforating peroneal artery
Navicular artery

Correct Answer: Deltoid branch of the artery of the tarsal canal

Explanation:

DISCUSSION: A Hawkins III fracture-dislocation generally presents with posteromedial displacement with the deltoid ligament intact. Therefore, the only remaining blood supply is the deltoid branch of the artery of the tarsal canal originating from the posterior tibial artery. Often, the medial malleolus is fractured, assisting in reduction and visualization of fracture reduction. If the medial malleolus is intact, a medial malleolus osteotomy allows visualization of the reduction without compromising the last remaining blood supply to the talus.
REFERENCES: Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br 1970;52:160-167.
Vallier HA, Nork SE, Barei DP, et al: Talar neck fractures: Results and outcomes. J Bone Joint Surg Am 2004;86:1616-1624.

Question 17:

Options:

4 mm of tibiofemoral joint space on a 45-degree weight-bearing AP radiograph
Intact anterior cruciate ligament on MRI and physical examination
Recurrent effusions
Flattening of the femoral condyles
Healed high tibial osteotomy

Correct Answer: Flattening of the femoral condyles

Explanation:

Question 18:

In a longitudinal study of children with spastic diplegia, analysis of long-term function will most likely reveal

Options:

a deterioration of gait stability and an increase in double support time.
a deterioration of gait stability and a decrease in double support time.
improved excursion about the knee, ankle, and pelvis.
improvement in the popliteal angle.
increases in single support time.

Correct Answer: a deterioration of gait stability and an increase in double support time.

Explanation:

Question 19:

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Options:

a bone scan.
a skeletal survey.
MRI of the hips.
CT of the hips.
a CBC count and a C-reactive protein.

Correct Answer: a skeletal survey.

Explanation:

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 20:

Options:

Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space

Correct Answer: Thenar space

Explanation:

DISCUSSION: Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
REFERENCES: Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.
Lee D, Ferlic R, Neviaser R: Hand infections, in Berger R, Weiss AP (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 1784-1785.

Question 21:

Figure 33 shows the CT scan of a 40-year-old man who injured his left shoulder while skiing. What structure is attached to the bony fragment?

Options:

Superior glenohumeral ligament
Anterior band of the inferior glenohumeral ligament
Middle glenohumeral ligament
Subscapularis tendon
Long head of the biceps tendon

Correct Answer: Anterior band of the inferior glenohumeral ligament

Explanation:

Question 22:

Locked lateral plate fixation of the proximal tibia is most appropriate for what Schatzker type fracture?

Options:

I - lateral plateau split
II - lateral plateau split/depression
III - lateral plateau depression
IV - medial plateau fracture
V - bicondylar tibial plateau fracture

Correct Answer: V - bicondylar tibial plateau fracture

Explanation:

Question 23:

Options:

Repeat debridement, followed by 6 weeks of IV antibiotics
Repeat debridement, followed by direct exchange arthroplasty
Delayed exchange reimplantation
Immediate knee arthrodesis
Amputation

Correct Answer: Delayed exchange reimplantation

Explanation:

Question 24:

- Figures 43a and 43b show the radiographs of an 8-year-old boy who was referred by his gym teacher because of an awkward running pattern. The patient denies any pain in his hips. Examination reveals a mild Trendelenberg gait and decreased internal rotation of the left hip to 25 degrees compared to 40 degrees on the right. What is the most likely diagnosis?

Options:

SCFE
MED
Perthes disease
Hypothyroidism
Chondrolysis

Correct Answer: Perthes disease

Explanation:

Question 25:

03 An 18 year old female Olympic basketball player is seeking advice on how to prevent future ACL injury. What recommendations can be made based on available scientific data?

Options:

Use of custom-fitted derotational bracing
Use of “off-the-shelf” derotational bracing
Arthroscopic prophylactic notchplasty
Plyometrics and neuromuscular training for 6 weeks 5) Oral contraceptive use
back answer Question 36.03

Correct Answer: Plyometrics and neuromuscular training for 6 weeks 5) Oral contraceptive use

Explanation:

The reference article is a landmark in Female-ACL Injuryliterature. Hewett et al, “Plyometric Training in Female Athletes.” Am. J. Sports Med 1996, 24(6) pg 765-773. The conclusion: “This training may have significant effect on knee stabilization and prevention of serious knee injury among female athletes.”
In researching this answer I searched Ovid, looked in sports texts and looked online for “derotation brace.” Every article mentioned “derotation brace” with “the ACL-deficient knee.” I could not find any mention of prophylactic ACL injury prevention with derotation brace.
Prophylactic surgery and oral contraceptive prescription would never be correct answers. As with “derotation brace”, they are buzzwordsin the femaleACL injury literature and you could pick them as an answer if you didn’t have enough knowledge of the subject. It’s hypothesized that estrogen levels may have a role in when females injure there ACLs.
Finally, notchplasty relates to resecting part of the lateral femoral condyle during ACL reconstruction for both visualization of graft placement and to prevent impingement on the graft.
back to this question next question
Figure 7 shows the clinical photograph of the knee of a chronic

Question 26:

Options:

Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.
Site A is the AER. Site A tissue expresses FGF8.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses Shh protein.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses FGF8 protein.
Site A is non-AER ectoderm. Site A tissue expresses WNT7a.

Correct Answer: Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.

Explanation:

Question 27:

What is the primary mechanism by which anabolic steroids increase muscle tissue? Review Topic

Options:

Increased production of cortisol
Increased production of messenger RNA
Increased secretion of vascular endothelial factor
Decreased production of HDL
Attenuation of the effects of cortisol

Correct Answer: Increased production of messenger RNA

Explanation:

Question 28:

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

Options:

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

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

Explanation:

Question 29:

Options:

Electrode placement
Stimulation failure
Anesthetic effect
Cord ischemia from retraction
Cerebral ischemia from retraction

Correct Answer: Cerebral ischemia from retraction

Explanation:

Question 30:

Options:

Annual monitoring of serum metal ion levels
Repeated MRI with MARS in 6 months
Conversion of the THA to a cobalt alloy femoral head and polyethylene bearing
Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Correct Answer: Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Explanation:

Question 31:

What is the most common diagnosis in a patient older than age 40 years with a destructive bony lesion?

Options:

Metastatic carcinoma
Osteosarcoma
Lymphoma
Multiple myeloma
Chondrosarcoma

Correct Answer: Metastatic carcinoma

Explanation:

Question 32:

Options:

Distal femoral/opening lateral wedge osteotomy
Distal femoral/closing lateral wedge osteotomy
High tibial osteotomy; opening medial wedge with increased tibial slope
High tibial osteotomy; closing lateral wedge with decreased tibial slope

Correct Answer: High tibial osteotomy; opening medial wedge with increased tibial slope

Explanation:

Question 33:

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

Question 34:

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 35:

Options:

Similar incidence of postsurgical neck pain with higher risk for radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and adjacent-level radiculopathy
Lower incidence of adjacent segment degeneration and postsurgical neck pain

Correct Answer: Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level

Explanation:

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617.
View Abstract at PubMed
Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 36:

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Options:

Observation
External beam radiation therapy
Intra-articular radiation therapy
Resection of nodule only
Open complete synovectomy

Correct Answer: Resection of nodule only

Explanation:

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.
J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 37:

Options:

a hypoplastic lateral femoral condyle.
a contracted medial collateral ligament.
an excessive proximal tibial slope.
trochlear dysplasia.

Correct Answer: a hypoplastic lateral femoral condyle.

Explanation:

Question 38:

Options:

revision in situ pinning and application of a cast.
hip fusion.
curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.
non-weight-bearing on the affected side and electrical stimulation of the fracture site.
vascularized fibula grafting and application of a cast.

Correct Answer: curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.

Explanation:

Question 39:

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

Options:

observation.
marsupialization of the nail fold.
application of copper sulfate.
application of calcium gluconate.
incision and drainage of the pulp.

Correct Answer: observation.

Explanation:

Question 40:

What is the most common MRI appearance of a malignant soft-tissue sarcoma?

Options:

Well defined, homogeneous, and deep to fascia
Well defined, heterogeneous, and deep to fascia
Ill defined, homogeneous, and deep to fascia
Ill defined, heterogeneous, and superficial to fascia
Ill defined, homogeneous, and superficial to fascia

Correct Answer: Well defined, heterogeneous, and deep to fascia

Explanation:

Question 41:

A 6-year-old girl sustains an ankle injury after falling on roller blades. An AP radiograph is shown in Figure 68. Treatment should consist of which of the following?

Options:

Closed manipulation and a long leg cast
Closed manipulation and a short leg cast
Long leg cast without manipulation
Open reduction and internal fixation with a screw crossing the growth plate
Open reduction and internal fixation with fixation parallel to the physis

Correct Answer: Open reduction and internal fixation with fixation parallel to the physis

Explanation:

Question 42:

Options:

Ulnar neuritis
Excessive olecranon resection
Osteochondritis dissecans of the capitellum
Olecranon stress fracture
Valgus extension overload

Correct Answer: Excessive olecranon resection

Explanation:

Question 43:

During total hip arthroplasty, profuse bleeding is noted following predrilling for placement of an acetabular component screw. The drill most likely penetrated too deep in the

Options:

anterior-superior acetabular quadrant.
posterior-superior acetabular quadrant.
posterior-inferior acetabular quadrant.
medial acetabular wall.
ischial body.

Correct Answer: anterior-superior acetabular quadrant.

Explanation:

Question 44:

Options:

multiple osteotomies and femoral rodding.
pharmocologic doses of vitamin D and phosphate.
biopsy, followed by appropriate chemotherapy.
pamidronate therapy.
radiation therapy and a bone marrow transplant.

Correct Answer: multiple osteotomies and femoral rodding.

Explanation:

Question 45:

Options:

Long-leg splinting of bilateral lower extremities, monitoring of bilateral pedal pulses for 48 hours
Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals
Perform CT angiography for bilateral lower extremities
Perform CT angiography for the left lower extremity, monitor right pedal pulses for 48 hours
Surgical exploration of bilateral lower extremities

Correct Answer: Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals

Explanation:

Question 46:

Options:

Posterior wall/ posterior column
Transverse
T-Type
Anterior column/ posterior hemitransverse
Both columns

Correct Answer: Posterior wall/ posterior column

Explanation:

Question 47:

Options:

a local steroid injection into the flexor hallucis longus tendon sheath.
range-of-motion exercises.
open reduction and internal fixation.
nonsteroidal anti-inflammatory drugs.
excision of the fragment.

Correct Answer: excision of the fragment.

Explanation:

Question 48:

Persistent symptoms and decreased function following distal clavicle resection, coracoacromial ligament transfer, and augmentation (modified Weaver-Dunn) are most likely related to Review Topic

Options:

anterior-posterior translation.
superior-inferior translation. 3inadequate resection of the distal clavicle.
excessive reduction of the clavicle relative to the coracoid.
unrecognized instability of the sternoclavicular joint.

Correct Answer: anterior-posterior translation.

Explanation:

Question 49:

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Options:

Early post-operative knee range of motion
Delayed weightbearing
Short working length of the construct
Bridge plate fixation
Plate-screw density less than 0.5

Correct Answer: Plate-screw density less than 0.5

Explanation:

Question 50:

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

Options:

Hand
Knee
Shoulder
Spine
Pelvis

Correct Answer: Pelvis

Explanation:

Question 51:

The Cotton test evaluates which of the following structures?

Options:

Calcaneofibular ligament
Lateral ulnar collateral ligament of the elbow
Ligamentum flavum
Deep deltoid ligament
Ankle syndesmosis

Correct Answer: Calcaneofibular ligament

Explanation:

Question 52:

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Options:

pubic symphysis diastasis.
sagittal plane pelvic rotation.
sacroiliac diastasis.
spinopelvic dissociation.
a vertical transforaminal sacral fracture.

Correct Answer: spinopelvic dissociation.

Explanation:

Question 53:

Which of the following has been associated with a decreased rate of glenoid component radiolucent lines?

Options:

A curve-backed pegged cemented polyethylene glenoid component
A curve-backed keeled cemented polyethylene glenoid component design
A flat-backed keeled cemented polyethylene glenoid component
An oversized pegged cemented glenoid component
A superiorly placed pegged glenoid component

Correct Answer: A curve-backed pegged cemented polyethylene glenoid component

Explanation:

DISCUSSION: According to a recent study, cemented pegged glenoid components had fewer radiolucent lines initially and at 2-year follow-up when compared to a cemented keeled design. Curve-backed designs have also shown fewer radiolucent lines when compared to flat-backed designs. Oversizing the glenoid can lead to impaired rotator cuff function and decreased range of motion. An off-centered glenoid can lead to early loosening.
REFERENCES: Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg 2005;14:252-257.
Szabo I, Buscayret F, Edwards TB, et al: Radiographic comparison of flat-back and convex-back glenoid components in total shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:636-642.
Mileti J, Boardman ND III, Sperling JW, et al: Radiographic analysis of polyethylene glenoid components using modern cementing techniques. J Shoulder Elbow Surg 2004;13:492-498.

Question 54:

Options:

ice and elevation, followed by graduated range-of-motion exercises.
a long leg cast.
excision of the fragment.
open reduction and internal fixation.
observation until maturity, followed by anterior cruciate ligament repair.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 55:

Options:

Knee aspiration for culture
CT of the knee to assess implant rotation
Indium-111 leukocyte/technetium-99m sulfur colloid scan of the knee
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Correct Answer: Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) laboratory studies

Explanation:

Question 56:

The spread of malignant cells to the vertebrae is often through

Options:

epidural extension.
Batson’s vertebral plexus.
the lymphatic system.
direct tumor extension.
arterial circulation including the artery of Adamkiewicz.

Correct Answer: Batson’s vertebral plexus.

Explanation:

Question 57:

Figure 43 shows the lateral radiograph of a 12-year-old boy with mild osteogenesis imperfecta who injured his left elbow after pushing his brother. Treatment should consist of

Options:

closed reduction and cast immobilization.
closed reduction and percutaneous pinning.
open reduction and fixation using an absorbable suture.
open reduction and fixation using two Kirschner wires and a figure-of-8 tension band of absorbable suture.
open reduction and fixation using an intramedullary screw.

Correct Answer: open reduction and fixation using two Kirschner wires and a figure-of-8 tension band of absorbable suture.

Explanation:

Question 58:

Options:

Incision and drainage of the abscess
Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks
Open biopsy
Hematoma evacuation and musculotendinous repair
Primary wide resection followed by radiation therapy

Correct Answer: Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks

Explanation:

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T
1
-weighted MRI scan, the defined fluid signal on the T
2
-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 59:

- A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Options:

Positive-pressure ventilation
An immediate radiograph of the chest
Adjustment of the position of the endotrachael tube
Insertion of a large-bore needle into the pericardial space
Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Correct Answer: Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Explanation:

Question 60:

Options:

Removal of hardware with tendon transfer
Repair of the extensor pollicis longus (EPL) tendon primarily
Thumb interphalangeal (IP) arthrodesis
Nonsurgical treatment with cast placement keeping the thumb in a fully extended position for 4 weeks

Correct Answer: Removal of hardware with tendon transfer

Explanation:

Question 61:

Options:

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

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

Explanation:

Question 62:

Options:

irrigation and debridement of the fractures and application of an external fixator.
irrigation and debridement of the fractures and a reamed intramedullary nail.
irrigation and debridement of the fracture and percutaneous Kirschner wire fixation.
submuscular plating.
reduction and a short leg cast.

Correct Answer: irrigation and debridement of the fractures and application of an external fixator.

Explanation:

Question 63:

Options:

Patellofemoral syndrome
Bipartite patella
Stress fracture of the distal femur
Patella alta
Patella baja

Correct Answer: Patellofemoral syndrome

Explanation:

Question 64:

- Which of the following conditions is most likely inherited as an autosomal dominant trait?

Options:

Syndactyly
Macrodactyly
Camptodactyly
Preaxial polydactyly
Postaxial polydactyly

Correct Answer: Postaxial polydactyly

Explanation:

Question 65:

Options:

Stretching exercises with a physical therapist
Arthroscopic debridement
Core decompression of the humeral head
Humeral hemiarthroplasty
Resection of the proximal humerus

Correct Answer: Humeral hemiarthroplasty

Explanation:

Question 66:

In a retroperitoneal approach to the lumbar spine, what nerve is commonly found on the psoas muscle?

Options:

Ilioinguinal
Iliohypogastric
Genitofemoral
Obturator
Femoral

Correct Answer: Genitofemoral

Explanation:

Question 67:

Options:

follow-up with repeat radiographs in 6 months.
brace treatment.
posterior spinal fusion with instrumentation.
anterior and posterior spinal fusion with instrumentation.
anterior spinal fusion with instrumentation.

Correct Answer: anterior and posterior spinal fusion with instrumentation.

Explanation:

Question 68:

During particle-induced osteolysis around implants, what cell secretes most of the interleukin-6 (IL-6)?

Options:

Osteoblasts from surrounding bone
B-lymphocytes in the bone marrow
Fibroblastic cells in the periprosthetic lining
T-lymphocytes in the circulating blood
Macrophages in the granuloma

Correct Answer: Fibroblastic cells in the periprosthetic lining

Explanation:

Question 69:

Options:

lateral column lengthening.
open reduction and internal fixation.
double arthrodesis (talonavicular and calcaneocuboid joints).
tarsometatarsal arthrodesis.
medial displacement calcaneal osteotomy and tendon transfer.

Correct Answer: tarsometatarsal arthrodesis.

Explanation:

Question 70:

Options:

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

Correct Answer: Central cord syndrome

Explanation:

Question 71:

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Options:

Conduction strength
Tensile strength
Conduction velocity
Compressive strength
Cross-linkage

Correct Answer: Conduction velocity

Explanation:

Question 72:

Options:

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

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

Explanation:

Question 73:

Options:

The addition of a neck roll to the helmet and continuation of play
Electrodiagnostic studies
A series of epidural steroid injections, followed by a return to play
Methylprednisolone dose pack, followed by a return to play in 1 week
No further participation in football

Correct Answer: No further participation in football

Explanation:

Question 74:

Options:

Inadequate restoration of the weight-bearing axis
Partial growth arrest of the medial tibial physis
Age older than 3 years
Obesity (greater than the 95th percentile)
A metaphyseal-diaphyseal angle of greater than 20 degrees

Correct Answer: Partial growth arrest of the medial tibial physis

Explanation:

DISCUSSION: Although inadequate correction, obesity, patient age of older than 5 years and an increased metaphyseal-diaphyseal angle are all associated with a poorer outcome, the radiographs show a growth arrest of the medial tibial physis. If not recognized and treated with early surgery, progressive genu varum will occur with continued growth of the lateral physis. In addition to repeat osteotomy, options for treating the arrest include physeal bar resection or, as necessary, completion of the growth arrest by epiphyseodesis of the lateral physes, followed by a limb equalization procedure at a later date.
REFERENCES: Brooks WC, Gross RH: Genu varum in children: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:326-335.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,
pp 840-950.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1068-1073.

Question 75:

What is a risk factor for interdigital neuroma?

Options:

Female gender
Increased mobility between the third and fourth rays
Achilles tendon contracture
Prolonged standing at work

Correct Answer: Female gender

Explanation:

Question 76:

A patient undergoes excision of a 3- x 3-cm soft-tissue sarcoma. The final histology results show tumor at the surgical margin. The surgical procedure performed is classified as

Options:

intralesional.
marginal.
wide.
wide contaminated.
radical.

Correct Answer: intralesional.

Explanation:

Question 77:

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

Options:

Romosozumab
Zoledronic acid
Denosumab
Teriparatide
Blosozumab

Correct Answer: Denosumab

Explanation:

Question 78:

Which wear mechanism is most likely responsible for the wear damage on the modular tibial insert retrieval shown in Figure 82?

Options:

Adhesive
Abrasive
Fatigue
Creep

Correct Answer: Fatigue

Explanation:

Question 79:

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

Options:

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

Correct Answer: Anatomic alignment

Explanation:

Question 80:

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Options:

L2.
L3.
L4.
L2 and L3.
L3 and L4.

Correct Answer: L2 and L3.

Explanation:

Question 81:

Amphotericin exerts antifungal activity by

Options:

inhibiting DNA-dependent RNA polymerase.
blocking folic acid synthesis.
binding to sterols and disrupting the cell membrane.
binding to cellular ribosomes and inhibiting protein synthesis.

Correct Answer: binding to sterols and disrupting the cell membrane.

Explanation:

Question 82:

Options:

infection. B. instability. C. loosening.
periprosthetic fracture.

Correct Answer: periprosthetic fracture.

Explanation:

Question 83:

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Options:

Floating toe
Nonunion
Osteonecrosis
Inadequate shortening
Dorsal displacement

Correct Answer: Floating toe

Explanation:

DISCUSSION: Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or “floating toe.” Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy.
REFERENCES: Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int
2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.

Question 84:

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

Options:

Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Instability

Explanation:

Question 85:

Options:

45%
65%
85%
100% DISCUSSION… Metastatic bone cancer is common, affecting nearly 5.3% of the nearly 5 million people with cancer in the United States each year. This is a typical presentation of a patient with a newly diagnosed pathologic femur fracture. Without a known history of cancer, this presentation should initiate a complete metastatic work-up including a radiograph of the pathologic site; blood tests; whole-body bone scan; and a CT scan of the chest, abdomen, and pelvis. Additional imaging at the site of concern such as an MRI scan or CT scan may be helpful in certain cases. The next step is to obtain a biopsy of lesional tissue before proceeding to immediate fixation. However, it is important to note that this lesion may be a primary cancer for which case resection or amputation is necessary. A skeletal survey would be helpful in the setting of multiple myeloma. A DEXA scan has no value in this clinical setting. A bone marrow biopsy should be considered in the case of myeloma, but not metastatic carcinoma. Chemotherapy cannot be initiated in any case without a tissue diagnosis. The knowledge that the patient was found to have a large solid renal mass is highly suspicious for renal cell carcinoma, which is among the 5 most common primary carcinomas to metastasize to the bone (breast, lung, thyroid, kidney, and prostate). Treatment of the femur should focus on a robust repair (whether biologic or not) to outlive the patient. A distal femoral resection with megaprosthesis is the most durable option for periarticular renal cell carcinoma metastasis, which is known to respond poorly to radiotherapy. The pathology shown is classic for a clear cell carcinoma of the kidney. In current practice, most primary cancers are identified as the result of a metastatic work-up. Approximately 85% to 90% of primaries are determined from the history, physical, blood tests, imaging, and biopsy results. PREFE RES16..: 4- a CT scan of the chest, abdomen, and pelvis with a whole-body bone scan. PREFERRED RESPONSE 17..: 3- Biopsy of the fracture site

Correct Answer: 45%

Explanation:

Question 86:

Options:

debridement and repair.
cast immobilization.
aggressive overload eccentric strengthening.
ice massage and continued athletic participation.
steroid injection.

Correct Answer: debridement and repair.

Explanation:

Question 87:

Options:

Repeat epidural steroid injections
Wide lumbar laminectomy
Microdiskectomy from either a midline approach or far lateral approach
Referral to pain management
Minimally invasive posterior lumbar interbody fusion

Correct Answer: Microdiskectomy from either a midline approach or far lateral approach

Explanation:

DISCUSSION: The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms.
REFERENCES: Weinstein JN, Lurie JD, Tosteson TD, et al: Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA 2006;296:2451-2459.
Yorimitsu E, Chiba K, Toyama Y, et al: Long-term outcomes of standard discectomy for lumbar disc herniation: A follow-up study of more than 10 years. Spine 2001;26:652-657.

Question 88:

Options:

reconstruction of the sternoclavicular capsule.
symptomatic nonsurgical treatment.
medial clavicle excision.
medial clavicle excision with capsular imbrication.
medial clavicle excision and rhomboid ligament reconstruction.

Correct Answer: symptomatic nonsurgical treatment.

Explanation:

Question 89:

Options:

Closed reduction and casting
Bed rest and skeletal traction
Open reduction and internal fixation
Retrograde intramedullary nailing
Revision of the femoral component with a stemmed component

Correct Answer: Open reduction and internal fixation

Explanation:

DISCUSSION: The radiographs show an oblique periprosthetic distal femoral fracture. Of the options listed, open reduction and internal fixation is the most appropriate surgical option because a well-fixed, posterior stabilized closed box femoral component is present. Nonsurgical methods are not favored because of the highly displaced, unstable fracture pattern and prolonged immobility. Revision with a stemmed component is an option but would sacrifice more bone stock in this younger patient.
REFERENCES: Moran MC, Brick GW, Sledge CB, et al: Supracondylar femoral fracture following total knee arthroplasty. Clin Orthop 1996;324:196-209.
Raab GE, Davis CM III: Early healing with locked condylar plating of periprosthetic fractures around the knee. J Arthroplasty 2005;20:984-989.
Tharani R, Nakasone C, Vince KG: Periprosthetic fractures after total knee arhtroplasty.
J Arthroplasty 2005;20:27-32.

Question 90:

Options:

Surgical repair of the Bankart lesion
Exploration of the axillary nerve
MRI neurography
Repeat EMG studies
Continued observation and physical therapy

Correct Answer: Repeat EMG studies

Explanation:

Question 91:

- 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 92:

If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be

Options:

anterior corpectomy with percutaneous pedicle screw stabilization.
percutaneous pedicle screw stabilization.
posterior pedicle screw stabilization with fusion.
MRI.

Correct Answer: MRI.

Explanation:

DISCUSSION
The treatment of thoracolumbar burst fractures has evolved over the years. In the absence of a neurologic deficit or a posterior ligamentous complex injury, nonsurgical treatment is as effective as surgery. The degree of spinal canal compromise is not a risk factor for neurologic symptoms. Similarly, although kyphosis may be a marker of more significant injury, the degree of kyphosis does not correlate with chronic pain. In the setting of a burst fracture, MRI can be used to evaluate the integrity of the posterior ligamentous complex. Polytrauma may be considered a relative indication for surgical intervention in the setting of a stable burst fracture.
RECOMMENDED READINGS
Rechtine GR 2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S22-7; discussion S36. Review. PubMed PMID: 16685232.
View Abstract at PubMed
Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine (Phila Pa 1976). 1999 Feb 15;24(4):412-5. PubMed PMID: 10065527.
View Abstract at PubMed
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024.
View Abstract at
PubMed
Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. doi: 10.1016/j.spinee.2012.10.041. Review. PubMed PMID: 24332321.
View Abstract at PubMed

Question 93:

Figure 37 shows the T2-weighted MRI scan of the hip joint. What structure is labeled A?

Options:

Ischiofemoral ligament
Ligamentum teres
Obturator internus
Piriformis
Coccygeus

Correct Answer: Obturator internus

Explanation:

Question 94:

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Options:

Sartorius and gluteus maximus
Gluteus minimus and rectus femoris
Rectus femoris and sartorius
Tensor fascia lata and sartorius
Tensor fascia lata and rectus femoris

Correct Answer: Tensor fascia lata and sartorius

Explanation:

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons
Figure 3Id Figure 31e

Question 95:

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Options:

Central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome
Central cord syndrome, Brown-Sequard syndrome, anterior cord syndrome
Brown-Sequard syndrome, anterior cord syndrome, central cord syndrome
Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome
Anterior cord syndrome, central cord syndrome, Brown-Sequard syndrome

Correct Answer: Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome

Explanation:

Question 96:

Options:

In extension with internal rotation/valgus force, the medial tibial plateau is subluxated; with flexion, the medial tibial plateau reduces.
In extension with internal rotation/valgus force, the medial tibial plateau is reduced; with flexion, the medial tibial plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is reduced; with flexion, the lateral plateau subluxates.
In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Correct Answer: In extension with internal rotation/valgus force, the lateral tibial plateau is subluxated; with flexion, the lateral plateau reduces.

Explanation:

Question 97:

Options:

Neuroplasty of the sural nerve
Neuroplasty or excision and burial of the deep peroneal nerve
Neuroplasty or excision and burial of the medial branch of the superficial peroneal nerve
Repeat arthroscopy for worsening of the talus osteochondral defect
Anaesthetic skin patches

Correct Answer: Neuroplasty or excision and burial of the medial branch of the superficial peroneal nerve

Explanation:

DISCUSSION: The patient clearly has entrapment of the superficial peroneal nerve in the lateral portal. It is most likely only the medial branch by examination. If the nerve is in good condition, it can simply be released. If the nerve is cut or severely thinned, it is better excised and buried. The sural nerve most likely would be caught in a posterior-lateral portal.
REFERENCES: Jobe MT, Wright PE: Peripheral nerve injuries, in Canale ST (ed): Campbell’s Operative Orthopaedics. St Louis, MO, Mosby, 1998, pp 3839-3844.
Saito A, Kikuchi S: Anatomic relations between ankle arthroscopic portal sites and the superficial peroneal and saphenous nerves. Foot Ankle Int 1998;19:748-752.

Question 98:

Options:

Physical therapy to improve hip stability
Use of an abduction brace to limit the patient’s range of motion
Conversion to a constrained acetabular liner
Cobalt and chromium serum metal ion level testing

Correct Answer: Cobalt and chromium serum metal ion level testing

Explanation:

Question 99:

Options:

Complex regional pain syndrome
Osteoarthritis
Osteosarcoma
Osteonecrosis
Inflammatory arthritis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone of the medial tibial plateau. The diagnosis is more easily established with a bone scan where increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic involvement of the medial compartment, uptake is over both the medial femoral condyle and the medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing accompanying the weight-bearing pain.
REFERENCES: Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-424.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am 1995;77:596-601.

Question 100:

Options:

Arthroscopic capsular plication
Arthroscopic thermal shift
Arthroscopic subacromial decompression
Posterior capsular stretching
Selective external rotation stretching

Correct Answer: Posterior capsular stretching

Explanation:

DISCUSSION
: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES
: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

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

Orthopedic Surgery Board Review MCQs: Hip, Shoulder Arthroplasty & Infection | Part 227

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 227

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index