OITE & AAOS Orthopedic Board Review MCQs: Part 233

About This Board Review Set

This is Part 233 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 233

This module focuses heavily on: Cartilage, Foot, Fracture, Infection, Knee, Spine.

Sample Questions from This Set

Sample Question 1: Which of the following results cannot be achieved with an in-shoe orthosis?...

Sample Question 2: A 35-year-old rock climber sustains an L1 burst fracture from a 30-foot fall while climbing. He sustained no other fractures or serious injuries. He is neurologically intact and has minimal posterior tenderness without increased spinous pro...

Sample Question 3: Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?...

Sample Question 4: The risk for postoperative wound infection after lumbar spine surgery is reduced most by the use of...

Sample Question 5: When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?...

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

Which of the following results cannot be achieved with an in-shoe orthosis?

Explanation

DISCUSSION: Depending on the type of materials used, an orthotic can be fabricated to achieve a variety of results. While a rigid fixed deformity can be stabilized or cushioned, an orthotic will not correct a deformity that is not passively correctable.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 55-64.
Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.
Buonomo LJ, Klein JS, Keiper TL: Orthotic devices: Custom-made, prefabricated, and material selection. Foot Ankle Clin 2001;6:249-252.
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Question 2

A 35-year-old rock climber sustains an L1 burst fracture from a 30-foot fall while climbing. He sustained no other fractures or serious injuries. He is neurologically intact and has minimal posterior tenderness without increased spinous process separation on examination. Radiographs reveal kyphosis of 20 degrees between T12 and L2 with 30% vertebral height loss. A CT scan shows 55% canal compromise. What is the most appropriate management? Review Topic

Explanation

Wood and associates have shown that the use of a TLSO or a body jacket was equally effective as surgery for the treatment of thoracolumbar burst fractures without neurologic deficit. The only difference in any of the measured parameters (including pain, functional outcome, residual canal compromise, and kyphosis) was a decreased complication rate in the nonsurgical group compared with the surgical group. The maximum time to mobilization in the nonsurgical group was 5 days.

Question 3

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

Explanation

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

Question 4

The risk for postoperative wound infection after lumbar spine surgery is reduced most by the use of

Explanation

By far, the most impact on lowering the incidence of perioperative site infections after lumbar surgery is achieved by the use of intravenous perioperative antibiotics that are infused prior to skin incision. Ideally, these are administered within 1 hour of incision time. The use of an iodine versus a chlorhexidine solution has not been demonstrated to influence infection after spinal surgery. While adequate hand washing is an important practice, scrubbing for more than 10 minutes is not critical. Laminar-flow air circulation has been demonstrated to be helpful in total joint arthroplasty; however, this has not been demonstrated in spinal surgery. Furthermore, it is not likely that its use would influence the rate of infection as much as perioperative antibiotic prophylaxis.

Question 5

When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?

Explanation

DISCUSSION:
Excluding a diagnosis of meniscal tear, loose body, or mechanical derangement, treating knee osteoarthritis of indeterminate cause with arthroscopic lavage and debridement has been found to provide no discernable benefit to offset the risk of surgery. The effects of arthroscopy have not been clinically significant in the vast majority of patient-oriented outcomes measures for pain and function at multiple times between 1 week and 2 years after surgery.

Question 6

Figure 26 is the radiograph of a 33-year-old woman who was involved in a high-speed motor vehicle crash. Her initial blood pressure is 80/50 mm Hg and she has a pulse rate of 120 bpm. After hemodynamic stabilization and temporizing measures have been performed, the patient is cleared for surgery. What is the most appropriate method of definitive fixation?

Explanation

The patient has sustained an anterior posterior compression (APC) grade II pelvic ring injury. Initial management should consist of pelvic volume reduction with pelvic binding or sheeting. Once the patient is hemodynamically stable, the decision for definitive management should be made. In a retrospective review of more than 200 patients, Sagi and Papp investigated plate osteosynthesis of the pubic symphysis. They found significantly fewer malunions in the multi-hole plate group and a trend toward fewer surgeries in the same group. Typically external fixation should be reserved for temporary fixation and not a definitive management in stable patients. Posterior fixation is reserved for injuries with disruption of the posterior ligamentous constraints, typically APC grade III injuries. Triangular osteosynthesis is a strategy for fixation of unstable vertical shear fractures that require fixation of the pelvis to the lumbar spine.

Question 7

What term best describes the process involved when a growth factor produced by an osteoblast stimulates the differentiation of an adjacent undifferentiated mesenchymal cell during fracture repair?

Explanation

DISCUSSION: Growth factors are proteins secreted by cells that can act on target cells to produce certain biologic actions. These actions can be described as autocrine, paracrine, and endocrine. Autocrine actions are those in which the growth factor influences an adjacent cell of its origin or identical phenotype. Paracrine actions are those in which the protein influences an adjacent cell that is different in its origin or phenotype. Endocrine actions are those in which the factor influences a cell located at a distant anatomic site.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Zuscik MJ, Drissi MH, Reynolds PR, et al: Molecular and cell biology in orthopaedics, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006,

in press.

Question 8

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Explanation

Lateral meniscal cysts often arise from myxoid degeneration that progresses from the meniscal center and then outside the meniscus. Horizontal cleavage tears are commonly associated with the condition. Cysts of the lateral meniscus are most commonly the consequence of a tear located in the medial third. If the tear communicates with the joint, arthroscopic partial meniscectomy and cyst decompression are indicated. If the tear does not open into the joint, arthroscopy should be followed by an open cystectomy.

Question 9

A 12-year-old pitcher has had a 2-month history of pain in his right dominant shoulder after throwing. He reports that the pain has gradually progressed to the point where he cannot throw without pain. He also notes that the pain now awakens him at night if he has been active. Anti-inflammatory drugs have failed to provide relief. Examination reveals no abnormalities except for some localized tenderness over the proximal humerus. Figures 32a and 32b show radiographs of both shoulders. What is the most likely diagnosis?

Explanation

DISCUSSION: The history, examination, and radiographs are pathognomonic for Little League shoulder, a stress syndrome of the proximal humeral physis caused by overuse. Complete fracture rarely occurs, and recovery usually occurs with rest. Night pain is always a serious concern and further work-up is needed if the patient does not respond to activity modification. Occult instability is not a real concern in this patient, although it should be included in the differential diagnosis.
REFERENCES: Albert MJ, Drvaric DM: Little League shoulder: Case report. Orthopedics 1990;13:779-781.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 10

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data?

Explanation

DISCUSSION: Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery.
REFERENCES: Jones SC, Fernau R, Woeltjen BL: Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: Case reports and discussion. Spine J 2004;4:360-362.
Schwartz DM, Sestokas AK, Hilibrand AS, et al: Neurophysiological identification of position-induced neurologic injury during anterior cervical spine surgery. J Clin Monit Comput 2006;20:437-444.

Question 11

The infection work-up is negative. What is the best next step?

Explanation

DISCUSSION:
The cross-table lateral radiograph shows that the patient has decreased acetabular anteversion. She is likely impinging on her cup in flexion and levering the femoral component posteriorly. Given a well-fixed and well-aligned femoral component and a negative infection work-up, the preferred treatment is to revise the acetabulum with a goal of increasing acetabular anteversion to avoid prosthetic impingement. Conversion to a constrained or elevated rim liner is suboptimal in this setting, because the problem is impingement. Indications for a constrained liner are neuromuscular compromise, abductor deficiency, or instability despite well-fixed and well-placed components. Given her 5 of 5 abductor strength, gluteus medius repair is not indicated.

Question 12

Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?

Explanation

DISCUSSION: Anterior perforation of the femur has been attributed to a simple mismatch in the radius of curvature of implants and the apex anterior bowed femur.
The radius of curvature is generally smaller (114-120 cm) than many earlier generation femoral nails (up to 300 cm), and the referenced article by Ostrum et al describes a case series of 3 such patients with subtrochanteric fractures. He noted that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.
Illustration A shows an example of a nail penetrating the anterior femoral cortex.

Question 13

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Explanation

DISCUSSION:
The MSIS definition of periprosthetic joint infection was updated in 2014 with two major and six minor criteria. The presence of one major criterion or three minor criteria is diagnostic for infection. The major criteria are two positive cultures with the same organism or a draining sinus tract. The current MSIS minor criteria are 1) an elevated ESR (more than 30 mm/hr) and CRP level (more than 10 mg/L), 2) an elevated synovial WBC count (more than 3,000 cells per/microliter), 3) an elevated synovial fluid polymorphonuclear count (more than 80%), 4) a positive histological analysis of periprosthetic tissue, and 5) a single positive culture.

Question 14

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 15

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured? Review Topic

Explanation

The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability.

Question 16

The use of multiagent adjuvant chemotherapy is associated with a clear survival benefit in which of the following diseases?

Explanation

DISCUSSION: The use of multiagent chemotherapy has been shown to be associated with a survival benefit in patients with osteosarcoma. The use of chemotherapy in adults with soft-tissue sarcoma remains somewhat controversial. It has not been associated with improved survival rates in patients with renal carcinoma, dedifferentiated chondrosarcoma, or melanoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 53.
Link M, Goorin A, Miser A, et al: The effect of adjuvant chemotherapy and relapse free survival in patients with osteosarcoma of the extremity. N Engl J Med 1986;314:1600-1606.

Question 17

A 30-year-old man has pain in the left arm after a motor vehicle accident. His neurovascular examination is intact, and radiographs are shown in Figures 25a and 25b. What is the best course of management?

Explanation

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Yokoyama K, Itoman M, Kobayashi A, et al: Functional outcomes of “floating elbow” injuries in adult patients. J Orthop Trauma 1998;12:284-290.

Question 18

A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment? Review Topic

Explanation

Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following? Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury? Review Topic

Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 19

A 57-year-old man with type I diabetes mellitus has had a tender, erythematous right sternoclavicular joint for the past 2 weeks. Radiographs reveal mild osteolysis without arthritic changes, within normal limits. Management should consist of

Explanation

DISCUSSION: Sternoclavicular joint sepsis is a rare condition that is most often restricted to patients who are immunocompromised, diabetic, or IV drug abusers. Examination commonly reveals a tender, painful, and possibly swollen sternoclavicular joint. If suspicion remains high following a thorough history, physical examination, radiographs, and routine blood tests, joint aspiration should be performed prior to incision and drainage or administration of antibiotics.
REFERENCES: Bremner RA: Monarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.
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, p 488.

Question 20

A 35-year-old man has had a mass on the bottom of his foot for the past 6 months. He reports that initially the mass was exquisitely painful but now is minimally tender. Examination reveals a 2.5- x 2.0-cm firm, noncompressible, nonmobile mass contiguous with the plantar fascia in the distal arch. The mass is particularly prominent with passive dorsiflexion of the ankle and toes. What is the best course of action?

Explanation

DISCUSSION: The history is most consistent with a plantar fibroma. The nodules typically are located within the substance of the plantar aponeurosis. The clinical appearance is usually diagnostic without the need for advanced imaging studies. While the lesion may be prominent and painful to direct palpation, the anatomic location is usually off of the weight-bearing surface. Observation with or without an accommodative orthotic is the treatment of choice. Recurrence is common following attempted excision.
REFERENCES: Sammarco GJ, Mangone PG: Classification and treatment of plantar fibromatosis. Foot Ankle Int 2000;21:563-569.
Durr HR, Krodel A, Trouillier H, Lienemann A, Refior HJ: Fibromatosis of the plantar fascia: Diagnosis and indications for surgical treatment. Foot Ankle Int 1999;20:13-17.

Question 21

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Explanation

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 22

A 51-year-old plumber has a failed peroneus brevis tendon repair. He reports continued pain and swelling in the distal retrofibular area. MRI shows longitudinal tears of the peroneus longus and peroneus brevis. What is the surgical treatment of choice at this time?

Explanation

DISCUSSION: A flexor digitorum longus transfer, while not as strong as the peroneals, improves the tendon balance and maintains hindfoot mobility. Subtalar fusion is a salvage procedure. Posterior tibial tendon transfer compromises inversion strength and arch height. Functional absence of the peroneals results in an imbalance that could lead to forefoot varus.
REFERENCES: Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.
Borton DC, Lucas P, Jomha NM, et al: Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br 1998;80:781-784.

Question 23

A 45-year-old distance runner has a hyaluronic acid injection to his knee because of degenerative arthritis. He immediately develops a severe rash and a systemic hypersensitivity reaction. This patient most likely is also allergic to which of the following?

Explanation

DISCUSSION: Preparations of hyaluronic acid can be divided into low and high molecular weight compounds. Contraindications to intra-articular hyaluronic acid include joint or skin infection, overlying skin disease, and allergies to chicken or egg products if using a preparation derived from rooster comb.
REFERENCES: Gloyscen DN, Gillespie MJ, Schenek RC: The effects of medication in sports injuries, in DeLee JC, Drez D Jr, Miller MD (eds): Orthopedic Sports Medicine: Principles and Practice, ed 2.
Philadelphia, PA, WB Saunders, 2003, vol 1, pp 121-124.
Schenck RC Jr: New approaches to the treatment of osteoarthritis: Oral glucosamine and chondroitin sulfate. Instr Course Lect 2000;49:491-494.

Question 24

A 35-year-old man who has had a 6-month history of low back pain and tenderness now reports worsening pain and stiffness in the hips and entire back. An AP radiograph of the pelvis demonstrates fusion of the sacroiliac joints bilaterally. What is the next most appropriate step in management? Review Topic

Explanation

The patient has a classic presentation of early ankylosing spondylitis. Sacroiliac joint fusion is the earliest radiographic finding and is typically followed by cephalad spinal progression. Early treatment of ankylosing spondylitis consists of nonsteroidal anti-inflammatory drugs and physical therapy to preserve spinal motion. HLA-B27 testing is positive in most (about 95%) patients; however, it is not pathognomonic because it can be positive with other conditions. Considering the progressive nature of this
disease, further work-up in a patient with potential ankylosing spondylitis is not warranted. Sacroiliac joint anesthetic injections and sacroiliac fusion are not recommended treatments for early ankylosing spondylitis. Aspiration of the sacroiliac joints can be done if sacroiliac joint infection is suspected; however, in the absence of fever or other constitutional symptoms, infection is unlikely.

Question 25

A 65-year-old right–hand-dominant woman has been experiencing thenar and wrist pain for 18 months. She has no history of trauma. The pain worsens during the opening of jars, grasping, writing, and repetitive thumb use. Examination reveals tenderness to palpation over the volar thenar eminence, just distal to the scaphoid tubercle, and along the flexor carpi radialis sheath. A Watson scaphoid shift test produces pain but no instability or clunk. Radiographs reveal isolated scaphotrapeziotrapezoidal (STT) arthritis with mild dorsal intercalated segment instability (DISI) deformity. She has worn a splint on and off for the past year, has had multiple cortisone injections, and has modified her activity, all of which helped initially. She wants to move forward with surgical intervention. STT arthrodesis is chosen over distal pole scaphoid excision. What factor in her evaluation indicates that arthrodesis would be preferred over distal pole excision?

Explanation

EXPLANATION:
Isolated STT arthritis is common and can cause substantial patient disability and pain. After nonsurgical treatment has failed, surgical intervention is warranted. Surgical options include distal pole scaphoid excision, STT arthrodesis, or carpometacarpal (CMC) arthroplasty, if concomitant thumb CMC degenerative changes are present. Distal pole scaphoid excision is less commonly employed for the treatment of STT arthritis, because of the potential development of intercalated segmental instability. However, distal pole scaphoid excision is less technically demanding, engenders fewer surgical complications, and promotes a faster return to previous activity levels. In any patient with preoperative carpal malalignment, removing the distal pole of the scaphoid would exacerbate that deformity and could lead to symptoms from the DISI deformity. Thus, in this patient with mild DISI deformity seen on preoperative radiographs, STT arthrodesis is the most appropriate treatment option.

Question 26

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

Explanation

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

Question 27

A 16-year-old boy has had knee pain for the past 6 months, and activity restrictions have not provided relief. An MRI scan reveals a stable 1.5 cm by 1 cm osteochondritis dissecans on the weight-bearing surface of the lateral femoral condyle. What is the best course of treatment? Review Topic

Explanation

As a child approaches skeletal maturity, osteochondritis dissecans lesions are unlikely to heal with continued nonsurgical management. Drilling of the lesion has a high success rate. The lesion is stable and an open repair or osteochondral transplant is not needed.

Question 28

In hybrid arthroplasty, the use of a polymethylmethacrylate (PMMA) precoated femoral component has been shown to result in

Explanation

DISCUSSION: Precoating of the femoral stem with PMMA results in increased bonding of the stem to the cement mantle. However, this has not been shown to result in superior survivorship compared with nonprecoated stems of similar design. In one series, the rate of revision of precoated stems was greater than that of nonprecoated cohorts. The wear and infection rates have not been shown to differ between precoated and nonprecoated stems.
REFERENCES: Sporer SM, Callaghan JJ, Olejniczak JP, Goetz DD, Johnston RC: The effects of surface roughness and polymethylmethacrylate precoating on the radiographic and clinical results of the Iowa hip prosthesis: A study of patients less than fifty years old. J Bone Joint Surg Am 1999;81:481-492.
Schulte KR, Callaghan JJ, Kelley SS, Johnston RC: The outcome of Charnley total hip arthroplasty with cement after a minimum twenty-year follow-up: The results of one surgeon. J Bone Joint Surg Am 1993;75:961-975.

Question 29

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Explanation

DISCUSSION: The patient has severe acetabular protrusio, a condition that is frequently associated with Marfan syndrome. An echocardiogram is necessary to rule out the most serious consequence of this syndrome, aortic root widening, which can lead to aortic valve dysfunction or fatal aortic rupture. An electromyogram may be indicated for Charcot-Marie-Tooth disease, which is associated with acetabular dysplasia, but not protrusio. The renal ultrasound, the MRI scan, and the biopsy would be of no value in this patient. Protrusio can also be seen in patients with osteogenesis imperfecta and juvenile rheumatoid arthritis.
REFERENCES: Steel HH: Protrusio acetabuli: Its occurrence in the completely expressed Marfan syndrome and its musculoskeletal component and a procedure to arrest the course of protrusion in the growing pelvis. J Pediatr Orthop 1996;16:704-718.
Wenger DR, Ditkoff TJ, Herring JA, Mauldin DM: Protrusio acetabuli in Marfan’s syndrome. Clin Orthop 1980;147:134-138.

Question 30

Longitudinal radioulnar dissociation, including Essex Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT?

Explanation

DISCUSSION: The IOM includes 5 types of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The annular ligament is not a part of the IOM.
The IOM bridges the radius and ulna and acts as a hinge for rotation of radius about ulna. The central portion is thickened, and forms the central band which is the most important ligament for IOM load distribution characteristics.
Noda et al, in a cadaver study, identified the precise anatomical insertions and attachment points of each of the 5 IOM components. They found the most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head.
Pfaeffle et al also performed a cadaveric biomechanical study applying compressive loads to specimens with IOMs that are intact, cut, or cut/reconstructed with flexor carpi radialis allografts. They found that reconstruction of the IOM can restore the normal load transfer chararcteristics and that the central band of the IOM is the most important portion of the IOM to be reconstructed.

Question 31

What is the most common indication for revision following unconstrained elbow arthroplasty?

Explanation

DISCUSSION: Instability following unconstrained elbow arthroplasty occurs in 10% of patients. Subluxation is twice as common as frank dislocation; however, only 20% of these patients undergo revision. Instability following unconstrained elbow arthroplasty can be caused by component malposition or ligament insufficiency.
REFERENCES: King GJ, Itoi E, Niebur GL, et al: Motion and laxity of the capitellocondylar total elbow prosthesis. J Bone Joint Surg Am 1994;76:1000-1008.
Ring D, Koris M, Jupiter JB: Instability after total elbow arthroplasty. Orthop Clin North Am 2001;32:671-677.

Question 32

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Explanation

DISCUSSION: The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe.
REFERENCES: Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle.

Clin Anat 2006;19:611-614.
Williams PL, Bannister LH, Berry MM, et al (eds): Gray’s Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 21.

Question 33

A 68-year-old woman has been progressing slowly after undergoing humeral head replacement for a four-part fracture 3 months ago. She has not regained active elevation, she feels an audible clunk on attempting elevation, and she reports pain and weakness. She used a sling for 2 weeks in the immediate postoperative period. Radiographs are shown in Figure 37a through 37c. Management should consist of

Explanation

DISCUSSION: Immediate repair of the tuberosity and rotator cuff is recommended on identifying the avulsion or nonunion. Revising the humeral component to increase tension and length will overtighten the cuff and increase the chance of tuberosity pull-off. The glenoid is uninvolved and should not be replaced. Attempts to strengthen the rotator cuff will be unsuccessful because the insertions are no longer attached to the humerus when the tuberosities avulse.
REFERENCES: Brown TD, Bigliani LU: Complications with humeral head replacement. Orthop Clin North Am 2000;31:77-90.
Muldoon MP, Cofield RH: Complications of humeral head replacement for proximal humeral fractures. Instr Course Lect 1997;46:15-24.

Question 34

A skeletally mature 15-year-old girl who was thrown from the car in a rollover accident sustained the injuries shown in Figures 23a through 23d. Examination reveals no neurologic deficit, but the patient has moderate posterior spinal tenderness at the level of the injury. What is the most appropriate treatment?

Explanation

DISCUSSION: The majority of patients with thoracolumbar burst fractures without neurologic deficit can be effectively treated with a TLSO or a hyperextension body cast. Indications for surgery are neurologic deficit and/or significant deformity (greater than 50% loss of anterior vertebral body height or marked kyphosis).
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.

Question 35

-Figures a and b are the MRI scans of the cervical spine without contrast of a 38-year-old man with neck pain radiating into the right upper extremity for the past 4 weeks. He denies numbness or weakness.Examination was significant for reproduction of pain going down the right arm with neck extension and right lateral rotation. What is the next treatment step?

Explanation

Question 36

Figures 3a and 3b show the MRI scans of a patient with neck pain. What is the most likely diagnosis?

Explanation

DISCUSSION: Muliple neurofibromas result in marked foraminal enlargement as seen on the sagittal MRI scan. Collagen disorders leading to dural ectasia may show similar enlargement, but none of these is listed as a possible answer.
REFERENCES: Kim HW, Weinstein SL: Spine update: The management of scoliosis in neurofibromatosis. Spine 1997;22:2770-2776.
Funasaki H, Winter RB, Lonstein JB, et al: Pathophysiology of spinal deformities in neurofibromatosis: An analysis of seventy-one patients who had curves associated with dystrophic changes. J Bone Joint Surg Am 1994;76:692-700.

Question 37

A total knee arthroplasty is recommended to a mentally competent 68-year-old woman who has disabling knee pain caused by degenerative arthritis. Her son has researched the procedure on the internet and prefers the Acme Female Knee for his mother. You have designed the Axis Woman's Knee, for which you receive royalties, and use it exclusively. Which of the following ethical principles takes precedence in guiding her treatment?

Explanation

Informed consent incorporates a number of ethical principles relevant to this case. The fundamentals of medical ethics include nonmaleficence, beneficence, autonomy, and justice. The patient is competent and capable of exercising her autonomy in choosing the Acme Female Knee. She also depends on her physician's paternalism and knowledge in looking out for her best interests, which in his opinion, may be use of the Axis Woman's Knee. The physician has a fiduciary responsibility to inform the patient that he has a financial interest in the implant system he recommends. A thorough informed consent will respect the patient's autonomy, explain the rationale for the physician's recommendation, and notify the patient that there may be a perceived conflict of interest. The ethical principle of justice has no relevance in this case.

Question 38

What mechanism of injury is most likely to cause a fracture of the anteromedial facet of the coronoid?

Explanation

Early range of motion
Hinged elbow brace for 4 weeks
Repair lateral collateral ligament
Remove and upsize implant
Remove and downsize implant
The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.
Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intraoperatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.
Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by >or=6 mm.
Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.
Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,
Incorrect Answers:

Question 39

A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication,

Explanation

The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.

Question 40

In long-term follow-up studies of cemented total knee arthroplasty (TKA), the lowest rates of osteolysis have been associated with which design feature?

Explanation

DISCUSSION
The lowest reported rates of osteolysis involving cemented TKAs are associated with monolithic tibial components. Modular components and cemented metal-backed patella components are associated with a high prevalence of backside tibial insert wear and osteolysis.

Question 41

A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure? Review Topic

Explanation

Erb’s palsy is the most common form of obstetrical plexus palsy resulting in C5, C6, or upper trunk deficits. This causes loss of shoulder abduction and elbow flexion. The biceps muscle and the brachialis muscles are predominately responsible for flexion of the elbow. Each of these muscles is innervated by individual branches of the musculocutaneous nerve which are supplied predominately by axons from the C6 nerve root and the upper trunk of the brachial plexus

Question 42

An 18-year-old lacrosse player sustained a hamstring pull during a game. Examination the next day reveals ecchymosis through the posterior thigh and a palpable defect in the hamstring musculature in the middle third of the thigh. What is the most likely site of anatomic injury?

Explanation

DISCUSSION: Hamstring strains are common in athletes. Basic science research and clinical data indicate that the majority of these injuries occur at the myotendinous junction, not within the muscle belly. Avulsion of hamstring origin from the ischial tuberosity does occur but is less common. Complete tearing of all hamstring muscles is unlikely to occur.
REFERENCES: Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 17-33.
Clanton TO, Coupe KJ: Hamstring strains in athletes: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248.

Question 43

Figure 24 shows the radiograph of an otherwise healthy 56-year-old patient who reports hip pain after undergoing a primary cementless hip replacement 4 months ago. The next most appropriate step should consist of

Explanation

DISCUSSION: Periosteal new bone formation is a warning sign of prosthetic infection. Indomethacin may prevent heterotopic ossification if given early enough; however, it is irrelevant in this patient. A C-reactive protein and a sed rate are useful screening studies that add to the predictive value of the radiographs and may be performed routinely if sepsis is suspected. A bone scan obtained 4 months after surgery would show increased uptake in all cases. If results of a sed rate and C-reactive protein are normal, then a biopsy should be considered to rule out a neoplasm.
REFERENCE: Fitzgerald RH Jr: Infected total hip arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:249-262.

Question 44

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Question 45

A 38-year-old man sustained a complete thoracic spinal cord injury at age 14. An MRI scan of his shoulder, when compared with studies from uninjured controls, is more likely to show which of the following? Review Topic

Explanation

Children that sustain a spinal cord injury or otherwise use a wheelchair for mobility, and thus often have more pain and a higher incidence of structural and functional changes of the shoulder joint as an adult. MRI studies have shown a four-fold risk of rotator cuff tears in people with long-term paraplegia when compared with age-matched controls. An MRI scan would not show bone density changes. The other answer choices have not been demonstrated in higher numbers on MRI in paraplegics.

Question 46

A 30-year-old woman injured her ankle playing soccer 3 months ago. She now reports popping and pain over the lateral side of her ankle. An MRI scan is shown in Figure 33. What structure needs to be repaired to alleviate the popping?

Explanation

DISCUSSION: The symptoms and MRI scan indicate dislocated peroneal tendons. In this patient, the structure that needs to be repaired is the superior peroneal retinaculum. If the popping was coming from a torn peroneal tendon, repair would involve the peroneal longus or brevis tendon, but this is not shown in the MRI scan. The anterior talofibular ligament or the calcaneofibular ligament would need to be repaired if the patient had ankle instability due to an ankle sprain.
REFERENCES: Jones DC: Tendon disorders of the foot and ankle. J Am Acad Orthop Surg 1993;1:87-94.
Timins ME: MR imaging of the foot and ankle. Foot Ankle Clin 2000;5:83-101.

Question 47

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

Explanation

DISCUSSION:
Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to surgery.

Question 48

Figures below show the radiographs obtained from a 75-year-old woman who underwent right total hip arthroplasty in 2009. She did well until last month, when a right posterior hip dislocation occurred after she fell from her bed to the floor. Successful closed reduction was performed. She sustained two more posterior dislocations requiring closed reduction under anesthesia. The surgical report from the index arthroplasty notes a 54-mm monoblock acetabular component with a 28-mm inner diameter compression molded polyethylene and a high offset neck cementless stem with a +8-mm length, 28-mm head. What is the best next step?

Explanation

DISCUSSION:
This patient has demonstrated recurrent instability, and her current implants lack the modularity to upsize and improve the head-neck ratio and range to impingement. Given the monoblock acetabular component and a +7-mm neck length, the best option is revision to a large-diameter femoral head or dual-mobility component. Placement of a hip spica cast and resection arthroplasty are unreasonable. Revision to a longer ball length likely would not solve this recurrent instability pattern.

Question 49

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

Explanation

DISCUSSION: Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff. Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening. Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis. Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred.
REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg Br 1987;69:723-726.

Question 50

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Explanation

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 51

Figures 34a and 34b show the axial and sagittal MRI scans of a 36-year-old man who reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology? Review Topic

Explanation

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.

Question 52

A patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the site of the tenderness, about 7 cm above the lateral heel, provided temporary relief of the pain. What is the recommended course of management for the persistent burning pain?

Explanation

The patient has a sural nerve neuroma, which is a known complication of the extensile lateral approach. Of the available choices, excision and burial of the sural nerve in muscle or vein is the best choice because it gives better pain relief due to the better blood supply in muscle than bone. Recent authors advocate burying the nerve in vein as the best option. Neuroplasty is a possibility (but not of the superficial peroneal nerve), but the sural nerve is usually very sensitive and often pain relief with a release is incomplete. Additionally, implant removal is not indicated because of the patient's complaints; also, the implants should not be removed at 6 months. A subtalar fusion is the choice for posttraumatic arthritis from the calcaneus fracture. Electromyography/nerve conduction velocity studies are reasonable choices if there was an indication the pain could be coming from the back or there was no clear evidence of a sural nerve neuroma.

Question 53

Pedicle subtraction osteotomies (PSO) are commonly performed in the lumbar spine to treat sagittal imbalance. What is the most common complication following a PSO in the lumbar spine? Review Topic

Explanation

The rate of pseudarthrosis at 5-year follow-up is 29%, with most occurring at the thoracolumbar junction cephalad to the site of the PSO. The rate of postoperative neurologic deficits is 11%, with 2.8% resulting in permanent deficits. Spinal cord injury is rare because the PSO is typically performed in the lumbar spine below the conus.

Question 54

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management?

Explanation

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 55

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Explanation

Marfan syndrome is a challenging disease for the orthopaedic surgeon. Most problems of joint laxity, acetabular protrusio, and minor scoliosis curves are treated nonsurgically. Pseudarthrosis of the tibia is not seen in Marfan syndrome; it is more common in patients with neurofibromatosis (NF-1). Treating kyphosis is risky for vertebral subluxation. Rapidly progressive scoliosis in immature patients is associated with higher surgical complications, but surgery is indicated. Overcorrection is associated with significant cardiovascular complications and should be avoided.

Question 56

Following an acute dislocation of the patella, the risk of a recurrent dislocation is greater if the patient has which of the following findings?

Explanation

DISCUSSION: Recurrent dislocations may follow an earlier dislocation. One study found that in patients who had a patellar dislocation between the ages of 11 to 14 years, 60% had a recurrent dislocation. The incidence of recurrent dislocation dropped to 33% in patients who had a patellar dislocation between the ages of 15 to 18 years. The authors also found that the incidence of recurrence was greater in patients who demonstrated a predisposition to dislocation as determined by evaluation of the unaffected knee. Predisposing signs included passive lateral hypermobility of the patella, a dysplastic distal third of the vastus medialis obliquis muscle, and a high and/or lateral position of the patella. A second study found that the risk of redislocation was considerably higher in patients who were in their teens at the first episode of dislocation compared to older patients. There are no studies linking either a patella baja or a bipartite patella to an increased risk of redislocation.
REFERENCES: Cash JD, Hughston JC: Treatment of acute patellar dislocation. Am J Sports Med 1988;16:244-249.
Larsen E, Lauridsen F: Conservative treatment of patellar dislocations: Influence of evident factors on the tendency to redislocation and the theraputic result. Clin Orthop

1982;171:131-136.

Question 57

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

Explanation

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

Question 58

Figures 1 and 2 are the MR arthrogram images of a 20-year-old right-hand dominant collegiate basketball player who sustained an initial shoulder dislocation 1 year ago. In the month prior to presentation, he dislocated his shoulder two more times. Each time it occurred when going up for a rebound and an opponent grabbed the ball from behind him, hyperextending his shoulder. Physical examination demonstrates full range of motion, absence of atrophy, a positive apprehension sign and relocation test, and a positive Kim test. What is the best next step?

Explanation

The mechanism of injury/dislocation is most consistent with anterior glenohumeral joint instability. The axial cuts of the MR arthrogram reveals an anteroinferior labral tear, as well as a posterior labral tear. A Hill-Sachs lesion is also consistent with anterior glenohumeral joint instability. At the time of examination under anesthesia, this patient exhibited 2+ anterior and 2+ posterior glenohumeral joint instability. Patients with pan-labral tears and 270° tears can be challenging to diagnose, because patients can report anterior or posterior shoulder instability alone. The
physical examination and advanced imaging in these patients are crucial in directing appropriate treatment.

Question 59

-Which treatment approach for acetabular fractures carries the highest risk for heterotopic ossification?

Explanation

Question 60

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Explanation

Question 61

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Explanation

DISCUSSION: By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.
Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.
Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is rarely indicated in the proximal and middle tibia.

Question 62

A cartilage water content increase is the hallmark of which osteoarthritis stage?

Explanation

The first stage of osteoarthritis is marked by an increase in water content secondary to disruption of the matrix framework. This is followed by an increase in chondrocyte anabolic and catabolic activity in response to tissue damage. Wnt-induced signal protein 1 increases chondrocyte protease expression. Failure to restore tissue balance ultimately leads to continued destruction and osteoarthritis. One hallmark of osteoarthritic cartilage is a reduced repair mechanism attributable to decreased chondrocyte response to growth factor stimulation (transforming growth factor-alpha and insulin-like growth factor-1). Mitochondrial dysfunction and increased production of reactive oxygen species may promote cell senescence, a progressive slowing of cellular activity. Microscopic evidence of cartilage degeneration begins with fibrillation of the superficial and transition zones, followed by disruption of the tidemark by subchondral blood vessels and eventual subchondral bone remodeling. This process ultimately leads to cartilage degradation with decreased water content in the late and terminal phases of osteoarthritis.

Question 63

Figure 18a shows the clinical photograph of a 2-year old boy who has a deformity of the right leg. Examination reveals eight cutaneous markings similar to those shown in Figure 18b. Radiographs are shown in Figure 18c. Management should consist of

Explanation

DISCUSSION: The diagnosis of neurofibromatosis may be based on the presence of at least six cafe-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure 18c. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia.
REFERENCES: Crawford AH Jr, Bagamery N: Osseous manifestations of neurofibromatosis in childhood. J Pediatr Orthop 1986;6:72-88.
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, vol 2, pp 1059-1104.

Question 64

A patient reports a sudden recurrence of sciatica on her left side after undergoing a successful left L4-L5 diskectomy 15 months ago. Which of the following imaging modalities is most accurate in differentiating recurrence of the disk herniation from postoperative epidural scar tissue?

Explanation

The main complication of recurrence at the same level is the presence of scar tissue from the previous operation. In addition to a careful history and physical examination, contrast-enhanced MRI is useful for differentiating scar from reherniation. MRI has become the test of choice for assessing degenerative or herniated disks-even over that of CT. Answer #1 is incorrect because it will only provide information of cord or nerve root encroachment, not the
cause of the encroachment. Answer #2 makes no sense. Answers #3 and #4 are incorrect because the MRI is now the standard imaging modality.

Question 65

You are evaluating a patient with recurrent patellar instability who has failed conservative management. MRI demonstrates articular cartilage loss in the patella. In addition to a cartilage restoration procedure, you recommend the procedure depicted in Figures A and B. Which of the following imaging findings best supports your decision? Review Topic

Explanation

A tibial tubercle-trochlear groove (TT-TG) distance > 20mm is highly associated with patellar instability secondary to rotational malalignment and is an indication for anteromedialization of the tibial tubercle (AMZ), pictured in Figures A and B, to enhance patellofemoral stability and decrease patellofemoral contact pressures in the setting of cartilage restoration procedures.
Recurrent patellar instability is often associated with chondral lesions of the patellofemoral joint. In addition to managing the cartilage injury, the underlying etiology of the instability must also be addressed to ensure a successful outcome. Patellar instability may arise from coronal or rotational malalignment, patella alta, trochlear dysplasia or damage to soft tissue restraints including the medial patellofemoral ligament (MPFL). Rotational malalignment, defined by a TT-TG distance > 20mm, can be addressed by AMZ. Medialization of the tubercle restores a normal TT-TG distance while anteriorization of the tubercle unloads patellofemoral contact forces.
Beck et al performed a cadaveric study measuring patellofemoral contact pressures on the trochlear surface following AMZ. They found that anteromedialization decreased the mean contact pressures and shifted contact pressures to the medial trochlea. The authors concluded that while this procedure successfully unloads the lateral trochlea, it likely has minimal benefit for central chondral defects and may be detrimental for medial chondral defects where contact pressures are increased.
Strauss et al authored a review article detailing the surgical treatment options for patellofemoral cartilage lesions, including concomitant realignment/unloading procedures. AMZ is designed to correct rotational malalignment while unloading the patellofemoral compartment in the setting of cartilage restoration surgery. While AMZ has demonstrated good outcomes for lesions located in the lateral facet or distal
pole of the patella, poor outcomes have been seen with medial facet or central trochlear lesions.
Figures A and B are the AP and lateral radiographs, respectively, of a knee s/p AMZ, also know as a Fulkerson procedure. Illustration A is an algorithm detailing the approach to recurrent patellar instability in both skeletally immature and mature patients. Illustration B demonstrates how to measure the TT-TG distance, the distance between two lines drawn perpendicular to the posterior condylar axis to the tibial tubercle and deepest portion of the trochlear groove (normal 8-10mm). Illustration C depicts the measurement of the femoral trochlear angle or sulcus angle (normal 137°
+/- 8°). Illustration D shows how to measure lateral patellar tilt (normal < 5°). Illustration E is a postoperative radiograph after AMZ. A long (> 5cm) and thick (> 0.75cm) osteotomy cut is required to allow adequate fixation with two screws.
Incorrect Responses:

Question 66

Which of the following conditions is typically associated with the ankle deformity shown in figure 14?

Explanation

Figure 14 depicts an X-ray of a child with a Ball-and-Socket ankle. This is a rare deformity associated with such pre-existing conditions as congenital shortening of the lower limb, coalition of tarsal bones, absent digital rays and aplasia or hypoplasia of the fibula. Ball-and-socket joint is not congenital, but is an acquired deformity formed in compensation for the loss of inversion and eversion caused by tarsal coalition or various other pre-existing congenital conditions.

Question 67

A 63-year-old man has had increasing left leg pain over the last several months. History reveals that he has had recurring cyclic pain in the leg for the past several years. Radiographs show an enlarged, sclerotic tibia, with thickened coarse trabeculae and varus bowing. What is the most appropriate management for this patient? Review Topic

Explanation

Based on the signs and symptoms, Paget's disease is the most likely diagnosis. In Paget's disease, an elevated alkaline phosphatase level and high output heart failure may be seen. Hearing loss can be seen when there is involvement of the skull, and malignant degeneration is uncommon but recognized as a risk. Patients are often treated with bisphosphonate medications during the active disease process to help control osteoclastic activity and pain. Vitamin D and calcium are more appropriate for treatment of osteoporosis. Methotrexate is not indicated for the treatment of Paget's disease. NSAIDs may be helpful to treat pain associated with Paget's disease but will not alter the clinical course.

Question 68

A patient undergoes hip arthroscopy, and the pathology is seen in Figure 18. What is the most likely diagnosis?

Explanation

DISCUSSION: The motorized shaver is adjacent to the acetabular labrum, which is torn. The femoral head and acetabulum are normal in appearance. Neither the fat pad nor a loose body is identified.
REFERENCE: Byrd JWT: Operative Hip Arthroscopy. New York, NY, Thieme Medical Publishers, 1998, pp 93-104.

Question 69

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Explanation

The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.

Question 70

An orthopaedic surgeon frequently uses hip and knee prostheses from a specific manufacturer. The surgeon becomes acquainted with the manufacturer’s representative who provides the support for these prostheses in the hospital. They develop a personal relationship outside of work through a common interest in sailing. Together they become interested in buying a sailboat. The manufacture’s representative suggests a partnership in a boat costing $200,000. The manufacture’s representative would purchase a 90% interest and the surgeon a 10% interest in the boat. There would be no restrictions on use of the boat by the surgeon. What should the orthopaedic surgeon do?

Explanation

Rejecting this proposal is the only appropriate course of action. Accepting it would, in essence, be receiving a huge gift from industry in the form of a sailboat. Physicians frequently assert that they are not influenced by gifts and relationships with industry representatives, but evidence is to the contrary. Such an arrangement constitutes a tremendous incentive to use the manufacturer’s products. The fact that the boat
partnership seems completely outside of the orthopaedic business relationship does not excuse it. Conflicts of interest should always be resolved and in the best interest of patient care, and in this case the best course clearly is to avoid the conflict of interest totally. An equal interest in the boat does not eliminate the conflict of interest.

Question 71

Figure 22 shows the MRI scan of a 20-year-old female basketball player who has pain over the anterior knee that interferes with her performance. Examination reveals phase III Blazina patellar tendinosis. Management should consist of

Explanation

DISCUSSION: Excision of the affected mucoid degenerative area is considered appropriate management in the Blazina classification system. A finding of phase III indicates persistent pain with or without activities, as well as deterioration of performance. With the appearance of the mucoid degeneration and the vigorous activity level of the intercollegiate basketball player, it is unlikely that nonsurgical management will provide adequate relief. When excising the affected degenerative area, care must be taken to retain normal tendon fibers. The defect in the patellar tendon is closed with absorbable sutures, as is the paratenon. Postoperative rehabilitation involves initial mobilization extension, with progressive range-of-motion and mobilization exercises as tolerated and weight bearing as tolerated. Open chain and isokinetic exercises are delayed until full range of motion and mobility is obtained, generally within 4 weeks. A return to activities is achieved by 80% to 90% of athletes, although there may be occasional activity-related aching for 4 to 6 months after surgery.
REFERENCES: Blazina ME, et al: Jumper’s knee. Orthop Clin North Am 1973;4:665.
Kelly DW, Carter VS, Jobe FW, Kerlan RK: Patellar and quadriceps tendon ruptures: Jumper’s knee. Am J Sports Med 1984;12:375-380.
Krums PE, Ryder B: Operative treatment of patella tendon disorders. Operative Techniques Sports Med 1994;2:303.
Rows J, et al: Patella tendinitis (jumper’s knees). Am J Sports Med 1978;6:362.

Question 72

A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

Explanation

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations
with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance
tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

Question 73

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with Review Topic

Explanation

Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to 130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best.

Question 74

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

Explanation

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

Question 75

Figures 21a and 21b show the radiograph and CT scan of a 14-year-old patient with thigh pain. The next most appropriate step in management should consist of

Explanation

DISCUSSION: The radiographs show increased density and reactive bone formation. A faint nidus can be seen on the radiograph but is obvious on the CT scan. The initial therapy for an osteoid osteoma should be oral anti-inflammatory drugs. A biopsy or SPECT bone scan is not indicated because the osteoid osteoma is clearly seen on the CT scan. If the patient fails to respond to nonsurgical therapy, CT-guided radiofrequency ablation or surgical excision is indicated depending on the anatomic location.
REFERENCES: Frassica FJ, Waltrip RL, Sponseller PD, Ma LD, McCarthy EF Jr: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-574.
Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid osteoma. J Bone Joint Surg Am 1992;74:179-185.
Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ: Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998;80:815-821.

Question 76

A 20-year-old minor league baseball pitcher is diagnosed with a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has failed to provide relief. He has concomitant cubital tunnel symptoms that worsen while throwing. What is his best surgical option?

Explanation

DISCUSSION: High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Ciccotti MG, Jobe FW: Medial collateral ligament instability and ulnar neuritis in the athlete’s elbow. Instr Course Lect 1999;48:383-391.

Question 77

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis? Review Topic

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.

Question 78

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

Explanation

Hill-Sachs lesion is an impression fracture of the posterosuperior aspect of the humeral head, produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is demonstrated on plain AP radiograph in internal rotation.

Question 79

What assay most directly assesses gene expression at the posttranslational level?

Explanation

DISCUSSION: Gene expression at the posttranslational level refers to proteins, as opposed to DNA or RNA. The only assay above that targets protein expression directly is the Western blot. Standard PCR is amplification of targeted DNA segments, regardless of whether or not they are actively expressed. Real-time PCR, Northern blot, and microarray expression profile analysis all quantify RNA as a means to determine posttranscriptional gene expression.
REFERENCES: Brinker MR: Cellular and molecular biology, immunology, and genetics in orthopaedics, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 81-94.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 19-76.

Question 80

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Explanation

DISCUSSION: A positive margin is most closely related to subsequent local recurrence. The other factors cited, including the size and site of the tumor, may be related to local recurrence; however, they are more commonly prognostic because of the difficulty in obtaining wide surgical margins about large or proximal tumors. Radiation therapy has been noted to decrease the incidence of recurrence but is not felt to be as important as the surgical margin. The grade of the tumor has more influence on the prevalence of metastatic disease than the incidence of local recurrence.
REFERENCES: Lewis JJ, Leung D, Heslin M, Woodruff JM, Brennan MF: Association of local recurrence with subsequent survival in extremity soft tissue sarcoma. J Clin Oncol 1997;15:646-652.
Meterissian SH, Reilly JA Jr, Murphy A, Romsdahl MM, Pollock RE: Soft-tissue sarcomas of the shoulder girdle: Factors influencing local recurrence. Distant metastases and survival. Ann Surg Oncol 1995;2:530-536.

Question 81

You design a research study in which you ask patients who have a nonunion of the tibia to fill out a questionnaire in which they report on a variety of medical conditions and social/behavioral practices. You compare these findings to a similar group who did not develop a nonunion in order to identify medical and/or social conditions that might be risk factors for the development of tibial nonunions. This would be an example of what type of study?

Explanation

A case control series starts with the occurrence of a specific disease or observation, and then compares data on those individuals to a similar group without the disease (control group) in order to identify potential risk factors for the development of the disorder. A case series is an observational study in which an investigator follows a series of patients who received a specific treatment, recording the results and outcomes of that treatment. A meta-analysis is the combination of several separate studies that look at similar hypotheses in an effort to create a larger patient population for analysis. A cohort study looks for the incidence of a specific outcome in two groups (cohorts) of patients who are similar with the exception of a particular research variable (risk factor).

Question 82

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Explanation

DISCUSSION:
Vascular complications during TKA are rare but do occur. Traditionally, it was taught that the popliteal artery was situated posterior to the PCL; however, more recent anatomic dissections have demonstrated that this artery is usually located posterolateral to the PCL.

Question 83

Which of the following best describes the course of the median nerve at the elbow?

Explanation

DISCUSSION: The median nerve courses superficial to the ulnar artery, deep to the fibrous arch of the superficialis muscle, and deep to the superficial head of the pronator teres muscle. The median nerve lies within the interval between the flexor digitorum superficialis muscle and the flexor digitorium muscle as it progresses toward the wrist.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

pp 46-47.

Question 84

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Explanation

DISCUSSION: Historically, normal blood pressure, heart rate, and urine output have been endpoints to signal complete resuscitation in the polytrauma patient. The review article by Porter et al states that there is a high incidence of patients (as much as 85%) in "compensated" shock despite normal vital signs and urine output parameters. Compensated shock is secondary to a maldistribution of blood flow and tissue oxygenation as splanchnic organs have less distribution of the cardiac output compared to the heart and the brain. The article by Elliott is also a review, and it states that serum lactate is the best indicator of peripheral organ perfusion and tissue oxygenation. It also states that base deficit and gastric mucosal pH are appropriate end points to determine the complete resuscitation of trauma patients.

Question 85

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

Explanation

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T₁-weighted MRI scans and with high signal intensity on T₂-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 86

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Explanation

DISCUSSION: Epithelioid sarcoma is a rare soft-tissue sarcoma that most commonly arises in the hand or upper extremity, and it is frequently misdiagnosed as an infection or granuloma. It tends to have a higher incidence of lymph node metastasis than other soft-tissue sarcomas. The mainstay of treatment is wide surgical excision, even if amputation is necessary.
REFERENCES: Gupta TD, Chaudhuri P (eds): Tumors of the Soft Tissues, ed 2. Stamford, CT, Appleton and Lange, 1998, p 475.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St. Louis, MO, Mosby-Year Book, 1995, p 1074.

Question 87

In a fatigue test, the maximum stress under which the material will not fail, regardless of how many loading cycles are applied, is defined as

Explanation

Fatigue failure occurs with repetitive loading cycles at stress below the ultimate tensile strength. Fatigue failure depends on the magnitude of the stress and number of cycles. If the stress is less than a predetermined amount of stress, called the endurance limit, the material may be loaded cyclically an infinite number of times without breaking.

Question 88

Figures 1a and 1b are the recent radiographs of an 82-year-old man with rheumatoid arthritis who underwent total knee arthroplasty (TKA) 18 years ago. These radiographs reveal osteolysis with loosening of the tibial component. Aspiration and laboratory study findings for infection are negative. During the revision TKA, treatment of tibial bone loss should consist of

Explanation

DISCUSSION

Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 89

In the treatment of thoracic disk herniations, what approach is associated with the highest risk of iatrogenic paraplegia?

Explanation

DISCUSSION: Laminectomy is associated with the highest risk of iatrogenic paraplegia because retraction on the cord is necessary for visualization, but retraction is difficult because of tethering of the intradural dentate ligaments. All of the other approaches allow for access to the disk herniation through an angle that avoids the cord itself, although other limitations may exist.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 87-96.
Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH: Experience in the surgical mangement of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 1998;88:623-633.

Question 90

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Explanation

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 91

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Explanation

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 92

Figure 37 shows the standing lateral radiograph of a 62-year-old woman who reports lower back pain and the inability to stand upright. What permanent anatomic pelvic parameter should be measured and considered when determining the amount of lumbar lordosis correction that will be necessary to obtain sagittal balance? Review Topic

Explanation

Pelvic incidence (PI) is the anatomic angle between the sacral end plate and a line connecting the center of the femoral heads. Increased pelvic incidence has been found to correlate with the incidence and severity of spondylolisthesis. Patients with increased PI require increased lumbar lordosis to restore sagittal balance. Pelvic tilt (PT) and sacral slope (SS) have also been found to correlate with lumbar lordosis; however, both PT and SS can change depending on pelvic rotation. PI is the only
permanent pelvic parameter that is unaffected by pelvic rotation. Acetabular and femoral version have not been found to be associated with lumbar lordosis.

Question 93

A 52-year-old man who weighs 325 lb is wheelchair-bound from severe degenerative arthritis of the left hip. Twenty-four hours after cementless total hip arthroplasty, he develops shortness of breath and evaluation shows a saddle pulmonary embolus. The patient is started on enoxaparin sodium at 150 mg every 12 hours. Two days later, the patient’s hematocrit is 20% despite four units of transfused packed cells, and he now has developed a complete sciatic nerve palsy. What is the best course of action?

Explanation

DISCUSSION: The purpose of this question is to draw attention to the early risks of therapeutic anticoagulation that will be instituted by an intensivist or pulmonologist to treat a life-threatening pulmonary embolus. The temporary vena cava filter is a recent innovation but will effectively reduce the risk of further pulmonary emboli. This requires reversal of anticoagulation for safe insertion of the filter and creates a safe situation for additional surgical solutions. Sciatic nerve compromise was caused by the expanding hematoma in this patient, which could be mitigated by exploration both to assess the nerve and to remove a large hematoma that presents its own longterm risks.
REFERENCES: Della Valle CJ, Steiger DJ, Di Cesare PE: Thromboembolism after hip and knee arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:327-336.
Weil Y, Mattan Y, Goldman V, et al: Sciatic nerve palsy due to hematoma after thrombolysis therapy for acute pulmonary embolism after total hip arthroplasty. J Arthroplasty 2006;21:456-459.
American Academy of Orthopaedic Surgeons Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty, www.aaos.org/research/guidelines/ PEguide.asp

Question 94

In a retroperitoneal approach to the lumbar spine, what structure runs along the medial aspect of the psoas and along the lateral border of the spine?

Explanation

DISCUSSION: The sympathetic trunk runs longitudinally along the medial border of the psoas. The ilioinguinal nerve emerges along the upper lateral border of the psoas and travels to the quadratus lumborium, and the genitofemoral nerve lies more laterally on the psoas. The ureter is adherent to the posterior peritoneum and falls away from the psoas and the spine in the dissection, as does the aorta.
REFERENCES: Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983, p 107.
Johnson R, Murphy M, Sourthwick W: Surgical approaches to the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1559.

Question 95

Figure 1 is the radiograph of an 11-year-old baseball pitcher who has had right shoulder pain for the past 3 months. He has full range of motion and normal strength in both external rotation and abduction, although all tests cause him discomfort over the lateral and anterior shoulder. What is the most likely basis for his injury?

Explanation

The radiograph reveals a widened lateral physis at the proximal humerus, consistent with a physeal stress fracture or “Little Leaguer’s shoulder.” Numerous studies have established that children and adolescents are particularly prone to such overuse injuries. With regard to baseball participation, a major contributor is over-pitching, i.e., excessive numbers of pitches, excessive innings pitched, and insufficient rest days. Altered range of rotational motion, a gradual adaptation to the increased stresses of throwing, can predispose to long-term injury, especially internal impingement and labral pathology. A unicameral or aneurysmal bone cyst can often occur in the proximal humerus, but has a distinct radiographic appearance and would predispose to fracture. There is evidence that breaking pitches place increased stresses on the elbow and shoulder, but it remains controversial whether such
throws should be avoided at certain ages.

Question 96

A 32-year-old man presents to the emergency department with a humeral shaft fracture. He has wrist drop as well as impaired finger and thumb extension. Which motor function would be expected to recover last?

Explanation

DISCUSSION: The patient is presenting with radial nerve palsy secondary to his humerus fracture. Motor recovery proceeds in a proximal to distal direction.
Abrams et al detailed the order of innervation of the radial nerve and found the following order (proximal to distal): brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor digitorum communis, extensor carpi ulnaris, extensor digiti quinti, abductor policis longus, extensor policis longus, extensor policis brevis, and extensor indicis proprius.
Branovacki et al found a slightly different pattern: brachioradialis, extensor carpi radialis longus, superficial sensory, extensor carpi radialis brevis, supinator, extensor digitorum/extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis proprius.
While both extensor digitorum and extensor indicis proprius extend the index finger MCP joint, only extensor indicis proprius hyperextends the index finger past neutral

Question 97

Which of the following ligaments is most commonly involved in posterolateral rotatory instability of the elbow?

Explanation

DISCUSSION: Recurrent posterolateral rotatory instability of the elbow is difficult to diagnose. Such instability can be demonstrated only by the lateral pivot-shift test. The cause for this condition is laxity of the ulnar part of the lateral collateral ligament, which allows a transient rotatory subluxation of the ulnohumeral joint and a secondary dislocation of the radiohumeral joint. The annular ligament remains intact, so the radioulnar joint does not dislocate. Treatment consists of surgical reconstruction of the lax ulnar part of the lateral collateral ligament. The anterior band is the most important part of the medial collateral which is lax in valgus instability of the elbow.
REFERENCES: Morrey BF: Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117-128.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 98

A deficiency of which of the following is associated with an increased risk of venous thromboembolism?

Explanation

Protein C and Protein S are endogenous proteins whose action is to inhibit the coagulation cascade. Deficiencies in these proteins are a risk factor for the development of thrombus. Prothrombin is the precursor to thrombin, which is the final common pathway for both the intrinsic and extrinsic coagulation cascade. Thrombin acts to convert fibrinogen to fibrin and thus clot formation.

Question 99

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they want to “get the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared with nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 100

A 70-year-old man has worn through his metal-backed patellar component and sustained damage to the femoral component. Following removal of the components and debridement of the metal-stained synovium, the surgeon finds that the thickness of the remaining patella is 10 mm. Treatment should now include

Explanation

DISCUSSION: Revision of a failed patellar component can be difficult because of bone loss and damage to the extensor mechanism. Several authors have advised against reinsertion of a patellar component if the residual patellar thickness is 10 mm or less. Leaving an unresurfaced bony remnant in place at the time of revision or reimplantation surgery has been shown to be a reasonable option; however, the results are of a lower quality when compared with revision surgery where the patellar component can be retained or revised. The other treatment options have not been shown to be effective approaches to this problem.
REFERENCES: Rand JA: The patellofemoral joint in total knee arthroplasty. J Bone Joint Surg Am 1994;76:612-620.
Pagnano MW, Scuderi GR, Insall JN: Patellar component resection in revision and reimplantation total knee arthroplasty. Clin Orthop 1998;356:134-138.
Barrack RL, Matzkin E, Ingraham R, Engh G, Rorabeck C: Revision knee arthroplasty with patella replacement versus bony shell. Clin Orthop 1998;356:139-143.

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following results cannot be achieved with an in-shoe orthosis?

Options:

Correction of rigid deformity
Increased cushion
Diminished shear forces
Metatarsal head relief
Redistribution of plantar forces

Correct Answer: Correction of rigid deformity

Explanation:

Question 2:

Options:

Bed rest for 6 weeks, followed by a thoracolumbosacral orthosis (TLSO) until the fracture is healed
TLSO and or body cast for 3 to 6 months with mobilization when comfortable
Posterior spinal fusion and instrumentation
Anterior decompression with spinal fusion and instrumentation
Anterior decompression and anterior-posterior spinal fusion and instrumentation

Correct Answer: TLSO and or body cast for 3 to 6 months with mobilization when comfortable

Explanation:

Question 3:

Options:

Microfracture
Autologous chondrocyte implantation
Osteochondral allograft transfer
Dejour trochleoplasty

Correct Answer: Osteochondral allograft transfer

Explanation:

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

Question 4:

The risk for postoperative wound infection after lumbar spine surgery is reduced most by the use of

Options:

iodine-impregnated preparation solution.
chlorhexidine-impregnated preparation solution.
greater than 10 minutes of surgical scrub.
intravenous antibiotic prophylaxis prior to skin incision.
laminar-flow air circulation.

Correct Answer: intravenous antibiotic prophylaxis prior to skin incision.

Explanation:

Question 5:

When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?

Options:

Reliable and durable pain relief
No significant benefit for chronic osteoarthritis
Up to 75% pain relief for 2 months, then variable response
Three-month measurable pain relief, followed by recurrence

Correct Answer: No significant benefit for chronic osteoarthritis

Explanation:

Question 6:

Options:

External fixation
Open reduction and internal fixation of the pubic symphysis with a two-hole plate
Open reduction and internal fixation of the pubic symphysis with a two-hole plate and posterior triangular osteosynthesis
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate
Open reduction and internal fixation of the pubic symphysis with a multi-hole plate and posterior plate osteosynthesis

Correct Answer: Open reduction and internal fixation of the pubic symphysis with a multi-hole plate

Explanation:

Question 7:

What term best describes the process involved when a growth factor produced by an osteoblast stimulates the differentiation of an adjacent undifferentiated mesenchymal cell during fracture repair?

Options:

Mechanical
Autocrine
Paracrine
Endocrine
Systemic

Correct Answer: Paracrine

Explanation:

Question 8:

Which of the following types of intra-articular pathology is associated with lateral meniscal cysts? Review Topic

Options:

Discoid meniscus
Posterolateral corner injury
Vertical meniscal tears
Middle third lateral meniscal tears
Popliteus tendon tears

Correct Answer: Middle third lateral meniscal tears

Explanation:

Question 9:

Options:

Chondroblastoma
Osteoid osteoma
Occult instability
Rotator cuff tear
Injury to the proximal humeral physis

Correct Answer: Injury to the proximal humeral physis

Explanation:

Question 10:

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data?

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypotension

Correct Answer: Patient positioning

Explanation:

DISCUSSION: Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery.
REFERENCES: Jones SC, Fernau R, Woeltjen BL: Use of somatosensory evoked potentials to detect peripheral ischemia and potential injury resulting from positioning of the surgical patient: Case reports and discussion. Spine J 2004;4:360-362.
Schwartz DM, Sestokas AK, Hilibrand AS, et al: Neurophysiological identification of position-induced neurologic injury during anterior cervical spine surgery. J Clin Monit Comput 2006;20:437-444.

Question 11:

The infection work-up is negative. What is the best next step?

Options:

Revision of the acetabulum and evaluation of the femoral stem
Conversion to a constrained liner
Gluteus medius repair and application of a hip abductor brace
Revision to an elevated acetabular polyethylene liner

Correct Answer: Revision of the acetabulum and evaluation of the femoral stem

Explanation:

Question 12:

Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?

Options:

Non-anatomic reduction
Mismatch of the radius of curvature of implant and bone
Usage of too large an implant
Lateral patient positioning
Lateral proximal starting point

Correct Answer: Non-anatomic reduction

Explanation:

Question 13:

According to Musculoskeletal Infection Society (MSIS) guidelines, which set of patient laboratory study results fits the definition of chronic prosthetic joint infection?

Options:

Erythrocyte sedimentation rate (ESR) 50 mm/hr, C-reactive protein (CRP) 8 mg/L, joint aspiration white blood cell (WBC) count 542, 62% neutrophils, and positive leukocyte esterase
ESR 42 mm/hr, CRP 12 mg/L, joint aspiration WBC count 3,540, 72% neutrophils, and positive leukocyte esterase
ESR 20 mm/hr, CRP 15 mg/L, joint aspiration WBC count 4,135, 54% neutrophils, and negative leukocyte esterase
ESR 25 mm/hr, CRP 7 mg/L, joint aspiration WBC count 252, 82% neutrophils, and negative leukocyte esterase

Correct Answer: ESR 42 mm/hr, CRP 12 mg/L, joint aspiration WBC count 3,540, 72% neutrophils, and positive leukocyte esterase

Explanation:

Question 14:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

Question 15:

Options:

Annular
Anterior band of the medial collateral
Lateral orbicular
Lateral radial collateral
Lateral ulnar collateral

Correct Answer: Lateral ulnar collateral

Explanation:

Question 16:

The use of multiagent adjuvant chemotherapy is associated with a clear survival benefit in which of the following diseases?

Options:

Renal carcinoma
Osteosarcoma
Dedifferentiated chondrosarcoma
Adult soft-tissue sarcoma
Melanoma

Correct Answer: Osteosarcoma

Explanation:

Question 17:

Options:

Closed reduction and cast immobilization for 4 weeks, followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 2 weeks after surgery
Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon and humeral fractures, and splint immobilization for 4 weeks followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 4 weeks after surgery

Correct Answer: Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion

Explanation:

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Yokoyama K, Itoman M, Kobayashi A, et al: Functional outcomes of “floating elbow” injuries in adult patients. J Orthop Trauma 1998;12:284-290.

Question 18:

Options:

Correction of the flatfoot deformity
Achilles tendon lengthening followed by orthotic support
Excision of the tarsal coalition
Sinus tarsi debridement
Triple arthrodesis

Correct Answer: Correction of the flatfoot deformity

Explanation:

The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle,
appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity.
(SBQ13PE.64) A 5-year-old boy presents to clinic for evaluation of bilateral foot deformities shown in Figure 1. He is fully active and has no pain. The feet appear normal when he is sitting on the examination table, and there is supple passive motion at the subtalar joint. Passive ankle dorsiflexion is to neutral with knee in extension and 15 degrees with knee in flexion. What is the most appropriate next step?
Review
Topic
Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following?
Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury?
Review Topic
Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 19:

Options:

MRI.
sternoclavicular joint aspiration.
incision and drainage.
IV antibiotics.
nonsteroidal anti-inflammatory drugs.

Correct Answer: sternoclavicular joint aspiration.

Explanation:

Question 20:

Options:

Observation
Incisional biopsy
Excisional biopsy
MRI
Ultrasound

Correct Answer: Observation

Explanation:

Question 21:

Sterilization of ultra-high molecular weight polyethylene by gamma irradiation in air will degrade its wear performance because of

Options:

oxidation.
melting.
cross-linking.
corrosion.
creep.

Correct Answer: oxidation.

Explanation:

DISCUSSION: Gamma irradiation has long been used as a sterilization method for polyethylene. Exposure to gamma irradiation causes breakage of the chemical bonds in the polyethylene, and oxidation will occur if the material is subsequently exposed to air. The amount of oxidation and decrease in wear performance is also related to the length of time that the gamma-irradiated polyethylene is exposed to oxygen.
REFERENCES: Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
McKellop H, Shen FW, Lu B, et al: Effect of sterilization method and other modifications on the wear resistance of acetabular cups made of ultra-high molecular weight polyethylene: A hip-simulator study. J Bone Joint Surg Am 2000;82:1708-1725.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 22:

Options:

Subtalar fusion
Posterior tibial tendon transfer to the cuboid
Split posterior tibial tendon transfer to the lateral cuneiform
Flexor digitorum longus transfer to the fifth metatarsal
Excision of both the peroneus longus and brevis

Correct Answer: Flexor digitorum longus transfer to the fifth metatarsal

Explanation:

DISCUSSION: A flexor digitorum longus transfer, while not as strong as the peroneals, improves the tendon balance and maintains hindfoot mobility. Subtalar fusion is a salvage procedure. Posterior tibial tendon transfer compromises inversion strength and arch height. Functional absence of the peroneals results in an imbalance that could lead to forefoot varus.
REFERENCES: Redfern D, Myerson M: The management of concomitant tears of the peroneus longus and brevis tendons. Foot Ankle Int 2004;25:695-707.
Borton DC, Lucas P, Jomha NM, et al: Operative reconstruction after transverse rupture of the tendons of both peroneus longus and brevis: Surgical reconstruction by transfer of the flexor digitorum longus tendon. J Bone Joint Surg Br 1998;80:781-784.

Question 23:

Options:

Penicillin
Sulfur
Shellfish
Chicken or eggs
Lidocaine

Correct Answer: Chicken or eggs

Explanation:

Question 24:

Options:

Anesthetic injections in both sacroiliac joints
Sacroiliac fusion with plate fixation
Anti-inflammatory medications, physical therapy, and HLA-B27 testing
Patient reassurance and follow-up as needed
Immediate bilateral sacroiliac joint aspiration and culture

Correct Answer: Anti-inflammatory medications, physical therapy, and HLA-B27 testing

Explanation:

Question 25:

Options:

Failure of pain relief from steroid injection and NSAID use
Tenderness that is distal to the scaphoid tubercle
Isolated STT arthritis on radiograph
Mild DISI deformity on radiograph

Correct Answer: Mild DISI deformity on radiograph

Explanation:

EXPLANATION:
Isolated STT arthritis is common and can cause substantial patient disability and pain. After nonsurgical treatment has failed, surgical intervention is warranted. Surgical options include distal pole scaphoid excision, STT arthrodesis, or carpometacarpal (CMC) arthroplasty, if concomitant thumb CMC degenerative changes are present. Distal pole scaphoid excision is less commonly employed for the treatment of STT arthritis, because of the potential development of intercalated segmental instability. However, distal pole scaphoid excision is less technically demanding, engenders fewer surgical complications, and promotes a faster return to previous activity levels. In any patient with preoperative carpal malalignment, removing the distal pole of the scaphoid would exacerbate that deformity and could lead to symptoms from the DISI deformity. Thus, in this patient with mild DISI deformity seen on
preoperative radiographs, STT arthrodesis is the most appropriate treatment option.

Question 26:

Options:

Streptococcus pneumoniae
Staphylococcus aureus
Pseudomonas aeruginosa
Staphylococcus epidermis
Propionibacterium acnes

Correct Answer: Streptococcus pneumoniae

Explanation:

Question 27:

Options:

Continued activity restrictions for 6 more months or until asymptomatic
An aggressive physical therapy program that includes closed chain quadriceps strengthening
Arthroscopic drilling of the subchondral bone
Open debridement and screw fixation
Osteochondral autograft transplant procedure

Correct Answer: Arthroscopic drilling of the subchondral bone

Explanation:

Question 28:

In hybrid arthroplasty, the use of a polymethylmethacrylate (PMMA) precoated femoral component has been shown to result in

Options:

increased survivorship compared with nonprecoated stems.
increased bonding of the stem to the cement mantle.
a reduced rate of wear compared with nonprecoated stems.
a reduced rate of revision compared with nonprecoated stems.
a reduced rate of postoperative infection.

Correct Answer: increased bonding of the stem to the cement mantle.

Explanation:

Question 29:

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Options:

a renal ultrasound.
an echocardiogram.
an electromyogram.
an MRI scan of the spine.
an iliac crest biopsy.

Correct Answer: an echocardiogram.

Explanation:

Question 30:

Options:

Central band ligament
Accessory band ligament
Annular ligament
Dorsal oblique accessory cord ligament
Distal oblique bundle ligament

Correct Answer: Central band ligament

Explanation:

Question 31:

What is the most common indication for revision following unconstrained elbow arthroplasty?

Options:

Polyethylene wear
Loosening of the humeral component
Loosening of the ulnar component
Instability
Component failure

Correct Answer: Instability

Explanation:

Question 32:

The peroneus tertius is a commonly used landmark for arthroscopic portal placement. What is the function of this tendon?

Options:

Dorsiflexion
Eversion
Dorsiflexion and eversion
Fifth toe extension
Lesser toe extension

Correct Answer: Dorsiflexion and eversion

Explanation:

DISCUSSION: The peroneus tertius, although absent in 10% of the population, originates on the distal third of the extensor surface of the fibula and inserts onto the base of the fifth metatarsal, possibly extending to the fascia over the fourth interosseous space. The muscle is located in the anterior compartment of the leg and is innervated by the deep peroneal nerve. The tendon produces dorsiflexion and eversion when walking and can be used as an insertion point during tendon transfers to assist dorsiflexion. This tendon is peculiar to humans and is a proximally migrated deep extensor of the fifth toe.
REFERENCES: Joshi SD, Joshi SS, Athavale SA: Morphology of the peroneus tertius muscle.
Clin Anat 2006;19:611-614.
Williams PL, Bannister LH, Berry MM, et al (eds): Gray’s Anatomy, ed 38. London, Churchill Livingston, 1995, p 883.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 21.

Question 33:

Options:

tuberosity and rotator cuff repair with bone graft.
revision arthroplasty leaving the prosthesis proud to increase humeral length and muscle tension.
revision total shoulder arthroplasty to neutralize eccentric glenoid wear.
revision of the humeral head replacement alone with increased retroversion.
additional therapy to include internal and external rotation strengthening of the rotator cuff.

Correct Answer: tuberosity and rotator cuff repair with bone graft.

Explanation:

Question 34:

Options:

Chairback brace
Thoracolumbosacral orthosis (TLSO) molded in extension
Posterior stabilization of the fracture with segmental fixation and iliac crest bone grafting
Anterior corpectomy, strut grafting, and plating
Combined anterior corpectomy, structural grafting and plating, and posterior stabilization and fusion

Correct Answer: Thoracolumbosacral orthosis (TLSO) molded in extension

Explanation:

Question 35:

Options:

Physical therapy
Epidural steroid injection
High-dose intravenous steroid
Posterior cervical foraminotomy
Anterior cervical discectomy and fusion

Correct Answer: Physical therapy

Question 36:

Figures 3a and 3b show the MRI scans of a patient with neck pain. What is the most likely diagnosis?

Options:

Neurofibromatosis
Multiple sclerosis
Cervical spondylotic myelopathy
Acute poliomyelitis
Gaucher’s disease

Correct Answer: Neurofibromatosis

Explanation:

Question 37:

Options:

Informed consent
Patient autonomy
Fiduciary responsibility
Physician paternalism
Justice

Correct Answer: Informed consent

Explanation:

Question 38:

What mechanism of injury is most likely to cause a fracture of the anteromedial facet of the coronoid?

Options:

Extension and axial load
Varus and posteromedial rotation
Valgus and posteromedial rotation
Varus and posterolateral rotation
Valgus and posterolateral rotation

Correct Answer: Extension and axial load

Explanation:

The mechanism of injury in a fracture of the anteromedial facet of the coronoid is typically a varus and posteromedial rotation force on the forearm which is the opposite of a terrible triad injury. First, the lateral collateral ligament is injured and then the medial coronoid is compressed against and then under the medial trochlea.
(SBQ12TR.86) Figure A shows intraoperative radiographs of a 45-year-old patient with a left elbow injury. What would be the next most appropriate step in this patients care?
Early range of motion
Hinged elbow brace for 4 weeks
Repair lateral collateral ligament
Remove and upsize implant
Remove and downsize implant
The intraoperative images are consistent with overstuffing of the ulnohumeral joint during a radial head replacement. The most appropriate next step would be removing and downsizing the implant.
Overstuffing the radiohumeral joint by >2.5 mm can significantly alter elbow kinematics. It has also shown to lead to pain and early joint disease. The most sensitive method to assess for overstuffing of the joint is by direct visualisation intraoperatively. This can be performed by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. In comparison, radiographic asymmetry of the medial ulnohumeral joint has been shown to be less sensitive. Radiographic findings of incongruity of ulnohumeral joint only occurs when significant overlengthening of the radius occurs.
Frank et al. examined the effect of radial head thickness in seven cadaver specimens. They found that incongruity of the medial ulnohumeral joint would only become apparent radiographically after overlengthening of the radius by >or=6 mm.
Doornberg et al. examined seventeen computed tomography scans of the elbow to investigate the height of the radial head relative to the lateral edge and central ridge of the coronoid process. They found that the radial head was on average only 0.9 mm more proximal than the lateral edge of the coronoid process.
Figure A shows intraoperative radiographs of a patient that has undergone a radial head arthroplasty. There is significant widening of the medial ulnohumeral joint on an AP radiograph as well as widening of the ulnohumeral joint on the lateral radiograph,
Incorrect Answers:

Question 39:

A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication,

Options:

Anterior and superior acromioclavicular joint ligaments
Posterior and superior acromioclavicular joint ligaments
Conoid ligament
Trapezoid ligament

Correct Answer: Posterior and superior acromioclavicular joint ligaments

Explanation:

Question 40:

In long-term follow-up studies of cemented total knee arthroplasty (TKA), the lowest rates of osteolysis have been associated with which design feature?

Options:

Metal-backed patellar components
Modular cruciate-retaining tibial inserts
Modular cruciate-substituting tibial inserts
Monolithic tibial trays

Correct Answer: Monolithic tibial trays

Explanation:

Question 41:

A 4-month-old infant is unable to flex her elbow as a result of an obstetrical brachial plexus palsy. This most likely illustrates a predominate injury to what structure? Review Topic

Options:

C4
Upper trunk
Posterior cord
Lateral cord
Musculocutaneous nerve

Correct Answer: Upper trunk

Explanation:

Question 42:

Options:

Rupture of the biceps femoris at the myotendinous junction
Rupture of the biceps femoris muscle belly
Avulsion of the common hamstring origin from the ischium
Complete rupture of the semimembranosus muscle belly
Complete tear of all hamstring muscles

Correct Answer: Rupture of the biceps femoris at the myotendinous junction

Explanation:

Question 43:

Options:

indomethacin for 3 months.
C-reactive protein and a sed rate.
MRI scan.
bone scan.
follow-up radiograph in 3 months.

Correct Answer: C-reactive protein and a sed rate.

Explanation:

Question 44:

Options:

Continued observation
Open reduction and internal fixation of the fracture
Excision of the hook of the hamate
Carpal tunnel release
Guyon’s canal release

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 45:

Options:

Hypertrophied subscapular muscle
Rotator cuff tear
Posterior glenohumeral subluxation
Increased bone density
Supraspinatus nerve compression

Correct Answer: Rotator cuff tear

Explanation:

Question 46:

Options:

Peroneal longus tendon
Peroneal brevis tendon
Superior peroneal retinaculum
Anterior talofibular ligament
Calcaneofibular ligament

Correct Answer: Superior peroneal retinaculum

Explanation:

DISCUSSION: The symptoms and MRI scan indicate dislocated peroneal tendons. In this patient, the structure that needs to be repaired is the superior peroneal retinaculum. If the popping was coming from a torn peroneal tendon, repair would involve the peroneal longus or brevis tendon, but this is not shown in the MRI scan. The anterior talofibular ligament or the calcaneofibular ligament would need to be repaired if the patient had ankle instability due to an ankle sprain.
REFERENCES: Jones DC: Tendon disorders of the foot and ankle. J Am Acad Orthop Surg 1993;1:87-94.
Timins ME: MR imaging of the foot and ankle. Foot Ankle Clin 2000;5:83-101.

Question 47:

Options:

Stop all his opioids 5 days before surgery, and place the patient on a morphine pain control pump postoperatively with a basal rate.
Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.
Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.
Avoid using narcotics in the perioperative period to prevent overdose, and use acetaminophen only for pain control.

Correct Answer: Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.

Explanation:

Question 48:

Options:

Hip spica cast placement
Acetabular revision arthroplasty
Resection arthroplasty
Femoral head revision to a 28-mm diameter, +10-mm length head

Correct Answer: Acetabular revision arthroplasty

Explanation:

Question 49:

Options:

arthroscopic synovectomy.
humeral arthroplasty.
unconstrained total shoulder arthroplasty.
constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.
glenohumeral arthrodesis.

Correct Answer: unconstrained total shoulder arthroplasty.

Explanation:

Question 50:

Figure 26 shows the radiograph of an otherwise healthy Caucasian 5-year-old boy who has a painless limp. What is the best treatment option?

Options:

Shelf procedure
Salter osteotomy
Chiari osteotomy
Varus derotation osteotomy
Physical therapy and range-of-motion exercises

Correct Answer: Physical therapy and range-of-motion exercises

Explanation:

DISCUSSION: The prognosis of Legg-Perthes disease in children younger than age 6 years is good. There is no indication that surgical treatment will improve the outcome. Range-of-motion exercises to prevent contracture may be helpful.
REFERENCES: Herring JA, Kim HT, Browne R: Legg-Calve-Perthes disease: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am 2004;86:2121-2134.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 691-704.

Question 51:

Options:

Type I acromion
Type III acromion
Meso os acromiale
Meta os acromiale
Pre os acromiale

Correct Answer: Meso os acromiale

Explanation:

The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.

Question 52:

Options:

Subtalar fusion
Neuroplasty of the superficial peroneal nerve
Neuroplasty of the sural nerve and implant removal
Excision and burial of the sural nerve in deep muscle or vein
Electromyography/nerve conduction velocity studies to evaluate local nerve entrapment versus radiculopathy

Correct Answer: Excision and burial of the sural nerve in deep muscle or vein

Explanation:

Question 53:

Pedicle subtraction osteotomies (PSO) are commonly performed in the lumbar spine to treat sagittal imbalance. What is the most common complication following a PSO in the lumbar spine? Review Topic

Options:

Pseudarthrosis
Nerve root injury
Spinal cord injury
Aortic injury
Dural tear

Correct Answer: Pseudarthrosis

Explanation:

Question 54:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 55:

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Options:

Kyphosis
Ankle instability
Protrusio acetabula
Progressive scoliosis
Pseudarthrosis of the tibia

Correct Answer: Progressive scoliosis

Explanation:

Question 56:

Following an acute dislocation of the patella, the risk of a recurrent dislocation is greater if the patient has which of the following findings?

Options:

Bipartite patella
Age greater than 15 years at the time of the initial dislocation
Persistent atrophy of the vastus lateralis
Low-lying position of the patella (patella baja)
Passive lateral hypermobility of the unaffected knee

Correct Answer: Passive lateral hypermobility of the unaffected knee

Explanation:

Question 57:

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

Options:

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

Correct Answer: factor VIII deficiency.

Explanation:

Question 58:

Options:

Anterior labral repair
Anterior labral repair and remplissage
Posterior labral repair and rotator interval closure
Anterior and posterior labral repair

Correct Answer: Anterior and posterior labral repair

Explanation:

Question 59:

-Which treatment approach for acetabular fractures carries the highest risk for heterotopic ossification?

Options:

Ilioinguinal
Watson-Jones
Extended iliofemoral
Extended ilioinguinal
Modified Rives-Stoppa

Correct Answer: Extended iliofemoral

Question 60:

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Options:

Radiotherapy alone
Intralesional curettage
Intralesional curettage with adjuvants
Wide surgical resection and radiotherapy
Neoadjuvant chemotherapy and wide resection

Correct Answer: Intralesional curettage with adjuvants

Question 61:

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

Options:

Type IIIB intra-articular distal tibia fracture
Type IIIB segmental midshaft tibia fracture
Type IIIB transverse midshaft tibia fracture
Type IIIB Schatzker I proximal tibia fracture
Type IIIB Schatzker IV proximal tibia fracture

Correct Answer: Type IIIB intra-articular distal tibia fracture

Explanation:

Question 62:

A cartilage water content increase is the hallmark of which osteoarthritis stage?

Options:

Prearthritis
Early
Late
Terminal

Correct Answer: Early

Explanation:

Question 63:

Options:

fragmentation, realignment, and intramedullary nailing of the tibia.
resection of the dysplastic region of the tibia and insertion of a vascularized fibula.
supplemental vitamin D and phosphate.
a clamshell orthosis.
observation for spontaneous remodeling.

Correct Answer: a clamshell orthosis.

Explanation:

Question 64:

Options:

Myelography
Thermography
CT Scan
IV contrast-enhanced CT Scan
Gadolinium-enhanced MRI scan

Correct Answer: Gadolinium-enhanced MRI scan

Explanation:

Question 65:

Options:

Open tibial apophysis
Medial patellar cartilage defect
Femoral trochlear sulcus angle = 165°
Tibial tubercle-trochlear groove distance = 25mm
Patella tilt = 25°

Correct Answer: Open tibial apophysis

Explanation:

Question 66:

Which of the following conditions is typically associated with the ankle deformity shown in figure 14?

Options:

Genu varum
Tarsal coalition
Degenerative ankle arthrosis
Osteochondritis dissecans of the talus
Hemihypertrophy of the ipsilateral lower extremity

Correct Answer: Tarsal coalition

Explanation:

Question 67:

Options:

Vitamin D
Calcium supplement
Methotrexate
Nonsteroidal antiinflammatory drugs (NSAIDs)
Bisphosphonate therapy

Correct Answer: Bisphosphonate therapy

Explanation:

Question 68:

A patient undergoes hip arthroscopy, and the pathology is seen in Figure 18. What is the most likely diagnosis?

Options:

Femoral head articular defect
Acetabular articular defect
Haversian fat pad hypertrophy
Labral tear
Loose body

Correct Answer: Labral tear

Explanation:

Question 69:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

Question 70:

Options:

Accept the offer because it would allow the physician to have a boat and enjoy a hobby of sailing with a minimal financial outlay.
Accept this offer because it would have nothing to do with the orthopaedic practice and because the physician feels strongly that it would have no influence on practice decisions.
Reject the offer because it represents an unacceptable conflict of interest.
Accept the offer but disclose the relationship to patients when using the representative’s products.
Accept the offer but only with a equal interest arrangement in the purchase and use of the boat

Correct Answer: Reject the offer because it represents an unacceptable conflict of interest.

Explanation:

Question 71:

Options:

local modalities including iontophoresis.
quadriceps and iliotibial band stretching exercises.
progressive eccentric strengthening exercises.
a patellar tendon strap.
excision of the abnormal area.

Correct Answer: excision of the abnormal area.

Explanation:

Question 72:

Options:

Midsubstance tear of the lateral ulnar collateral ligament
Proximal avulsion of the ulnar collateral ligament
Proximal avulsion of the lateral ulnar collateral ligament
Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

Correct Answer: Proximal avulsion of the lateral ulnar collateral ligament

Explanation:

Question 73:

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with Review Topic

Options:

anterior superior escape.
rheumatoid arthritis.
an acromial stress fracture.
a centered head and an external rotation lag sign of 50 degrees.
active forward elevation of 130 degrees.

Correct Answer: anterior superior escape.

Explanation:

Question 74:

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

Options:

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

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

Explanation:

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

Question 75:

Figures 21a and 21b show the radiograph and CT scan of a 14-year-old patient with thigh pain. The next most appropriate step in management should consist of

Options:

blood cultures.
oral anti-inflammatory drugs.
a biopsy.
MRI.
a SPECT bone scan.

Correct Answer: oral anti-inflammatory drugs.

Explanation:

Question 76:

Options:

UCL repair and nighttime elbow extension splinting
UCL repair with ulnar nerve decompression in situ
Allograft UCL reconstruction with interference screws
Autograft UCL reconstruction with ulnar nerve transposition
Autograft UCL reconstruction using a docking technique

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

DISCUSSION: High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Ciccotti MG, Jobe FW: Medial collateral ligament instability and ulnar neuritis in the athlete’s elbow. Instr Course Lect 1999;48:383-391.

Question 77:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 78:

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

Options:

Lateral Y
Scapular AP
Neutral rotation AP
Internal rotation AP
External rotation AP

Correct Answer: Internal rotation AP

Explanation:

Question 79:

What assay most directly assesses gene expression at the posttranslational level?

Options:

Real-time polymerase chain reaction (PCR)
Standard PCR
Northern blot
Western blot
Microarray expression profile analysis

Correct Answer: Western blot

Explanation:

Question 80:

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Options:

the size of the tumor.
the grade of the tumor.
the site of the tumor.
the surgical margin.
radiation therapy.

Correct Answer: the surgical margin.

Explanation:

Question 81:

Options:

Case series
Meta-analysis
Case control study
Retrospective cohort study
Prospective cohort study

Correct Answer: Case control study

Explanation:

Question 82:

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Options:

directly posterior to the posterior cruciate ligament (PCL).
posteromedial to the PCL.
posterolateral to the PCL.
in the posteromedial corner of the knee.

Correct Answer: posterolateral to the PCL.

Explanation:

Question 83:

Which of the following best describes the course of the median nerve at the elbow?

Options:

Crosses superficial to the ulnar artery, deep to the fibrous arch of the superficialis muscle, deep to the superficial head of the pronator teres muscle
Crosses superficial to the ulnar artery, deep to the fibrous arch of the superficialis muscle, superficial to the superficial head of the pronator teres muscle
Crosses deep to the ulnar artery, deep to the fibrous arch of the superficialis muscle, deep to the superficial head of the pronator teres muscle
Crosses deep to the ulnar artery, deep to the fibrous arch of the superficialis muscle, superficial to the superficial head of the pronator teres muscle
Crosses deep to the ulnar artery, superficial to the fibrous arch of the superficialis muscle, superficial to the superficial head of the pronator teres muscle

Correct Answer: Crosses superficial to the ulnar artery, deep to the fibrous arch of the superficialis muscle, deep to the superficial head of the pronator teres muscle

Explanation:

Question 84:

All of the following indicators of resuscitation may be within normal limits for a trauma patient that is in "compensated" shock EXCEPT:

Options:

Systolic blood pressure
Urine output
Heart rate
Serum lactate
Mean arterial pressure

Correct Answer: Systolic blood pressure

Explanation:

Question 85:

Options:

aspiration and steroid injection.
rest.
acromioplasty.
arthroscopic repair and decompression.
rehabilitation.

Correct Answer: arthroscopic repair and decompression.

Explanation:

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T
1
-weighted MRI scans and with high signal intensity on T
2
-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 86:

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Options:

Upper extremity
Lower extremity
Pelvis and buttock
Retroperitoneum
Spine

Correct Answer: Upper extremity

Explanation:

Question 87:

- In a fatigue test, the maximum stress under which the material will not fail, regardless of how many loading cycles are applied, is defined as

Options:

Endurance limit
Failure stress
Critical stress
Yield stress
Elastic limit

Correct Answer: Endurance limit

Explanation:

Question 88:

Options:

filling the tibial defect with methylmethacrylate.
revision of the tibial component with porous metal augmentation.
reconstruction with iliac crest bone graft.
reconstruction with structural allograft.

Correct Answer: revision of the tibial component with porous metal augmentation.

Explanation:

DISCUSSION
Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 89:

In the treatment of thoracic disk herniations, what approach is associated with the highest risk of iatrogenic paraplegia?

Options:

Laminectomy
Costotransversectomy
Transpedicular
Transthoracic
Thoracoscopic

Correct Answer: Laminectomy

Explanation:

Question 90:

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Options:

Open reduction and internal fixation with a mini fragment plate and screws
Closed cannulated screw fixation
Short leg casting for 6 weeks
Hard-soled shoe and weight bearing as tolerated
Short leg cast and non-weight-bearing, followed by weight bearing as tolerated for 6 weeks in a fracture brace

Correct Answer: Hard-soled shoe and weight bearing as tolerated

Explanation:

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 91:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads?

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

DISCUSSION: The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.
REFERENCE: Rhee JM, Schaufele M, Abdu WA: Radiculopathy and the herniated lumbar disc: Controversies regarding pathophysiology and management. J Bone Joint Surg Am 2006;88:2070-2080.

Question 92:

Options:

Pelvic tilt
Pelvic incidence
Sacral slope
Acetabular version
Femoral version

Correct Answer: Pelvic incidence

Explanation:

Question 93:

Options:

Emergent exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30% and sequential neurovascular examinations
Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve
Transfusion to raise the hematocrit to 30%, continued administration of enoxaparin, and sequential neurovascular examinations
Placement of a temporary vena cava filter and exploration of the sciatic nerve

Correct Answer: Placement of a vena cava filter, halt anticoagulation, blood transfusion, and exploration of the sciatic nerve

Explanation:

Question 94:

In a retroperitoneal approach to the lumbar spine, what structure runs along the medial aspect of the psoas and along the lateral border of the spine?

Options:

Ilioinguinal nerve
Genitofemoral nerve
Sympathetic trunk
Ureter
Aorta

Correct Answer: Sympathetic trunk

Explanation:

Question 95:

Options:

Increased external rotation with an associated decrease in internal rotation
Excessive pitch counts
Use of breaking pitches such as sliders and curve balls
Congenital humeral cyst

Correct Answer: Excessive pitch counts

Explanation:

Question 96:

Options:

Elbow extension
Forearm supination
Wrist extension in radial deviation
Middle finger MCP extension
Index finger MCP hyperextension

Correct Answer: Elbow extension

Explanation:

Question 97:

Which of the following ligaments is most commonly involved in posterolateral rotatory instability of the elbow?

Options:

Annular
Lateral ulnar collateral
Anterior band of the medial collateral
Radial part of the lateral collateral
Posterior capsular

Correct Answer: Lateral ulnar collateral

Explanation:

Question 98:

A deficiency of which of the following is associated with an increased risk of venous thromboembolism?

Options:

Fibrinogen
Protein S
Factor VII
Factor VIII
Prothrombin

Correct Answer: Protein S

Explanation:

Question 99:

Options:

increased laxity.
increased risk for graft failure.
no differences in long-term results.
lower Knee Injury and Osteoarthritis Outcome Score (KOOS).

Correct Answer: no differences in long-term results.

Explanation:

Question 100:

Options:

insertion of a thicker cement mantle and a thicker patellar insert to achieve a total patellar thickness of 24 mm.
a lateral release after inserting a standard patella.
a distal femoral augmentation to maximize the moment-arm on a standard patellar insert.
leaving the patella alone and performing a lateral release, if necessary, for proper patellar tracking.
an oversized femoral component to improve the moment-arm on a standard patellar insert.

Correct Answer: leaving the patella alone and performing a lateral release, if necessary, for proper patellar tracking.

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

Orthopedic Surgery Board Review MCQs: Spine, Trauma, & Knee | Part 233

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 233

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index