Orthopedic Board Review MCQs: Ligament, Nerve & Spine

About This Board Review Set

This is Part 239 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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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 239

This module focuses heavily on: Ligament, Nerve.

Sample Questions from This Set

Sample Question 1: The findings in Brown-Sequard syndrome include loss of which of the following? Review Topic...

Sample Question 2: preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy....

Sample Question 3: Which of the following structures is most vulnerable during a medial sesamoidectomy of the hallux?...

Sample Question 4: -Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision.Examination reveals normal strength and sensation in both upper and lower extremit...

Sample Question 5: What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?...

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

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

Explanation

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

Question 2

preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

Explanation

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?
Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space CORRECT ANSWER: 5
Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?
Medial antebrachial cutaneous
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous
Medial brachial cutaneous
Dorsal antebrachial cutaneous
Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure

Question 3

Which of the following structures is most vulnerable during a medial sesamoidectomy of the hallux?

Explanation

DISCUSSION: The plantar-medial cutaneous nerve is at risk with the surgical approach to the medial sesamoid. It is found directly underlying an incision made at the junction of the glabrous skin of the hallux and must be identified before the approach can proceed. Transection will result in a painful neuroma that impinges on the plantar-medial surface of the toe and cause problems with shoe wear. The only other structure that lies near the surgical field is the abductor hallucis tendon which lies dorsal to the incision.
REFERENCE: Sarrafian SK: Anatomy of the Foot and Ankle, Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, p 377.

Question 4

-Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision. Examination reveals normal strength and sensation in both upper and lower extremities, normal rectal tone, and no other injuries. The C1-C2 lateral mass overhang measures 8.5 mm. What is the most appropriate treatment option?

Explanation

Question 5

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Explanation

DISCUSSION: The spinal nerves primarily responsible for bladder function are the S2, S3, and S4 nerve roots. With significant compression of the cauda equina by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976, p 254.
Pick TP, Howden R (edS): Gray’s Anatomy. New York, NY, Bounty Books, 1977, p 1004.

Question 6

03 A 23 year old sustains an isolated right knee dislocation in an MVA. A closed reduction is performed and confirmed with radiographs. What is the next appropriate study?

Explanation

This is simple A, B, Cs and doctoring. History and Physical exam come first. Noninvasive assessement includes visual inspection, clinical examination (feel pulses, check capillary refill, feel temperature of skin), and ABIs. X-ray, CT, and MRI would be good secondary studies to identify bony or soft tissue injuries—after initial reduction and splinting/stabilizatoin. Angiography would be indicated if there were asymmetric pulses or an ABI < 0.9, or if there was any other indication that a vessel injury may have occurred.
OKU Truama 2 says “the use of ABI with the blood pressure cuff and Doppler evaluation of the distal circulation has been proposed as effective in determining any occult vascular injury. A ratio > 0.9indicates a normal study.”[1] The referenced article confirms this. “Confirmation of the safety and accuracy of physical exam in the evaluation of knee dislocation for injury of the popliteal artery.” J. Trauma2002; 52: 247-252
back to this question next question
[1] OKU Trauma 2 pg 151-153

Question 7

Figure below depicts the radiograph obtained from a 52-year-old woman who has leg-length inequality and chronic, activity-related buttock discomfort. This problem has been lifelong, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

DISCUSSION:
A high hip center is not recommended for Crowe type IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step versus oblique cut, or strut grafts.

Question 8

During total knee arthroplasty using a posterior cruciate-retaining design, excessive tightness in flexion is noted, while the extension gap is felt to be balanced. Which of the following actions will effectively balance the knee?

Explanation

DISCUSSION: Excessive flexion gap tightness can be addressed with a variety of techniques; including: (a) recess and release the posterior cruciate ligament; (b) resect a posterior slope in the tibia; (c) avoid an oversized femoral component that moves the posterior condyles more distally; (d) resect more posterior femoral condyle and use a smaller femoral component placed more anteriorly; and (e) release the tight posterior capsule and balance the collateral ligaments.
REFERENCE: Ayers DC, Dennis DA, Johanson NA, Pelligrini VD: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.

Question 9

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

Explanation

DISCUSSION
Autologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.
RECOMMENDED READINGS
Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005 May-Jun;13(3):152-8. Review. PubMed PMID: 15938604. View Abstract at PubMed
Mitchell ME, Giza E, Sullivan MR. Cartilage transplantation techniques for talar cartilage lesions. J Am Acad Orthop Surg. 2009 Jul;17(7):407-14. Review. PubMed PMID: 19571296. View Abstract at PubMed
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Review. PubMed PMID: 23780543. View Abstract at PubMed

Question 10

What is the most common cause of rotator cuff injury in high school athletes?

Explanation

DISCUSSION: A large number of etiologies of rotator cuff injury have been proposed. Both intrinsic and extrinsic mechanisms have been suggested. In the young athlete the common underlying mechanism is overuse. Contributing factors include increased laxity, anatomic variation in the coracoacromial arch, and altered kinematics.
REFERENCES: Wilkins KE: Shoulder injuries: Epidemiology, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 175-182.
Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannnotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 3-30.

Question 11

Figures A and B show the six-month follow-up radiographs of a 62-year-old woman who sustained a hip fracture in a fall. Prior to the fall, the patient was active and had no difficulty with ambulation. The patient underwent open reduction and internal fixation with a sliding hip screw device. She has difficulty with ambulation, continues to walk with a walker, and reports startup pain. What is the most appropriate management at this time? Review Topic

Explanation

The radiographs demonstrate a healed fracture with penetration of the screw through the femoral head into the acetabulum as well as osteonecrosis and collapse of the femoral head (Figure 129b). Conversion to total hip arthroplasty with a long stem is necessary to bypass the femoral cortical defects from the screw holes. A primary tapered stem is not appropriate because of the proximal femoral deformity and the stress risers associated with the screw holes. Removal of hardware, valgus osteotomy, and revision of the internal fixation are not appropriate in the presence of the femoral head collapse and acetabular penetration.

Question 12

Figures 42a and 42b shows the radiographs of a 20-year-old man who sustained a hyperextension injury to his little finger. Multiple attempts at closed reduction have been unsuccessful. Management should now consist of

Explanation

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,

pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 13

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

Explanation

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

Question 14

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Explanation

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.

If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 15

An 11-year-old boy with bipolar disorder fell from a tree and sustained an open fracture dislocation of the right ankle with extensive abrasions of the leg. Immediate irrigation, debridement, reduction, and provisional fixation with Kirschner wires was performed. Twenty-four hours later, the patient’s blood pressure is 190/100 mm Hg and pulse rate is 120. He has required only 1 dose of an oral analgesic for pain control. His foot and ankle are markedly swollen, but there is no pain on passive extension of the toes. The dorsalis pedis pulse cannot be palpated. What is the most appropriate next treatment step? Review Topic

Explanation

In situ pinning of right hip
Protected weight bearing and MRI of right hip
Immediate endocrine referral and treatment
Open biopsy right hip
In situ pinning bilateral hips PREFERRED RESPONSE 5
In patients with slipped capital femoral epiphysis (SCFE) and concomitant endocrinopathy, bilateral pinning is the recommended treatment.
This patient's laboratory values reveal hypothyroidism, which increases the risk of bilateral involvement. Thus, the most appropriate treatment recommendation is surgical fixation of both hips.
Wells et al. analyzed 131 SCFEs over a 30-year period. The authors noted that 100% of patients with associated endocrinopathy went onto contralateral slip and recommended not only prophylactic pinning, but in those with open triradiate cartilage, recommended preventative screening with TSH/Free T4 laboratory studies.
Riad et al. followed 90 patients and analyzed impact of age, gender and race on contralateral slip development. Girls under the age of 10 and boys under the age of 12 had a significantly increased risk of contralateral involvement. Therefore, the authors recommended contralateral pinning for girls and boys that met those age criteria, respectively.
Figure A exhibits a right SCFE on bilateral frog lateral views. Incorrect Answers:

Question 16

During the revision surgical procedure, thoracic pedicle screws are placed. Following placement, triggered electromyography (EMG) is performed by stimulating the pedicle screw heads. During testing the right T2 pedicle screw head returns a threshold of 2 mA. What does this reading indicate?

Explanation

DISCUSSION
This patient has developed a proximal junctional kyphosis following a long posterior fusion performed for treatment of degenerative lumbar scoliosis. Risk factors for proximal junctional kyphosis in the setting of instrumented fusions performed for degenerative scoliosis include advanced age, 360-
degree fusions, extension of fusion constructs to the sacrum, and upper instrumented vertebrae at the level of T1-3. The patient's junctional kyphosis is attributable to failure of the disk and ligamentous structures at T2-3 and would be graded as type I using the classification system of Yagi and associates. Most symptomatic proximal junctional kyphoses are treated with posterior extension of the fusion construct to a more proximal level spanning the kyphosed region. The use of orthoses or simple removal of instrumentation is unlikely to substantively impact symptoms or address the proximal kyphosis. Diabetes and obesity are known factors that increase risk for postsurgical infection following a spine fusion procedure. The most frequent complication following revision surgery for proximal junctional kyphosis, however, is the need for further surgery. In the study by Yagi and associates, 48% of patients who underwent revision surgery for proximal kyphosis developed further adjacent segment degeneration. In the proximal thoracic spine, where the pedicle may be narrow, triggered EMG testing of inserted pedicle screws may be used to assess for violation of the pedicle wall during insertion. In the setting of triggered EMG, thresholds exceeding 10 mA indicate a well-placed pedicle screw. Thresholds lower than 4 mA to 6 mA indicate that a screw is directly contacting a neural structure. Thresholds between 9 mA and 10 mA suggest that a breach of the pedicle may be present, but the screw is not contacting a neural structure.
RECOMMENDED READINGS
Yagi M, Rahm M, Gaines R, Maziad A, Ross T, Kim HJ, Kebaish K, Boachie-Adjei O; Complex Spine Study Group. Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity.Spine (Phila Pa 1976). 2014 May 1;39(10):E607-14. doi: 10.1097/BRS.0000000000000266. PubMed PMID: 24525992. View
Abstract at PubMed
Cammarata M, Aubin CÉ, Wang X, Mac-Thiong JM. Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976). 2014 Apr 15;39(8):E500-7. doi: 10.1097/BRS.0000000000000222. PubMed
PMID: 24480964. View Abstract at PubMed
Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012 Oct 15;37(22 Suppl):S144-64. doi: 10.1097/BRS.0b013e31826d611b. PubMed PMID: 22885829. View Abstract at PubMed Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 17

What measure of physiologic status best evaluates whether an injured patient is fully resuscitated and best predicts that perioperative complications will be minimized following definitive stabilization of long bone fractures?

Explanation

DISCUSSION: Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries. Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L. The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion. The other markers may be an indication of current physiology but have not been correlated with perioperative risks.
REFERENCES: Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma. J Trauma 1999;47:964-977.
Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-267.
Shulman AM: Prediction of patients who will develop prolonged occult hypoperfusion following blunt trauma. J Trauma 2004;57:725-800.

Question 18

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Explanation

The weight-bearing potential of bone is influenced by the ratio of cortical to cancellous bone. The area of the spinal anatomy that has the highest ratio is the pedicles of the thoracic spine. This is followed by the lumbar pedicles. The vertebral bodies have a lower ratio than the pedicles, with the sacrum having the very lowest ratio.

Question 19

Figures 45a and 45b show the radiographs of a 40-year-old woman with rheumatoid arthritis who is unable to straighten her ring and little fingers. Examination reveals that the fingers can be passively corrected, but she is unable to actively maintain the fingers in extension. Management should consist of

Explanation

DISCUSSION: The patient has extensor tendon ruptures at the level of the wrist that are the result of synovitis at the distal radioulnar joint (Vaughn-Jackson syndrome). Extensor indius proprius transfer appropriately matches strength and excursion of the ruptured extensor digiti quinti and extensor digitorum communis tendons. An extensor tenosynovectomy with distal radioulnar joint resection decreases the synovitis, which if left untreated may cause additional tendon ruptures. Radial head resection is used for posterior interosseous nerve compression secondary to radial head synovitis, and in this patient only two fingers are involved, which rules out this diagnosis. Dynamic splinting is not indicated for ruptured tendons. Metacarpophalangeal arthroplasties and imbrication of the sagittal bands are used for metacarpophalangeal arthritis and extensor tendon subluxation. If this was the problem, the patient should be able to maintain the fingers in extension after they are passively extended. Total wrist arthrodesis prevents the tenodesis effect, thus limiting effective tendon excursion and making the proposed transfer less effective.
REFERENCES: Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases: Tendon ruptures, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999,

pp 1669-1684.
Moore JR, Weiland AJ, Valdata L: Tendon ruptures in the rheumatoid hand: Analysis of treatment and functional results in 60 patients. J Hand Surg Am 1987;12:9-14.
Leslie BM: Rheumatoid extensor tendon ruptures. Hand Clin 1989;5:191-202.

Question 20

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most appropriate surgical plan?

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability
and degenerative joint disease.

Question 21

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 22

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 23

Examination of a 12-year-old girl with a painful flatfoot deformity reveals tenderness in the region of the sinus tarsi and no appreciable subtalar motion. Radiographs are shown in Figures 48a through 48c. Two attempts to relieve her symptoms by cast immobilization fail to relieve the pain. Management should now consist of

Explanation

DISCUSSION: Surgical treatment is indicated for a symptomatic tarsal coalition that has failed to respond to nonsurgical management. In this patient, the radiographs reveal a calcaneonavicular coalition and no degenerative changes. The patient is symptomatic, and two attempts at use of a short leg walking cast have failed to provide relief. For calcaneonavicular coalitions, good results have been reported following resection and interposition of the extensor digitorum brevis. A retrospective study of this procedure achieved good to excellent results in 58 of 75 feet (77%). Degenerative arthritis or persistent pain following resection of a coalition is a reasonable indication for a triple arthodesis. A medial closing wedge osteotomy of the calcaneus may be indicated for a rigid flatfoot with severe valgus deformity. There are no studies documenting the long-term effectiveness of a manipulation under general anesthesia for this condition.
REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interpostion of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 211-218.

Question 24

A positive straight leg raising sign is when pain radiates distal to the knee when the affected leg is passively elevated. The increased tension generally occurs between Review Topic

Explanation

A positive straight leg raising sign causes pain radiating distal to the knee when the nerve is under tension. This increased tension generally occurs between 30 degrees and 70 degrees of passive elevation.

Question 25

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

Explanation

DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,

pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.

Question 26

Compared to postoperative radiation therapy, preoperative radiation therapy has a higher rate of what complication?

Explanation

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 27

Figure 74 shows the radiograph of an 84-year-old woman who reports severe right knee pain. At the time of total knee arthroplasty, she is found to have gross insufficiency and attenuation of the medial collateral ligament (MCL) complex. Optimal management should consist of

Explanation

DISCUSSION: Patients with severe valgus deformity may have near complete attenuation of the MCL. Attempts at ligament repair or reconstruction at the time of TKA can have unpredictable outcomes, leading to an unstable TKA. Although there may be a role for trying to reconstruct the ligament in conjunction with a nonconstrained implant in young patients with long life expectancies, in elderly patients a constrained prosthesis can provide varus-valgus stability with a predictable outcome. In younger patients, there is concern that the extra prosthetic constraint may shorten the longevity of the prosthetic fixation. In older patients, the constrained implant is likely to last a lifetime, with several studies documenting excellent survivorship (96%) at 10 years. Complete release of the LCL will leave the knee grossly unstable medially and laterally, and could necessitate a hinged prosthesis.
REFERENCES: Lachiewicz PF, Soileau ES: Ten-year survival and clinical results of constrained components in primary total knee arthroplasty. J Arthroplasty 2006;21:803-808.
Anderson JA, Baldini A, MacDonald JH, et al: Primary constrained condylar knee arthroplasty without stem extensions for the valgus knee. Clin Orthop Relat Res 2006;442:199-203.

Question 28

An 82-year-old osteoporotic woman undergoes total hip arthroplasty for osteoarthritis. During implant trialing, a crack is heard. Intraoperative fluoroscopy reveals a long, spiral fracture of the distal femur. The fracture is reduced and fixed with an anatomic locking plate. The rest of the total hip arthroplasty proceeds uneventfully. Following surgery the surgeon has a meeting with the family and apologizes and provides full disclosure, accepts responsibility, provides a detailed explanation as to what happened, and gives reassurance that steps will be taken to prevent recurrences. This communication approach will most likely

Explanation

The surgeon has provided all the elements of good communication with the patient and family. His actions will lead to improved patient satisfaction, compared to nondisclosure and attempting to push or shirk responsibility.
In the event of a medical error or adverse event, effective communication with the patient and family is necessary. Effective communication should comprise: an apology, full disclosure (an explanation of what happened), accepting responsibility, and corrective steps that will be taken to prevent recurrence.While accepting responsibility is integral to the explanation process, it is different from accepting blame.
Mazor et al. found patients would more likely change physicians and seek legal advice in situations with a life-threatening outcome where physicians chose nondisclosure. They recommend full disclosure, acceptance of responsibility, an apology, detailed explanations, and assurances that steps will be taken to prevent recurrences will result in positive outcomes in terms of patient satisfaction, trust, and emotional response.
MacDonald et al. addressed medical errors in an editorial. Besides full disclosure, they feel that an apology is necessary. This includes an acknowledgement of the event and one’s role in the event, and a genuine expression of regret. Apology laws exist to to reduce concerns about legal implications of disclosure and apology.
Incorrect Answers:

Question 29

A 20-year-old athlete sustains a 2- x 3-cm grade IV chondral injury to the right knee. After failure of nonsurgical management, which of the following procedures would ensure the highest percentage of hyaline-like cartilage?

Explanation

DISCUSSION: Autologous chondrocyte implantation was first reported by Brittberg in 1994 and has resulted in predominantly type II collagen (hyaline-like articular cartilage) in the repair tissue. The extracellular matrix in articular cartilage is made up primarily of type II collagen, proteoglycans, and water. Arthroscopic chondroplasty, microfracture, drilling, and abrasion arthroplasty all result eventually in fibrocartilage fill of the defect (predominantly type I collagen).
REFERENCES: Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895.
Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 787-804.

Question 30

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 31

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the
aspiration and proceed to a revision TKA with possible augments on standby.

Question 32

A 19-year-old college football player reports persistent weakness, tingling, and numbness of both upper extremities at half time. He states that these symptoms initially occurred after tackling an opposing player with his head early in the game. History reveals that he has had “burners” in the past that typically resolved within 15 to 30 minutes. Examination reveals pain-free cervical motion, weakness to shoulder abduction testing bilaterally, normal upper extremity reflexes, and decreased sensation over both shoulders and the upper arms. Appropriate initial management should consist of

Explanation

DISCUSSION: The player’s symptoms represent more than the mere “burner syndrome,” which leads to unilateral symptoms that typically last less than 1 minute. Return to play following a burner is allowed following nonsurgical management and once the symptoms have subsided and the player exhibits normal strength and motion of the neck and upper extremities. This player has the history, symptoms, and examination findings that are consistent with cervical neurapraxia. Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine. CT of the brain is indicated with a history of loss of consciousness or other symptoms suggestive of a concussion.
REFERENCES: Torg JS, Sennett B, Pavlov H, et al: Spear tackler’s spine: An entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. Am J Sports Med 1993;21:640-649.
Torg JS: Cervical spinal stenosis with cord neurapraxia and transient quadriplegia. Sports Med 1995;20:429-434.
Torg JS, Guille JT, Jaffe S: Injuries to the cervical spine in American football players. J Bone Joint Surg Am 2002;84:112-122.

Question 33

A 26-year-old professional rodeo bull rider sustained a grade III midshaft femoral fracture after being thrown from his bull. He underwent closed interlocking intermedullary nailing with a titanium rod, and his recovery was uneventful. Prior to returning to competition, the patient must

Explanation

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at

least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am

1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 34

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

Explanation

DISCUSSION
The clinical description and MR image point to an injury to the posterior cruciate ligament (PCL). This ligament is thought to be primarily composed of anterolateral and posteromedial bundles, with the former tightening in flexion and the latter in extension. Because of alterations in knee kinematics and increased varus alignment in PCL insufficiency, contact stresses and cartilage loads increase in the patellofemoral and medial compartments. Although good outcomes may be obtained with transtibial, open inlay, and arthroscopic inlay techniques, 1 major difference is the creation of the “killer-turn” during the transtibial approach. This sharp turn in the graft as it emerges from the tibia appears to lead to more pronounced attenuation and thinning of the graft during cyclic loading.
In Question 12, the scenario describes a patient with chronic PCL and posterolateral corner (PLC) injury, as evidenced by the varus thrust and abnormal Dial test finding. A valgus-
producing osteotomy may be effective, and, in fact, may be the only treatment necessary to address chronic PLC injury. Accordingly, an opening lateral osteotomy would not be appropriate. Of the remaining responses, an osteotomy that increases tibial slope would also address the PCL deficiency by reducing posterior tibial sag.
Vascular injury is an uncommon, but potentially devastating, complication associated with PCL surgery and may occur regardless of the technique used. Numerous strategies have been described to reduce the risk, including use of a posteromedial accessory incision to allow finger retraction of the popliteal neurovascular bundle, oscillating drills to prevent excessive soft-tissue entanglement, and tapered (rather than square) drill bits that may minimize cut-out of sharp edges as drilling reaches the posterior tibial cortex. Knee extension lessens, rather than increases, the distance between the posterior tibia and the neurovascular bundle and increases, not lessens, risk for vascular injury.

Question 35

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

Explanation

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

Question 36

A 7-year-old boy has a limp with pain and tenderness over the distal right femur. Radiographs are shown in Figures 5a and 5b. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The patient has a nonossifying fibroma, and the symptoms suggest that there is significant weakening of the cortex and/or microfracture; therefore, biopsy, curettage, and bone grafting is the treatment of choice. Based on the size of the lesion and the presence of symptoms, observation is likely to result in pathologic fracture. A biopsy will further weaken the bone unless combined with curettage and bone grafting. Radiation therapy is not used in the treatment of nonossifying fibroma and is rarely used in any benign condition affecting skeletally immature individuals. Steroid injection has been used in the treatment of unicameral bone cysts and in Langerhan’s cell histiocytosis but not for nonossifying fibroma.
REFERENCES: Dormans, JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.
Easley ME, Kneisl JS: Pathologic fractures through nonossifying fibromas: Is prophylactic treatment warranted? J Pediatr Orthop 1997;17:808-813.

Question 37

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint.
REFERENCES: Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214.
McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.
Ouzounian TJ: Metatarsophalangeal arthrodesis for salvage of failed hallux valgus surgery. Foot Ankle Clin 1997;2:741-752.

Question 38

A 13-year-old baseball pitcher presents with worsening medial-sided elbow pain. He pitches 7 months out of the year, throws 85 pitches per game and plays in two games per week. His fastball speed is approximately 75mph. He regularly plays outfield once he has been relieved of pitching. Which of the following is most likely contributing to his elbow pain? Review Topic

Explanation

Young athletes who throw greater than 80 pitches per game have an increased risk of shoulder and elbow injury. For a 13-year-old, the recommended maximum number of pitches per game is 75.
Little League elbow is a medial-sided overuse injury that occurs in the skeletally immature athlete. During execution of the baseball pitch, tremendous valgus and extension stresses occur at the elbow. Repetitive microtrauma can ultimately injure the medial epicondyle apophysis, ulnar collateral ligament or the flexor-pronator muscle mass. Limiting the number of pitches and innings played per game, as well as the number of months of competitive pitching per year, has been recommended to prevent these overuse injuries in the young athlete.
Olsen et al performed a case control study to determine risk factors associated with the development of shoulder and elbow injuries in adolescent baseball pitchers. Greater than 8 months of competitive pitching per year, more than 80 pitches per game and a fastball speed of greater than 85mph were all associated with increased risk of injury. Continued pitching despite arm fatigue and pain, being a starting pitcher, greater number of warm-up pitches, participating in showcases and regular use of NSAIDs were also associated with injury. The type of pitch (fastball, changeups and breaking balls) and continued play in a different position once being relieved was not associated with increased risk of injury.
Andrews et al authored a review article on ulnar collateral ligament injuries in throwing athletes. According to the USA Baseball Medical/Safety Advisory Committee, young baseball pitchers should avoid breaking pitches, such as curveballs and sliders, and avoid year-round baseball. A minimum of 3 months of complete rest from pitching per year is vital. Youth pitching coaches should be educated to ensure proper pitching mechanics are being reinforced.
Illustration A is a table depicting the recommended maximum number of pitches by age group.
Incorrect Answers:

Question 39

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

Explanation

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

Question 40

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

Explanation

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

Question 41

The pathophysiology of a claw toe deformity includes muscular imbalance caused by which of the following relatively strong structures?

Explanation

DISCUSSION: The dynamic forces acting to maintain the position of the proximal phalanx at the head of the metatarsal are a balance between the extensor digitorum longus and the weaker intrinsic muscles. With hyperextension at the metatarsophalangeal joint, the intrinsic muscles become less efficient as plantar flexors. Consequently, the hyperextension deformity progresses in the metatarsophalangeal joint as the opposition of the intrinsic muscles to the extensor tendon lessens. This is in contrast to the situation in the interphalangeal joints, where the stronger flexors overpower the weaker intrinsic muscles, which act as the extensors. This combination of events leads to hyperextension at the metatarsophalangeal joint and flexion deformities at the interphalangeal joints, resulting in claw toe.
REFERENCES: Mizel MS, Yodlowski ML: Disorders of the lesser metatarsophalangeal Joints.

J Am Acad Orthop Surg 1995;3:166-173.
Coughlin MJ, Mann RA: Surgery of the Foot and Ankle, ed. 7. St Louis, MO, Mosby, 1999,

pp 325-328.

Question 42

What procedure can eliminate a sulcus sign? Review Topic

Explanation

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

Question 43

A 10-year-old girl is treated for a tibia/fibula fracture with a long leg cast. The on-call resident is called to evaluate the patient for increasing pain medicine requirements and tingling in her foot. Examination of the cast reveals that the ankle has been immobilized in 10 degrees of dorsiflexion. What ankle position results in the safest compartment pressures in a casted lower leg?

Explanation

DISCUSSION: Agitation, anxiety, and increasing analgesic requirments are the "3 A's" of pediatric compartment syndrome.
Weiner et al measured intramuscular compartment pressure in the anterior and deep posterior compartments of the leg in seven healthy adults who had long leg casts placed. They found that in a casted leg the intramuscular pressure in the anterior compartment was lowest with the ankle in neutral, and the deep posterior compartments was lowest when the ankle joint was in the resting position to approximately 37 degrees of plantar flexion. Based on this, they concluded that the safest ankle casting position regarding compartment pressure is between 0 and 37 degrees of plantar flexion. After the cast was bivalved, they noted a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment. Constrictive casts and abberant ankle positioning can exacerbate pain/symptoms. Loosening of the cast by bivalving, spreading, and cutting underlying stockinette/softroll should always be the first step in management of possible compartment syndrome.

Question 44

The oblique radiograph of the foot and the CT scan shown in Figures 10a and 10b show a patient whose symptoms have failed to respond to rest and non-steroidal anti-inflammatory drugs. What is the best course of action?

Explanation

DISCUSSION: The radiograph and MRI scan show elongation and fragmentation of the os peroneum. Although casting, orthoses, and steroid injection may relieve symptoms, excision of the os peroneum and primary repair when necessary, with or without tenodesis of the peroneus longus to the peroneus brevis, have been shown to produce excellent results.
REFERENCES: Haddad SL: Disorders of tendons: Peroneal tendon dysfunction, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,

pp 812-817.
MacDonald BD, Wertheimer SJ: Bilateral os peroneum fractures: Comparison of conservative and surgical treatment and outcomes. J Foot Ankle Surg 1997;36:220-225.

Question 45

Which of the following design features of a femoral component used in a total knee arthroplasty best minimizes the patellar component contact stresses?

Explanation

DISCUSSION: Several studies have shown that design of the femoral component, especially the trochlear groove portion, largely influences patellar tracking and patellofemoral contact stresses. A deep, curved anatomic femoral trochlear groove has been shown to have the lowest contact stresses.
REFERENCES: Petersilge WJ, Oishi CS, Kaufman KR, Irby SE, Colwell CW Jr: The effect of trochlear design on patellofemoral shear and compressive forces in total knee arthroplasty. Clin Orthop 1994;309:124-130.
Theiss SM, Kitziger KJ, Lotke PS, Lotke PA: Component design affecting patellofemoral complications after total knee arthroplasty. Clin Orthop 1996;326:183-187.
Healy WL, Wasliewski SA, Takei R, Oberlander M: Patellofemoral complications following total knee arthroplasty:. Correlation with implant design and patient risk factors. J Arthroplasty 1995;10:197-201.

Question 46

A 20-year-old college soccer player comes for an evaluation 6 months after an injury during which he landed awkwardly from a jump. Although physical therapy, ice, and activity modification have helped him return to baseline motion, strength, and swelling, he continues to have lateral knee pain. He also notes a popping sensation on the lateral side of his knee with activity. A Lachman test, anterior and posterior drawer tests, a pivot shift test, and McMurray test findings are all negative. MR images reveal a 12-mm x 15-mm osteochondral defect in the lateral femoral condyle with full-thickness cartilage loss and approximately 4 mm of subchondral bone loss.

Explanation

DISCUSSION
Patellofemoral pain in a young athlete without patellar instability or a chondral or osteochondral defect often can be managed with nonsurgical treatment such as physical therapy and a home exercise program. Microfracture surgery is associated with good short-term results for younger athletes. Patients with no history of prior surgery, primary chondral rather than osteochondral lesions, and lesions smaller than 2 cm have experienced the best results. Microfracture surgery performed for chondral lesions of the central aspect of the medial femoral condyle is associated with worse results. Decreased activity levels over time of patients who undergo microfracture surgery are a concern. OAT provides good outcomes and return-to-sports rates for athletic people who are younger and have lesions smaller than 2 cm. Patients with lesions on the lateral femoral condyle have better success rates. Both microfracture surgery and OAT provide better results for chondral defects than osteochondral defects. OAT is associated with better results than microfracture for medium-sized lesions between 2 cm and 4 cm, while autologous chondrocyte implantation yields better improvement for patients with defects larger than 4 cm. All of the surgical techniques listed for articular cartilage repair are associated with better outcomes for patients younger than age 30.

Question 47

A 10-year-old boy has 2 months of right knee pain that started at summer camp. The patient denies constitutional symptoms. There is no lymphadenopathy present. CT of the chest shows no signs of metastatic disease. Imaging studies and biopsy results are shown in Figures A-E. What is the most likely diagnosis?

Explanation

The age, imaging and histology are consistent with an osteosarcoma. The radiograph shows an aggressive (lytic, mottled, sclerotic) appearing lesion around the distal femur metadiaphyseal region. The T2 weighted MRI image shows a significant soft tissue mass which appears to arise from the distal femur with destruction of the adjacent cortex. The biopsy shows an infiltrative pattern with elements of osteoid and bone.
Treatment for osteosarcoma includes neoadjuvant chemotherapy, wide resection, and adjuvant chemotherapy.

Question 48

A 17-year-old girl is involved in a motor vehicle collision and sustains the injury shown in Figures 46a through 46c. She is neurologically intact in her bilateral lower extremities. Definitive treatment should consist of A B C

Explanation

DISCUSSION
The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.
RECOMMENDED READINGS
Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508. View Abstract at PubMed
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.

Question 49

Gaucher’s disease is manifested by reticuloendothelial system macrophage accumulation of

Explanation

DISCUSSION: Gaucher’s disease is characterized by macrophage accumulation of glucocerebroside that is caused by a deficiency of lysosomal enzyme glucocerebrosidase. It is an autosomal-recessive trait and is most commonly found in Ashkenazi Jews. Orthopaedic surgeons see patients with Gaucher’s disease usually because of osteonecrosis of the hip. Calcium pyrophosphate is associated with pseudogout. Hydroxyproline is a breakdown product of collagen and is found in high levels in patients with Paget’s disease. Homogentisic acid is associated with ochronosis (alkaptonuria).
REFERENCES: Beatty JH: Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 247-252.
Goldblatt J, Sacks S, Beighton P: The orthopedic aspects of Gaucher disease. Clin Orthop 1978;137:208-214.
Beutler E: Gaucher’s disease. N Engl J Med 1991;325:1354-1360.

Question 50

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. Based on the pathology noted, which finding may be found on plain knee radiographs?

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 51

Well-differentiated liposarcomas never have chromosomal abnormalities. Liposarcomas account for approximately 10% to 15% of sarcomas. Some general statements about liposarcomas are listed below:

Explanation

Which of the following soft tissue lesions has a characteristic reciprocal transformation between chromosomes 12 and 16:

Question 52

A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?

Explanation

DISCUSSION: Sudden cardiac arrest following a blow to the chest in young athletes has been termed “commotio cordis.” It is most common in Little League and other youth projectile sports (eg, ice hockey, lacrosse). The cause, although not completely determined, is most likely an arrhythmia related to the impact in a vulnerable time in the cardiac cycle. Resuscitation has proven to be exceedingly difficult, resulting in a high mortality rate.
REFERENCES: Maron BJ, Strasburger JF, Kugler JD, Bell BM, Brodkey FD, Poliac LC: Survival following blunt chest impact-induced cardiac arrest during sports activities in young athletes. Am J Cardiol 1997;79:840-841.
Link MS, Maron BJ, Estes NAM III: Commotio cordis, in Estes NAM III, Salem DN, Wang PJ (eds): Sudden Cardiac Death in the Athlete. Armonk, NY, Futura, 1998, pp 515-528.

Question 53

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?

Explanation

DISCUSSION: Cancellous bone strength and stiffness are determined primarily by the apparent density (the amount of bone per unit volume). Strength varies approximately as the square of the density, and stiffness as the cube of the density; therefore, these are very strong relationships. Cancellous bone strength also depends on the mineral content, the rate of loading (it is viscoelastic), the anatomic level, and the trabecular number (an histomorphometry term), but all to a markedly lesser extent than density.
REFERENCES: Carter DR, Hayes WC: The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg Am 1977;59:954-962.
Keaveny TM: Strength of trabecular bone, in Cowin SC (ed): Bone Mechanics Handbook. Boca Raton, FL, CRC Press, 2001, pp 16-1-16-8.

Question 54

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

Explanation

DISCUSSION: The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.
REFERENCE: Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadephia, PA, Mosby-Year Book, 1998, p 110.

Question 55

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 56

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?

Explanation

DISCUSSION: 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.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.
Lemley F, Berlet G, Hill K, et al: Current concepts review: Tarsal coalition. Foot Ankle Int 2006;27:1163-1169.

Question 57

A 55-year-old woman with type I diabetes mellitus has a chronic ulcer over the dorsum of her right foot and reports forefoot pain. Examination reveals 1- x 2-cm nondraining ulcer over the dorsum of the foot. The patient has 1-2+ pain with compression of the foot and ankle. She has a weakly palpable posterior tibial pulse and an absent dorsalis pedis pulse. There is no erythema, cellulitis, or drainage. Radiographs are normal. Which of the following diagnostic studies should be obtained?

Explanation

DISCUSSION: The presence of a dorsal ulcer in the presence of weak or absent pulses strongly suggests the possibility of arterial insufficiency. The best initial noninvasive study to assess for ischemia is the Doppler arterial study. A determination of the vascular status is of a greater priority than an assessment for infection or neuropathy because of the location and presentation of the ulcer. If ankle pressures are less than 45 mm Hg, there is a high risk that these lesions will not heal without revascularization.
REFERENCES: Wagner FW Jr: The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64-122.
Apelqvist J, Castenfors J, Larson J, Stenstrom A, Agardh CD: Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer. Diabetes Care 1989;12:373-378.

Question 58

Two weeks after undergoing total knee arthroplasty, a 68-year-old woman experiences moderate, yet worsening, knee pain. Upon examination, she can walk with a cane but she has swelling with mild reactive erythema. She has a well-healed incision with no drainage. A review of her medications reveals the she has been taking warfarin and has an international normalized ratio (INR) of 4.0. Her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are slightly elevated, and radiographs are unremarkable other than for effusion. What is the most likely diagnosis?

Explanation

DISCUSSION
This patient likely has a hemarthrosis related to INR elevation. The slight elevations in ESR and CRP are likely attributable to the nature of the surgery itself rather than an infection, and the mild reactive erythema is likely attributable to the hemarthrosis.

Question 59

A 25-year-old woman has significant pain and swelling in her left ankle after falling off her bicycle. Examination reveals that she is neurovascularly intact. Radiographs are shown in Figures 33a through 33c. What is the next most appropriate step in management?

Explanation

DISCUSSION: The radiographs show a displaced ankle fracture with widening of the syndesmosis. Open reduction and internal fixation is indicated with fixation of the mortise with syndesmotic screws.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Harper MC: Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18.

Question 60

-A 51-year-old man has a slowly expanding upper-extremity mass. Examination reveals a firm 3-cm mass in his midvolar forearm. Radiographs are normal. You suspect a soft-tissue sarcoma. The best imaging study would be

Explanation

Question 61

A 43-year-old former professional hockey player reports severe pain in his chest after being checked from the side in a pick-up hockey game. An MRI scan and plain radiographs are shown in Figures 25a through 25c. What is the most likely diagnosis?

Explanation

DISCUSSION: Anterior dislocation is the most common type of sternoclavicular dislocation. The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum. In a study by Omer, 31% of athletic injuries have been known to cause a dislocation of the sternoclavicular joint. The serendipity view can show this dislocation, as will CT of the chest. This view requires the x-ray beam to be aimed at the manubrium with 40 degrees of cephalic tilt. An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view.
REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 566-572.
Omer GE Jr: Osteotomy of the clavicle in surgical reduction of anterior sternoclavicular dislocation. J Trauma 1967;7:584-590.

Question 62

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Explanation

The patient presents with MRI suggestive of far lateral disc herniation at the L3-L4 disc space. He would be expected to have symptoms in L3 nerve distribution, near the medial epicondyle of the femur. Associated motor manifestations may include quadriceps weakness and/or diminished patellar reflex.
Far lateral disc herniations constitute approximately 5-10 percent of disc hernations in the lumbar spine. Given the more vertical anatomy of lumbar nerve roots, at a given disc level, a central or paracentral herniation will affect the traversing nerve root (e.g. nerve root of level below) and a far lateral herniation will affect the exiting nerve root (e.g. nerve root of the level above). Similar to the more common central and paracentral herniations, approximately 90% of patients will improve without surgical intervention. When surgical intervention is needed, the paraspinal approach of Wiltse is utilized.
Marquadt et al. reported long term outcomes of surgical management of far lateral disc herniations. At an average of 146 months follow up, 56.3% of patients had complete relief of symptoms and 27.6% had permanent residual symptoms. Over 75% of patients subjectively rated their outcomes as excellent.
Figure A and B are T2 and T1 axial MRI images, respectively, showing the L3-L4 disc space with a left far lateral disc herniation. Figure C is a left parasagittal T2 MRI image showing impingement on the L3 nerve root. Structures are labeled in illustration A. Illustration B shows the dermatomes of the lower extremity.
Incorrect Answers:

Question 63

The optimal method with which to diagnose component malrotation in total knee arthroplasty (TKA) is

Explanation

CLINICAL SITUATION FOR QUESTIONS 20 THROUGH 22
Figures 20a and 20b are the radiographs of an elderly woman who underwent total knee arthroplasty (TKA) several years ago. She now states that something is not right; her knee frequently swells and is diffusely painful, especially at the end of the day. She does not trust her knee, especially while going up and down stairs or getting up from a chair.

Question 64

What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage?

Explanation

Hyaluronic acid (HA) is abundant in cartilage and synovial fluid and is thought to be integral to joint lubrication, although its role is not clearly understood. HA binds to lubricin, a glycoprotein, creating a cross-linked network. Boundary lubrication occurs when the fluid film has been depleted and the contacting bearing surfaces are separated only by a boundary lubricant of molecular thickness, which prevents excessive bearing friction and wear. In articular cartilage, this monolayer of glycoprotein is adsorbed on each of the opposing articular surfaces. Friction experiments in a porcine model have shown that with compression, HA diffuses out of the cartilage and becomes physically trapped and constricted by the collagen network at the interface. This in effect creates a "boundary lubricant." Vitronectin is a glycoprotein similar in the N and C terminal to lubricin. It does not bind to HA. Aggrecan is the second-most-common protein by dry weight of cartilage extracellular matrix. Aggrecan interacts with HA and link proteins to create a proteoglycan aggregate that attracts water to cartilage and gives the tissue its viscoelastic properties. Chondroitin sulfate contributes to matrix proteoglycan structure rather than boundary lubrication.

Question 65

The first branch of the lateral plantar nerve innervates the

Explanation

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

pp 325-328.

Question 66

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

Explanation

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

Question 67

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

Explanation

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

Question 68

The skeletal muscle length-tension relationship for voluntary force generation is observed with which of the following biomechanical paradigms? Review Topic

Explanation

Muscle force during isometric contractions (muscle not allowed to shorten) varies with starting length. If the length is too long, the sarcomeres generate little or no active tension. If a muscle is overstretched during certain surgical procedures, then the patient may generate less than 30% maximal force. The force-velocity relationship describes isotonic (constant load) conditions.

Question 69

A 42-year-old athletic trainer has a persistent popping sensation about the lateral ankle associated with weakness and pain following a remote injury. Deficiency in what structure directly leads to this pathology?

Explanation

DISCUSSION: The patient has instability of the peroneal tendon. The superior peroneal retinaculum is the primary retaining structure preventing peroneal subluxation. It is a thickening of fascia that arises off the posterior margin of the distal 1 to 2 cm of the fibula and runs posteriorly to blend with the Achilles tendon sheath. The inferior peroneal retinaculum attaches to the peroneal tubercle of the calcaneus and is not involved in this pathology. A deficient groove in the posterior distal fibula may also be a contributing factor in the development of

the condition.
REFERENCE: Maffuli N, Ferran NA, Oliva F, et al: Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986-992.

Question 70

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?

Explanation

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523.
Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

Question 71

An 11-year-old basketball player reports that he felt a painful pop in the left knee when he stumbled while running. He is unable to bear weight on the extremity and cannot actively extend the knee against gravity. Examination reveals a large knee effusion. A lateral radiograph is shown in Figure 7. Management should consist of Review Topic

Explanation

The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.

Question 72

Figures 132a and 132b are the lateral and anteroposterior radiographs of a 15-year-old boy with a 6-month history of recurrent, activity-related posterior elbow pain when pitching. Two separate 6-week periods of rest have failed to provide relief. What is the next best step to enable him to return to play? Review Topic

Explanation

Intramedullary screw fixation of the olecranon stress fracture is most likely to allow him to return to play. Stress fractures through a persistent olecranon apophysis have been well described in the literature. The AP radiograph reveals the other physes of the elbow to be closed. After patients fail to respond to appropriate periods of rest and
cessation from throwing followed by appropriate physiotherapy, surgical management with cannulated screw fixation is appropriate and has been demonstrated to have favorable success rates. Hinged-elbow bracing will not facilitate healing or return to play. Long-arm casting is likely to result in stiffness and would not be unreasonable for a short duration at the onset of symptoms, but is less likely to be helpful at this point. Plate fixation is not indicated for treatment of this injury.

Question 73

A 25-year-old man is brought to the emergency department following a motor vehicle accident. Extrication time was 2 hours, and in the field he had a systolic blood pressure by palpation of 90 mm Hg. Intravenous therapy was started, and on arrival in the emergency department he has a systolic blood pressure of 90 mm Hg with a pulse rate of 130. Examination reveals a flail chest and a femoral diaphyseal fracture. Ultrasound of the abdomen is positive. The trauma surgeons take him to the operating room for an exploratory laparotomy. At the conclusion of the procedure, he has a systolic pressure of 100 mm Hg with a pulse rate of 110. Oxygen saturation is 90% on 100% oxygen, and he has a temperature of 95.0° F (35° C). What is the recommended treatment of the femoral fracture at this time?

Explanation

DISCUSSION: This is a “borderline trauma” patient where serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an ISS > 20 and thoracic trauma (AIS > 2); polytrauma and abdominal/pelvic trauma (Moore > 3) and hemodynamic shock (initial BP < 90 mm Hg); ISS > 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure > 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing > 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS > 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (eg, Il-6 > 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care.
REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53:452-461.
Bosse M, Kellam JF: Orthopaedic decision making in the multiple trauma patient, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 133-146.

Question 74

Which of the following conditions is considered a relative contraindication to interscalene nerve block for patients scheduled to undergo shoulder surgery?

Explanation

DISCUSSION: A common side effect of interscalene nerve block for shoulder surgery is the blockade of the ipsilateral phrenic nerve. This, in turn, results in paresis of the diaphragm and up to a 30% reduction in pulmonary function volumes. Therefore, interscalene nerve block generally is not recommended for patients whose respiratory function is compromised. Other relative and absolute contraindications for interscalene nerve blocks include allergy to local anesthetics, infection at the injection site, uncontrolled seizure disorder, coagulation abnormality, and preexisting neurologic injury.
REFERENCES: Chelly JE: Indications for upper extremity blocks, in Chelly JE (ed): Peripheral Nerve Blocks, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 19-27.
Misamore GW, Sallay PI: A prospective analysis of the safety and efficacy of interscalene brachial plexus block anesthesia for shoulder surgery. J Shoulder Elbow Surg 2007;16:e39.

Question 75

A 3-year-old child has refused to walk for the past 2 days. Examination in the emergency department reveals a temperature of 102.2 degrees F (39 degrees C) and limited range of motion of the left hip. An AP pelvic radiograph is normal. Laboratory studies show a WBC count of 9,000/mm P 3 P , an erythrocyte sedimentation rate (ESR) of 65 mm/h, and a C-reactive protein level of 10.5 mg/L (normal < 0.4). What is the next most appropriate step in management?

Explanation

DISCUSSION: Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mmP³^P. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.
Kocher MS, Zurakowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-1670.

Question 76

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

Explanation

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

Question 77

A 3-year-old child sustains a T2/T3 fracture-dislocation with complete paraplegia secondary to a car accident in which the child was an unrestrained passenger. What is the likelihood that this child will develop subsequent spinal deformity in the future? Review Topic

Explanation

More than than 90% of preadolescent children who sustain a significant spinal cord injury subsequently develop scoliosis. Conversely, progressive paralytic spinal deformity is uncommon in the postadolescent patient. Bracing has not been shown to be effective in the prevention of scoliosis in the preadolescent patient with spinal cord injury.

Question 78

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities including walking. Examination reveals a grade 3+ Lachman test with a soft endpoint, varus laxity at 30°, and a positive dial test at 30° that dissipates at 90° of knee flexion. He has mild medial joint line tenderness. When walking, there is a slight varus thrust. What treatment is most likely to lead to a successful outcome?

Explanation

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.

Question 79

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

Explanation

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

Question 80

A 24-year-old man has bilateral hip pain. An examination and imaging studies (plain radiographs and MR imaging) confirm evidence of femoroacetabular impingement (FAI) with a CAM deformity in both hips. The patient mentions that he has a 19-year-old brother who has occasional hip pain. With respect to his brother’s pain, how should you counsel the patient?

Explanation

CLINICAL SITUATION FOR QUESTIONS 145 THROUGH 147
Figures 145a and 145b are the radiographs of a 56-year-old man who has had persistent pain in his right groin since undergoing primary total hip surgery 11 months ago. His erythrocyte sedimentation rate (ESR) is 38 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 28 mg/L (rr, 0.08-3.1 mg/L). A hip aspiration performed while the patient was taking antibiotics demonstrated 3200 white blood cells/µL with no growth. Treatment should consist of

Question 81

An 11-year-old girl is struck in the leg by a loaded sled while sledding and is seen in the emergency department; she is reporting severe knee pain. Radiographs are read as normal. Examination reveals that she is exquisitely tender over the proximal tibial physis. The neurovascular examination is normal. What is the next step in management?

Explanation

DISCUSSION: The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.
REFERENCES: McGuigan JA, O’Reilly MJ, Nixon JR: Popliteal arterial thrombosis resulting from disruption of the upper tibial epiphysis. Injury 1984;16:49-50.
Burkhart SS, Peterson HA: Fractures of the proximal tibial epiphysis. J Bone Joint Surg Am
1979;61:996- 1002.

Question 82

A patient sustained a puncture wound to the plantar aspect of his foot. He was wearing shoes and socks at the time of the injury. Systemic antibiotic administration with specific coverage for which bacterial species (in addition to Staphylococcus aureus) should be instituted?

Explanation

DISCUSSION
Puncture wounds sustained through a shoe and sock increase risk for Pseudomonas infection. Clostridium are associated with soil-contaminated wounds. Mycobacterium marinum is associated with injuries sustained within water.
RECOMMENDED READINGS
DeCoster TA, Miller RA. Management of Traumatic Foot Wounds. J Am Acad Orthop Surg. 1994 Jul;2(4):226-230. PubMed PMID: 10709013. View Abstract at PubMed
Raikin SM. Common infections of the foot. In: Richardson EG, ed. Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:199-205.

Question 83

A 19-year-old woman reports persistent neck pain for 2 years. Pain is relieved with aspirin. A bone scan shows intense uptake in the superior, posterior portion of the C3 vertebral body. A sagittal CT reconstruction is shown in Figure 5. Treatment should consist of

Explanation

DISCUSSION: The CT scan shows an osteoblastic nidus pathognomic for an osteoid osteoma. Surgical treatment should include an en bloc excision of the lesion. Surgical treatment is not mandatory because the lesion often becomes asymptomatic over time. This lesion is not amenable to radiofrequency ablation due to its proximity to the spinal cord. A complete corpectomy is not necessary to adequately resect the lesion, as only the nidus needs to be removed. Radiation therapy and antibiotics are not appropriate treatments for an osteoid osteoma. Posterior C2-C3 fusion will not address the pathology.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
Hadjipavlou AG, Lander PH, Marchesi D, et al: Minimally invasive surgery for ablation of osteoid osteoma of the spine. Spine 2003;28:E472-E477.

Question 84

A 77-year-old man who underwent right total knee replacement surgery 2 and a half years ago has had knee pain since surgery. The pain is diffuse, constant, and made worse with activity. He notes warmth and swelling in his knee. Examination shows a well-healed incision, no erythema, moderate warmth, synovitis, and an effusion. The knee is stable, and has an arc of flexion between 3° and 120°. Radiographs show well-fixed and well-aligned implants. What is the most appropriate initial treatment?

Explanation

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

Question 85

Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?

Explanation

Torque is defined as: T=r x F, where r is the moment arm and F is the force applied. The moment arm is the perpendicular distance from the line of action or axis of rotation. Thus torque is a vector
quantity having a magnitude and direction. Torsion involves shear and tensile stresses that cause deformation. Thus torsional rigidity is related to bone rotation and the torque applied to it.

Question 86

The cervical disk herniation shown in the MRI scans in Figures 30a and 30b will most likely create which of the following constellations of symptoms?

Explanation

DISCUSSION: The MRI scans reveal a right-sided C5-6 herniated nucleus pulposus. A disk herniation in this region encroaches on the C6 root and is accompanied by a sensory change along the thumb and index finger, alterations in the brachioradialis reflex, and possible wrist extension weakness. Although the nerve root associated with the vertebral body passes above the pedicles such that the C6 root passes above the C6 pedicle, it is still the C6 root that is encroached on because the herniation affects the exiting root rather than the traversing root as seen in the lumbar spine.
REFERENCES: Klein JD, Garfin SR: Clinical evaluation of patients with suspected spine problems, in Frymoyer JW (ed): Adult Spine: Principles and Practice, ed 2. Philadephia, PA, Lippincott-Raven, 1997, pp 319-330.
Hoppenfeld S: Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-49.

Question 87

A 37-year-old recreational tennis player undergoes surgery for tennis elbow. Following surgery, she describes clicking and popping on the lateral aspect of the elbow. A lateral pivot shift test is positive. What is the most likely cause of her symptoms?

Explanation

DISCUSSION: The patient has a posterolateral rotatory instability (PLRI) of the elbow that is most likely the result of iatrogenic injury to the lateral ulnar collateral ligament, the main ligament implicated in PLRI. The anterior band of the medial collateral ligament is implicated in valgus instability. Injury to the radial nerve is unlikely, and the lateral radial collateral ligament makes less of a contribution to elbow stability than does the ulnar component. While the origin of the extensor carpi radialis brevis may contribute to elbow stability, it is not as important a stabilizer as the lateral ulnohumeral ligament.
REFERENCES: O’Driscoll SW, Morrey BF: Surgical reconstruction of the lateral collateral ligament, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 169-182.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 88

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

Explanation

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 89

Figures 31a and 31b show the radiograph and MRI scan of an otherwise normal 3-month-old infant who has a spinal deformity. MRI reveals no intraspinal anomalies. What is the next step in management?

Explanation

DISCUSSION: Congenital scoliosis in an infant warrants evaluation of the renal, cardiac, and neurologic systems because frequently there is concurrent pathology. Progression in this instance is possible but not certain; therefore, progression must be documented prior to any surgical intervention. Close observation with serial radiographs every 4 to 6 months is appropriate. All of the surgical options listed may be reasonable choices in the future, but cardiac evaluation is the most important issue at this time.
REFERENCES: Basu PS, Elsebaie H, Noordeen MH: Congenital spinal deformity:

A comprehensive assessment at presentation. Spine 2002;27:2255-2259.
Hedequist D, Emans J: Congenital scoliosis. J Am Acad Orthop Surg 2004;12:266-275.

Question 90

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Explanation

DISCUSSION: The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

Question 91

Histologically, synovial chondromatosis is characterized by

Explanation

DISCUSSION: Histologically, there is metaplastic cartilage arising from the synovium. These lobules of zonates hyaline cartilage are of variable size, are embedded within edematous synovium, and protrude into the joint. The lobules calcify and ossify, leading to the characteristic radiographic appearance. Inflammatory synovitis is not characteristic of synovial chondromatosis. The fluid is clear and serosanguin, not blood tinged.
REFERENCES: Milgram JM: Synovial osteochondromatosis: A histopathological study of thirty cases. J Bone Joint Surg Am 1977;l59:792-801.
Murphy FP, Dahlin DC, Sullivan CR: Articular synovial chondromatosis. J Bone Joint Surg Am 1962;44:77.

Question 92

Figure 10 shows the radiograph of an 18-year-old woman who sustained a spinal cord injury in a motor vehicle accident. Based on the radiographic findings, her injury is best described as

Explanation

DISCUSSION: The Allen and Ferguson mechanistic classification system is a useful tool for evaluating cervical spine injuries. Cervical fractures are classified as compressive extension, distractive extension, compressive flexion, distractive flexion, vertical compression, and lateral flexion. The patient has a distractive flexion injury.
REFERENCE: Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.

Question 93

A 43-year-old woman has an enlarging mass in the left groin. A radiograph, CT scan, and a biopsy specimen are shown in Figures 42a through 42c. Treatment should consist of

Explanation

DISCUSSION: The patient has a pelvic chondrosarcoma. The radiograph shows a lytic bone lesion emanating from the left inferior pubic ramus and extending into the soft tissues. Punctate calcifications are revealed on the radiograph and CT scan. The histology is consistent with a malignant cartilage lesion. Appropriate treatment for a pelvic chondrosarcoma is wide resection. In this location, wide resection of the ischiopelvic region (type 3 internal hemipelvectomy) is the treatment of choice. A type 2 internal hemipelvectomy involves resection of the periacetabular region. A type 1 internal hemipelvectomy involves resection of the ilium. No reconstruction is required for a type 3 resection. A classic hemipelvectomy is not necessary because the tumor can be removed with an adequate margin while maintaining the neurovascular structures and hip joint.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Sheth DS, Yasko AW, Johnson ME, Ayala AG, Murray JA, Romsdahl MM: Chondrosarcoma of the pelvis: Prognostic factors for 67 patients treated with definitive surgery. Cancer 1996;78:745-750.
Enneking WF, Dunham WK: Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg Am 1978;60:731-746.

Question 94

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Explanation

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.

High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 95

An operating room intervention that should be undertaken by anesthesia staff during the cementing of a femoral stem is to

Explanation

DISCUSSION
Young age is a risk factor for early failure of cementless femoral components. Surgeons could consider cementing for patients older than 80 years of age. The Dorr classification has been shown to favor a cemented femoral stem in Dorr type C bone. Dorr type B bone can potentially sustain a proximally porous ingrowth stem. Osteoporosis is a risk factor for early failure of cementless femoral components.
Earlier designs for cemented femoral stems used microtexture to interlock the stem into the cement mantle. If these stems became loose, they would abrade the cement and loosen the stem further. Successful cemented femoral components are polished and have smooth edges with tapered bodies. Collars do not add to the design of femoral stems.
Patients are at risk for hypotension during the femoral pressurization process. With that in mind, the surgeon should make sure the anesthesiologist is ready to respond to hypotension. The FiO2 should be increased. The IV fluid rate also should be increased, and the anesthesiologist should be prepared with phenylephrine to support the patient’s blood pressure if he or she becomes hypotensive.

Question 96

Figure 18 shows the radiograph of a patient with a total hip arthroplasty dislocation. During revision, increasing the diameter of the femoral head while maintaining the ratio of head-to-neck diameter constant has the effect of

Explanation

DISCUSSION: Although there is strong clinical and laboratory evidence that suggests smaller head size is linked with lower rates of polyethylene wear, moving to the use of 22-mm heads from larger sizes would tend to increase the dislocation rate. The key premise to this argument is that the absolute size of the femoral neck remains unchanged. While neck diameters were appropriate for the early monoblock femoral components, the use of modular femoral stems allows the surgeon to place 22-mm heads onto the same neck and trunion as used by larger heads. This has the effect of lessening the head-to-neck diameter ratio, which then accentuates the rate of impingement and dislocation. Reducing the neck diameter in proportion to the head diameter would eliminate the range-of-motion penalty accompanying head size reduction.
Scifert and associates used a three-dimensional finite element model to study various combinations of femoral head size and neck ratios. They found that increasing the diameter of the femoral head while maintaining a constant head-to-neck diameter had the effect of significantly increasing the resisting moment necessary to induce a dislocation. The higher the head-to-neck ratio, the greater the range of motion until impingement and the greater the range of motion to dislocation.
REFERENCE: Scifert CF, Brown TD, Pedersen DR, Callaghan JJ: A finite element analysis of factors influencing total hip dislocation. Clin Orthop 1998;355:152-162.

Question 97

A patient undergoes a simple excision of a 3-cm superficial mass in the thigh at another institution. The final pathology reveals a leiomyosarcoma, without reference to the margins. What is the recommendation for definitive treatment?

Explanation

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,

a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 98

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

Explanation

DISCUSSION: The key to this question is the fact that the patient initially lost flexion postoperatively and this relates to anterior placement of the femoral tunnel, thus capturing the knee. The bone plug seen on the radiograph is actually from the tibial tunnel, but this occurred as the patient forced flexion until failure of the ACL graft and pullout of the plug from the tunnel. Although it could be argued that better tibial fixation would have prevented this failure, poor placement of the femoral tunnel led to the failure of this ACL reconstruction.
REFERENCES: Fu FH, Bennett CH, Latterman C, et al: Current trends in anterior cruciate ligament reconstruction: Part 1. Biology and biomechanics of reconstruction. Am J Sports Med 1999;27:821-830.
Fu FH, Bennett CH, Ma CB, et al: Current trends in anterior cruciate ligament reconstruction: Part II. Operative procedures and clinical correlations. Am J Sports Med 2000;28:124-130.

Question 99

A 25-year-old man injures his shoulder while skiing. Examination reveals increased passive external rotation, pain in the cocked position, and a positive lift-off test. What is the most likely diagnosis?

Explanation

DISCUSSION: A positive lift-off test and increased passive external rotation are diagnostic of a subscapularis tear or detachment. Although a similar injury could produce anterior instability, this will test the integrity of the subscapularis. A locked dislocation has limited passive movement. A ruptured biceps tendon will most likely produce ecchymosis and findings similar to supraspinatus trauma. Internal impingement is not associated with subscapularis weakness.
REFERENCES: Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Hawkins RJ, Bokor DJ: Clinical evaluation of the shoulder, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 149-177.

Question 100

A 12-year-old boy has had progressive pain and flatfeet for the past year. Pain is increased with weight-bearing activities. Examination reveals that subtalar motion is absent. On standing, the patient has obvious hindfoot valgus and loss of the normal arch bilaterally. Plain radiographs are shown in Figures 43a through 43c, and a CT scan is shown in Figure 43d. What is the most likely diagnosis?

Explanation

DISCUSSION: The axial views show fusion of the talus and calcaneus at the medial facet (talocalcaneal coalition). Peroneal spastic flatfoot is a descriptive term applying to the symptoms of painful flatfoot associated with apparent peroneal spasm and is sometimes caused by tarsal coalition; however, this is not the most appropriate diagnosis for this patient. Flexible flatfoot with a short Achilles tendon often causes symptoms similar to the ones listed above, but subtalar motion should be normal. A diagnosis of calcaneonavicular coalition can be made based on plain oblique views of the foot but is not seen in these views. Posterior tibial tendon dysfunction in the absence of other pathology is uncommon in children.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 583-595.

Full Question & Answer Text (for Search Engines)

Question 1:

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

Options:

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

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

Explanation:

Question 2:

preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.

Options:

The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?
Ulnar artery and accompanying vein
Deep and superficial branches of the ulnar nerve
Radial and ulnar digital nerves to the little finger
Palmar cutaneous and thenar motor branch of the median nerve
Dorsal cutaneous branch of the ulnar nerve and common digital artery to the fourth web

Correct Answer: The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?

Explanation:

The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon’s canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon’s canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon’s canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon’s canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon’s canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist
A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?
Central space
Hypothenar space
Carpal tunnel
Posterior adductor space
Thenar space
CORRECT ANSWER: 5
Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection.
New painful paresthesias near the site of the incision after an ulnar nerve transposition is the result of injury to what nerve?
Medial antebrachial cutaneous
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous
Medial brachial cutaneous
Dorsal antebrachial cutaneous
Branches of the medial antebrachial cutaneous nerve can often be identified during routine ulnar nerve surgery crossing the medial aspect of the elbow. It should be preserved to avoid development of painful paresthesias.
A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure

Question 3:

Which of the following structures is most vulnerable during a medial sesamoidectomy of the hallux?

Options:

Abductor hallucis tendon
Intermetatarsal ligament
Plantar-medial cutaneous nerve of the hallux
Dorsomedial cutaneous nerve of the hallux
Crista

Correct Answer: Plantar-medial cutaneous nerve of the hallux

Explanation:

DISCUSSION: The plantar-medial cutaneous nerve is at risk with the surgical approach to the medial sesamoid. It is found directly underlying an incision made at the junction of the glabrous skin of the hallux and must be identified before the approach can proceed. Transection will result in a painful neuroma that impinges on the plantar-medial surface of the toe and cause problems with shoe wear. The only other structure that lies near the surgical field is the abductor hallucis tendon which lies dorsal to the incision.
REFERENCE: Sarrafian SK: Anatomy of the Foot and Ankle, Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, p 377.

Question 4:

Options:

Halo-vest orthosis
C1-C2 posterior cervical fusion
Occiput to C2 posterior cervical fusion
Cervical traction and closed reduction
Open reduction and internal fixation of C1

Correct Answer: C1-C2 posterior cervical fusion

Question 5:

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Options:

L1, L2, and L3
L4 and L5
L5 and S1
S2, S3, and S4
Filum terminale

Correct Answer: S2, S3, and S4

Explanation:

Question 6:

03 A 23 year old sustains an isolated right knee dislocation in an MVA. A closed reduction is performed and confirmed with radiographs. What is the next appropriate study?

Options:

CT of knee
MRI of knee
radiographs of femur and tibia
angiography of the leg
noninvasive assessment of lower extremity perfusion backanswer Question 43.03

Correct Answer: noninvasive assessment of lower extremity perfusion backanswer Question 43.03

Explanation:

This is simple A, B, Cs and doctoring. History and Physical exam come first. Noninvasive assessement includes visual inspection, clinical examination (feel pulses, check capillary refill, feel temperature of skin), and ABIs. X-ray, CT, and MRI would be good secondary studies to identify bony or soft tissue injuries—after initial reduction and splinting/stabilizatoin. Angiography would be indicated if there were asymmetric pulses or an ABI < 0.9, or if there was any other indication that a vessel injury may have occurred.
OKU Truama 2 says “the use of ABI with the blood pressure cuff and Doppler evaluation of the distal circulation has been proposed as effective in determining any occult vascular injury. A ratio > 0.9indicates a normal study.”
[1]
The referenced article confirms this. “Confirmation of the safety and accuracy of physical exam in the evaluation of knee dislocation for injury of the popliteal artery.” J. Trauma2002; 52: 247-252
back to this question next question
[1]
OKU Trauma 2 pg 151-153

Question 7:

Options:

High hip center
Anatomic hip center with trochanteric osteotomy and progressive femoral shortening
Anatomic hip center with subtrochanteric shortening osteotomy
Iliofemoral lengthening followed by an anatomic hip center

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 8:

Options:

Resect more distal femur.
Resect more anterior tibia.
Use a larger femoral component.
Use a smaller polyethylene insert.
Recess the posterior cruciate ligament.

Correct Answer: Recess the posterior cruciate ligament.

Explanation:

Question 9:

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

Options:

Autologous osteochondral transplantation
Arthroscopic bone marrow stimulation
Chondroplasty
Osteochondral allograft transplantation

Correct Answer: Autologous osteochondral transplantation

Explanation:

DISCUSSION
Autologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.
RECOMMENDED READINGS
Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005 May-Jun;13(3):152-8. Review. PubMed PMID: 15938604.
View Abstract
at PubMed
Mitchell ME, Giza E, Sullivan MR. Cartilage transplantation techniques for talar cartilage lesions. J Am Acad Orthop Surg. 2009 Jul;17(7):407-14. Review. PubMed PMID: 19571296.
View Abstract at PubMed
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Review. PubMed PMID: 23780543.
View Abstract at PubMed

Question 10:

What is the most common cause of rotator cuff injury in high school athletes?

Options:

A curved or type III acromion
A tight coracoacromial ligament
Overuse
Limited internal rotation
Scapulothoracic dyskinesia

Correct Answer: Overuse

Explanation:

Question 11:

Options:

Valgus osteotomy
Removal of the hardware
Intramedullary fixation after removal of the hardware
Conversion to total hip arthroplasty with a long cementless stem
Conversion to total hip arthroplasty with a primary tapered stem

Correct Answer: Conversion to total hip arthroplasty with a long cementless stem

Explanation:

Question 12:

Options:

external traction.
open reduction and internal stabilization.
repeat closed reduction under general anesthesia.
open reduction.
percutaneous pin fixation in the current position.

Correct Answer: open reduction.

Explanation:

DISCUSSION: The radiographs show a complex dislocation of the little finger metacarpophalangeal joint. This is characterized by obvious dislocation on the AP and lateral views and a type of bayonet apposition best visualized on the lateral view. Irreducibility of this injury is caused by displacement of the volar plate that has been traumatically avulsed from its origin on the metacarpal, with subsequent displacement into the metacarpophalangeal joint. This abnormal position of the volar plate causes irreducibility that can be corrected only by open reduction. This can be effected either by dorsal or palmar approaches.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999,
pp 711-771.
Becton JL, Christian JD Jr, Goodwin HN, Jackson JG III: A simplified technique for treating the complex dislocation of the index metacarpophalangeal joint. J Bone Joint Surg Am 1975;57:698-700.
Green DP, Terry GC: Complex dislocation of the metacarpophalangeal joint: Correlative pathological anatomy. J Bone Joint Surg Am 1973;55:1480-1486.

Question 13:

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

Options:

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

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

Explanation:

Question 14:

Figures 10a and 10b show the clinical photograph and MRI scan of a plantar foot lesion. If excisional biopsy is performed, what is the most likely complication?

Options:

Metastatic spread
Recurrence of the lesion
High likelihood of wound breakdown
Injury to the medial plantar nerve
Loss of the local windlass effect of the plantar fascia

Correct Answer: Recurrence of the lesion

Explanation:

DISCUSSION: The MRI scan shows plantar fibromatosis. The treatment is usually nonsurgical.
If surgery is indicated, wide local excision with excision of the entire plantar fascia is usually indicated. The main problem with simple excision of the lesion is the high chance of recurrence. The other listed complications are those that are a result of the wide local excision.
REFERENCES: Aluisio FV, Mair SD, Hall RL: Plantar fibromatosis: Treatment of primary and recurrent lesions and factors associated with recurrence. Foot Ankle Int 1996;17:672-678.
Bos GD, Esther RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 15:

Options:

Remove the Kirschner wires and reposition the ankle
Measure foot compartment pressures
Order an echocardiogram
Order serum blood urea nitrogen and creatinine levels

Correct Answer: Remove the Kirschner wires and reposition the ankle

Explanation:

The most common symptom of compartment syndrome in the extremities is intense pain. Compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. In compartment syndrome of the leg, pain on passive extension of the toes is the most frequent clinical diagnostic finding. However, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present. Swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Repositioning the ankle will add to further swelling. The clinician must be alerted regarding elevations in blood pressure and pulse because such elevations may be the only manifestation of the deeper problem. The transient blood pressure elevation does not require cardiac screening with electrocardiogram or echocardiogram as in chronic hypertension. Kidney function testing is not necessary because the blood pressure elevation is not renal in origin. Compartment pressures should be measured immediately in the foot and will require anesthesia in the pediatric age group.
(SBQ13PE.91) An 12-year-old girl presents with right hip pain. Bilateral frog laterals are shown in Figure A. Laboratory work-up reveals TSH 11 mIU/L (Ref range: 0.4-4.0 mIU/L) and Free T4 is 0.5 ng/dL (Ref range: 0.7-1.9 ng/dL). What is the most appropriate treatment recommendation?
Review Topic
In situ pinning of right hip
Protected weight bearing and MRI of right hip
Immediate endocrine referral and treatment
Open biopsy right hip
In situ pinning bilateral hips PREFERRED RESPONSE 5
In patients with slipped capital femoral epiphysis (SCFE) and concomitant endocrinopathy, bilateral pinning is the recommended treatment.
This patient's laboratory values reveal hypothyroidism, which increases the risk of bilateral involvement. Thus, the most appropriate treatment recommendation is surgical fixation of both hips.
Wells et al. analyzed 131 SCFEs over a 30-year period. The authors noted that 100% of patients with associated endocrinopathy went onto contralateral slip and recommended not only prophylactic pinning, but in those with open triradiate cartilage, recommended preventative screening with TSH/Free T4 laboratory studies.
Riad et al. followed 90 patients and analyzed impact of age, gender and race on contralateral slip development. Girls under the age of 10 and boys under the age of 12 had a significantly increased risk of contralateral involvement. Therefore, the authors recommended contralateral pinning for girls and boys that met those age criteria, respectively.
Figure A exhibits a right SCFE on bilateral frog lateral views. Incorrect Answers:

Question 16:

Options:

The right T2 pedicle screw is well seated within the pedicle.
The right T2 pedicle screw has breached the pedicle wall and has violated the costovertebral junction.
There is a breach in the right T2 pedicle wall, but the screw is not in contact with a neural structure.
There is a breach in the right T2 pedicle and the screw is in contact with a neural structure.

Correct Answer: There is a breach in the right T2 pedicle and the screw is in contact with a neural structure.

Explanation:

DISCUSSION
This patient has developed a proximal junctional kyphosis following a long posterior fusion performed for treatment of degenerative lumbar scoliosis. Risk factors for proximal junctional kyphosis in the setting of instrumented fusions performed for degenerative scoliosis include advanced age, 360-
degree fusions, extension of fusion constructs to the sacrum, and upper instrumented vertebrae at the level of T1-3. The patient's junctional kyphosis is attributable to failure of the disk and ligamentous structures at T2-3 and would be graded as type I using the classification system of Yagi and associates. Most symptomatic proximal junctional kyphoses are treated with posterior extension of the fusion construct to a more proximal level spanning the kyphosed region. The use of orthoses or simple removal of instrumentation is unlikely to substantively impact symptoms or address the proximal kyphosis. Diabetes and obesity are known factors that increase risk for postsurgical infection following a spine fusion procedure. The most frequent complication following revision surgery for proximal junctional kyphosis, however, is the need for further surgery. In the study by Yagi and associates, 48% of patients who underwent revision surgery for proximal kyphosis developed further adjacent segment degeneration. In the proximal thoracic spine, where the pedicle may be narrow, triggered EMG testing of inserted pedicle screws may be used to assess for violation of the pedicle wall during insertion. In the setting of triggered EMG, thresholds exceeding 10 mA indicate a well-placed pedicle screw. Thresholds lower than 4 mA to 6 mA indicate that a screw is directly contacting a neural structure. Thresholds between 9 mA and 10 mA suggest that a breach of the pedicle may be present, but the screw is not contacting a neural structure.
RECOMMENDED READINGS
Yagi M, Rahm M, Gaines R, Maziad A, Ross T, Kim HJ, Kebaish K, Boachie-Adjei O; Complex Spine Study Group. Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity.Spine (Phila Pa 1976). 2014 May 1;39(10):E607-14. doi: 10.1097/BRS.0000000000000266. PubMed PMID: 24525992.
View
Abstract at PubMed
Cammarata M, Aubin CÉ, Wang X, Mac-Thiong JM. Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976). 2014 Apr 15;39(8):E500-7. doi: 10.1097/BRS.0000000000000222. PubMed
PMID: 24480964.
View Abstract at PubMed
Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012 Oct 15;37(22 Suppl):S144-64. doi: 10.1097/BRS.0b013e31826d611b. PubMed PMID: 22885829.
View Abstract at PubMed
Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 17:

Options:

Urine output of greater than 100 mL/h
Cardiac output of greater than 2
Serum lactate level of less than 2.5 mmol/L
Systolic blood pressure of greater than 100 mm Hg
Hemoglobin level of greater than 10 g/dL

Correct Answer: Serum lactate level of less than 2.5 mmol/L

Explanation:

Question 18:

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Options:

Thoracic vertebral bodies
Lumbar vertebral bodies
Sacrum
Pedicles of the lower lumbar spine
Pedicles of the thoracic spine

Correct Answer: Pedicles of the thoracic spine

Explanation:

Question 19:

Options:

radial head resection.
dynamic splinting.
metacarpophalangeal arthroplasties.
total wrist arthrodesis with a flexor digitorum sublimis to extensor digitorum communis transfer.
distal ulnar resection with an extensor indius proprius to extensor digitorum communis transfer.

Correct Answer: distal ulnar resection with an extensor indius proprius to extensor digitorum communis transfer.

Explanation:

DISCUSSION: The patient has extensor tendon ruptures at the level of the wrist that are the result of synovitis at the distal radioulnar joint (Vaughn-Jackson syndrome). Extensor indius proprius transfer appropriately matches strength and excursion of the ruptured extensor digiti quinti and extensor digitorum communis tendons. An extensor tenosynovectomy with distal radioulnar joint resection decreases the synovitis, which if left untreated may cause additional tendon ruptures. Radial head resection is used for posterior interosseous nerve compression secondary to radial head synovitis, and in this patient only two fingers are involved, which rules out this diagnosis. Dynamic splinting is not indicated for ruptured tendons. Metacarpophalangeal arthroplasties and imbrication of the sagittal bands are used for metacarpophalangeal arthritis and extensor tendon subluxation. If this was the problem, the patient should be able to maintain the fingers in extension after they are passively extended. Total wrist arthrodesis prevents the tenodesis effect, thus limiting effective tendon excursion and making the proposed transfer less effective.
REFERENCES: Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases: Tendon ruptures, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999,
pp 1669-1684.
Moore JR, Weiland AJ, Valdata L: Tendon ruptures in the rheumatoid hand: Analysis of treatment and functional results in 60 patients. J Hand Surg Am 1987;12:9-14.
Leslie BM: Rheumatoid extensor tendon ruptures. Hand Clin 1989;5:191-202.

Question 20:

Options:

Arthroscopic infraspinatus tenodesis
Arthroscopic posterior labral repair
Arthroscopic capsular shift and rotator interval closure
Posterior glenoid opening-wedge osteotomy

Correct Answer: Arthroscopic posterior labral repair

Explanation:

Question 21:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 22:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

Question 23:

Options:

triple arthrodesis.
manipulation of the foot under general anesthesia.
continued nonsurgical management until the synchondrosis ossifies.
resection of the coalition and interposition with the extensor digitorum brevis.
a medial closing wedge osteotomy of the calcaneus.

Correct Answer: resection of the coalition and interposition with the extensor digitorum brevis.

Explanation:

Question 24:

A positive straight leg raising sign is when pain radiates distal to the knee when the affected leg is passively elevated. The increased tension generally occurs between Review Topic

Options:

0 degrees to 30 degrees.
30 degrees to 70 degrees.
45 degrees to 90 degrees.
60 degrees to 90 degrees.
90 degrees.

Correct Answer: 30 degrees to 70 degrees.

Explanation:

Question 25:

Options:

a shoulder spica cast with the upper extremity in the salute position.
a sling and swathe for 3 weeks, followed by gradual motion and strengthening.
closed reduction and antegrade intramedullary pinning.
closed reduction and retrograde intramedullary nailing.
open reduction and internal fixation with small plates and screws.

Correct Answer: a sling and swathe for 3 weeks, followed by gradual motion and strengthening.

Explanation:

DISCUSSION: In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture.
REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994,
pp 144-148.
Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.

Question 26:

Compared to postoperative radiation therapy, preoperative radiation therapy has a higher rate of what complication?

Options:

Fibrosis
Lymphedema
Wound necrosis
Local recurrence
Neuropathy

Correct Answer: Wound necrosis

Explanation:

DISCUSSION: Radiation therapy is commonly used as an adjuvant in the treatment of soft-tissue sarcomas, but a controversy exists whether it should be preoperative or postoperative. Radiation therapy can be given prior to or following resection of the tumor. Postoperative radiation is usually given in a higher dose to a larger treatment field. This commonly results in a higher incidence of fibrosis and lymphedema. There is no statistical difference in local recurrence rate between the two radiation treatment plans. Neuropathy is more commonly a complication of chemotherapy. Preoperative radiation therapy has been shown to have a higher wound complication rate than postoperative radiation.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Davis AM, O’Sullivan B, Turcotte R, et al: Late radiation morbidity following randomization to preoperative versus postoperative radiotherapy in extremity soft tissue sarcoma. Radiother Oncol 2005;75:48-53.

Question 27:

Options:

primary repair of the MCL and use of a posterior stabilized total knee arthroplasty (TKA) prosthesis.
augmentation of the MCL with a collagenous tissue scaffold and use of a posterior stabilized TKA
prosthesis.
complete release of the lateral collateral ligament (LCL) and use of a posterior stabilized TKA prosthesis.
lateral unicompartmental arthroplasty.
use of a varus-valgus constrained TKA prosthesis.

Correct Answer: lateral unicompartmental arthroplasty.

Explanation:

Question 28:

Options:

Lead to lower patient satisfaction rates
Lead to higher patient satisfaction rates
Lead to higher likelihood the patient will take legal action against surgeon
Lead to higher likelihood the patient will change physicians
Prevent any legal action

Correct Answer: Lead to lower patient satisfaction rates

Explanation:

Question 29:

Options:

Arthroscopic chondroplasty
Autologous chondrocyte implantation
Microfracture
Arthroscopic drilling
Abrasion arthroplasty

Correct Answer: Autologous chondrocyte implantation

Explanation:

Question 30:

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 31:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 32:

Options:

no treatment, the athlete may return to play.
modification of the shoulder pads and a return to play.
shoulder rehabilitation exercises and a return to play when strength is normal.
MRI of the cervical spine.
CT of the brain.

Correct Answer: MRI of the cervical spine.

Explanation:

Question 33:

Options:

be able to run and walk without pain.
refrain from vigorous activity for 6 months.
achieve full hip and knee range of motion.
achieve symmetric lower extremity strength.
have radiographic evidence of a circumferential external bridging callus.

Correct Answer: have radiographic evidence of a circumferential external bridging callus.

Explanation:

DISCUSSION: While it is recommended that a patient gain full range of motion, pain-free function, and symmetric strength prior to returning to vigorous activities, it is absolutely essential that radiographs of the fracture site reveal a circumferential external bridging callus to prevent refracture. This is particularly important for comminuted femoral fractures with various sized fragments. It is also recommended that a return to rodeo riding be postponed for at
least 1 year.
REFERENCES: Brumback RJ, Ellison TS: Intermedullary nailing of femoral stress fractures. J Bone Joint Surg Am 1992;74:106-112.
Bucholz RW, Jones A: Fractures of the shaft of the femur. J Bone Joint Surg Am
1991;73:1561-1566.
Butler MS, Brumback RJ: Interlocking nailing for ipsilateral fractures of the femur, femoral shaft, and distal part of the femur. J Bone Joint Surg Am 1991;73:1492-1502.

Question 34:

Risk for vascular injury during transtibial drilling for reconstruction of this injury is increased by

Options:

accessory incisions.
use of tapered drill bits.
use of oscillating drills.
greater knee extension.

Correct Answer: greater knee extension.

Explanation:

Question 35:

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

Options:

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

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

Explanation:

Question 36:

A 7-year-old boy has a limp with pain and tenderness over the distal right femur. Radiographs are shown in Figures 5a and 5b. Based on these findings, what is the best course of action?

Options:

Observation
Radiofrequency ablation
Biopsy, curettage, and bone grafting
Radiation therapy
Steroid injection

Correct Answer: Biopsy, curettage, and bone grafting

Explanation:

Question 37:

Options:

Open treatment of the metatarsal malunion
Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis
Cast application and an external bone stimulator
Hallux valgus correction
Hallux metatarsophalangeal arthrodesis

Correct Answer: Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis

Explanation:

Question 38:

Options:

The number of months he plays per year
The number of pitches he throws per game
The number of games he plays per week
His fastball speed
Playing in another position once being relieved of pitching

Correct Answer: Playing in another position once being relieved of pitching

Explanation:

Question 39:

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

Options:

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

Correct Answer: anterior-posterior translation.

Explanation:

Question 40:

Options:

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

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

Explanation:

Question 41:

The pathophysiology of a claw toe deformity includes muscular imbalance caused by which of the following relatively strong structures?

Options:

Intrinsics overpowering a relatively weak extensor digitorum longus
Plantar plate overpowering a relatively weak extensor digitorum brevis
Lumbricals overpowering relatively weak intrinsics
Extensor digitorum longus overpowering relatively weak intrinsics
Extensor digitorum longus overpowering a relatively weak extensor digitorum brevis

Correct Answer: Extensor digitorum longus overpowering relatively weak intrinsics

Explanation:

DISCUSSION: The dynamic forces acting to maintain the position of the proximal phalanx at the head of the metatarsal are a balance between the extensor digitorum longus and the weaker intrinsic muscles. With hyperextension at the metatarsophalangeal joint, the intrinsic muscles become less efficient as plantar flexors. Consequently, the hyperextension deformity progresses in the metatarsophalangeal joint as the opposition of the intrinsic muscles to the extensor tendon lessens. This is in contrast to the situation in the interphalangeal joints, where the stronger flexors overpower the weaker intrinsic muscles, which act as the extensors. This combination of events leads to hyperextension at the metatarsophalangeal joint and flexion deformities at the interphalangeal joints, resulting in claw toe.
REFERENCES: Mizel MS, Yodlowski ML: Disorders of the lesser metatarsophalangeal Joints.
J Am Acad Orthop Surg 1995;3:166-173.
Coughlin MJ, Mann RA: Surgery of the Foot and Ankle, ed. 7. St Louis, MO, Mosby, 1999,
pp 325-328.

Question 42:

What procedure can eliminate a sulcus sign? Review Topic

Options:

Rotator interval closure
SLAP repair
Bankart repair
Supraspinatus repair
Subacromial decompression

Correct Answer: Rotator interval closure

Explanation:

Question 43:

Options:

50 degrees of plantar flexion
20 degrees of ankle dorsiflexion
Neutral to 30 degrees of plantar flexion
Neutral to 10 degrees of dorsiflexion
Ankle position has no effect on calf compartment pressure

Correct Answer: 50 degrees of plantar flexion

Explanation:

Question 44:

Options:

Excision of the damaged portion of the peroneus longus with possible transfer of the proximal peroneus longus into the peroneus brevis
Excision of the damaged portion of the peroneus brevis with possible transfer of the peroneus brevis into the peroneus longus
Excision of the bony fragments of the calcaneus with planing down of the lateral wall of the calcaneus to avoid irritation of the peroneal tendons
Casting to allow the avulsed portion of the base of the fifth metatarsal to heal
Debridement of the posterior tibial tendon, transfer of the flexor digitorum longus tendon into the navicular, and medial translational osteotomy of the calcaneus

Correct Answer: Excision of the damaged portion of the peroneus longus with possible transfer of the proximal peroneus longus into the peroneus brevis

Explanation:

DISCUSSION: The radiograph and MRI scan show elongation and fragmentation of the os peroneum. Although casting, orthoses, and steroid injection may relieve symptoms, excision of the os peroneum and primary repair when necessary, with or without tenodesis of the peroneus longus to the peroneus brevis, have been shown to produce excellent results.
REFERENCES: Haddad SL: Disorders of tendons: Peroneal tendon dysfunction, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 812-817.
MacDonald BD, Wertheimer SJ: Bilateral os peroneum fractures: Comparison of conservative and surgical treatment and outcomes. J Foot Ankle Surg 1997;36:220-225.

Question 45:

Which of the following design features of a femoral component used in a total knee arthroplasty best minimizes the patellar component contact stresses?

Options:

Shallow, flat anatomic femoral trochlear groove
Deep, curved anatomic femoral trochlear groove
Narrow femoral trochlear groove
Universal trochlear groove (same for right and left)
Thickened anterior flange

Correct Answer: Deep, curved anatomic femoral trochlear groove

Explanation:

Question 46:

Options:

Physical therapy and a home exercise program
Corticosteroid injection
Arthroscopic debridement
Microfracture
Osteochondral autograft transplantation (OAT)

Correct Answer: Osteochondral autograft transplantation (OAT)

Explanation:

Question 47:

Options:

Synovial sarcoma
Malignant fibrous histiocytoma
Chondrosarcoma
Ewing's sarcoma
Osteosarcoma

Correct Answer: Osteosarcoma

Explanation:

Question 48:

Options:

anterior reduction, stabilization, and fusion at L1-2.
anterior reduction, stabilization, and fusion at T12-L3.
posterior reduction, stabilization, and fusion at L1-2.
posterior reduction, stabilization, and fusion at T12-L4.

Correct Answer: posterior reduction, stabilization, and fusion at T12-L4.

Explanation:

DISCUSSION
The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.
RECOMMENDED READINGS
Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508.
View
Abstract at PubMed
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.

Question 49:

Gaucher’s disease is manifested by reticuloendothelial system macrophage accumulation of

Options:

cholesterol.
hydroxyproline.
calcium pyrophosphate.
homogentisic acid.
glucocerebroside.

Correct Answer: glucocerebroside.

Explanation:

Question 50:

Options:

Shallow trochlear groove
Squaring of the lateral femoral condyle
Deepening of the sulcus terminalis
Medial joint space narrowing

Correct Answer: Squaring of the lateral femoral condyle

Explanation:

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment
of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 51:

Well-differentiated liposarcomas never have chromosomal abnormalities. Liposarcomas account for approximately 10% to 15% of sarcomas. Some general statements about liposarcomas are listed below:

Options:

Most liposarcomas occur below the fascia.
Superficial liposarcomas have an excellent prognosis.
Lipomas do not undergo transformation into liposarcomas.
Liposarcomas rarely occur in children.
Reciprocal transformation between chromosomes 12 and 16 occurs in myxoid and round cell liposarcoma.
Well-differentiated liposarcomas have giant marker and ring chromosome abnormalities with amplification of MDM2, SAS, and GLI genes.
Liposarcomas express peroxisome proliferator-activated receptor gamma (PPAR gamma).
Liposarcomas are not induced by irradiation.

Correct Answer: Most liposarcomas occur below the fascia.

Explanation:

Which of the following soft tissue lesions has a characteristic reciprocal transformation between chromosomes 12 and 16:

Question 52:

A 16-year-old ice hockey player is struck on the chest by the puck. He skates a few strides and then collapses. What is the most likely diagnosis?

Options:

Acute aortic dissection
Pulmonary contusion
Commotio cordis
Acute cardiac tamponade
Splenic rupture

Correct Answer: Commotio cordis

Explanation:

Question 53:

Vertebral fractures are common in the thoracolumbar spine. What is the most important factor that determines the strength of the cancellous bone in the vertebral body?

Options:

Mineral content
Rate of loading
Anatomic level of the vertebra
Apparent density
Trabecular number

Correct Answer: Apparent density

Explanation:

Question 54:

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

Options:

A patent ulnar artery and deep palmar arch
A patent ulnar artery and superficial palmar arch
A patent radial artery and deep palmar arch
A patent radial artery and superficial palmar arch
A patent radial artery and an ulnar artery aneurysm

Correct Answer: A patent radial artery and deep palmar arch

Explanation:

DISCUSSION: The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.
REFERENCE: Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadephia, PA, Mosby-Year Book, 1998, p 110.

Question 55:

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 56:

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: Excision of the tarsal coalition

Explanation:

DISCUSSION: 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.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 757-765.
Lemley F, Berlet G, Hill K, et al: Current concepts review: Tarsal coalition. Foot Ankle Int 2006;27:1163-1169.

Question 57:

Options:

MRI
Doppler arterial study
Arteriography
Electromyography
Triple phase bone scan (technetium Tc 99m)

Correct Answer: Doppler arterial study

Explanation:

Question 58:

Options:

Deep periprosthetic joint infection
Deep vein thrombosis
Hemarthrosis
Extensor mechanism disruption

Correct Answer: Hemarthrosis

Explanation:

Question 59:

Options:

Closed reduction and casting
Open reduction and internal fixation of the ankle fracture
Open reduction and internal fixation of the ankle fracture with syndesmosis fixation
Percutaneous pinning of the ankle fracture
Pins in plaster immobilization

Correct Answer: Open reduction and internal fixation of the ankle fracture with syndesmosis fixation

Explanation:

Question 60:

Options:

ultrasound.
CT scan.
bone scan.
gadolinium-enhanced MRI scan.
fluorodeoxyglucose positron emission tomography.

Correct Answer: gadolinium-enhanced MRI scan.

Question 61:

Options:

Anterior sternoclavicular joint dislocation
Posteroinferior sternoclavicular joint dislocation
Anterior acromioclavicular joint dislocation
Posterior acromioclavicular joint dislocation
Acromial fracture

Correct Answer: Anterior sternoclavicular joint dislocation

Explanation:

Question 62:

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Options:

Pain/parasthesias near the medial malleolus due to impingement of L4 nerve root
Pain/parasthesias near the medial malleolus due to impingement of L3 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L4 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L3 nerve root
Intermittent claudication due to impingement on segmental vessel

Correct Answer: Intermittent claudication due to impingement on segmental vessel

Explanation:

Question 63:

The optimal method with which to diagnose component malrotation in total knee arthroplasty (TKA) is

Options:

clinical assessment of foot position and patellar tracking.
radiographic skyline view of the patella.
CT scan with metal artifact suppression.
MR imaging with metal artifact reduction sequences.

Correct Answer: CT scan with metal artifact suppression.

Explanation:

DISCUSSION
The epicondylar axis and tibial tubercle can be used as references on CT scans to quantitatively measure rotational alignment of the femoral and tibial components. This technique has been used to determine whether rotational malalignment is present and whether revision of 1 or both components may be indicated. Although clinical assessment is useful, malrotation can occur as a result of deformities unrelated to the arthroplasty. Similarly, an isolated radiographic skyline view of the patella may indicate a problem with patellar maltracking, but cannot quantitatively assess malrotation of the components. MR imaging proves useful for evaluating painful TKA, but it is dependent on the center’s quality and has not yet been shown to quantify component malrotation.
CLINICAL SITUATION FOR QUESTIONS 20 THROUGH 22
Figures 20a and 20b are the radiographs of an elderly woman who underwent total knee arthroplasty (TKA) several years ago. She now states that something is not right; her knee frequently swells and is diffusely painful, especially at the end of the day. She does not trust her knee, especially while going up and down stairs or getting up from a chair.

Question 64:

What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage?

Options:

Lubricin
Vitronectin
Aggrecan
Chondroitin sulfate

Correct Answer: Lubricin

Explanation:

Question 65:

The first branch of the lateral plantar nerve innervates the

Options:

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

Correct Answer: abductor digiti quinti.

Explanation:

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

Question 66:

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

Options:

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

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

Explanation:

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

Question 67:

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

Options:

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

Correct Answer: Physiologic cross-sectional area

Explanation:

Question 68:

The skeletal muscle length-tension relationship for voluntary force generation is observed with which of the following biomechanical paradigms? Review Topic

Options:

Isometric
Isotonic
Isokinetic
Concentric
Eccentric

Correct Answer: Isometric

Explanation:

Question 69:

Options:

Lateral talar process
Superior peroneal retinaculum
Inferior peroneal retinaculum
Extensor retinaculum
Crural fascia

Correct Answer: Superior peroneal retinaculum

Explanation:

DISCUSSION: The patient has instability of the peroneal tendon. The superior peroneal retinaculum is the primary retaining structure preventing peroneal subluxation. It is a thickening of fascia that arises off the posterior margin of the distal 1 to 2 cm of the fibula and runs posteriorly to blend with the Achilles tendon sheath. The inferior peroneal retinaculum attaches to the peroneal tubercle of the calcaneus and is not involved in this pathology. A deficient groove in the posterior distal fibula may also be a contributing factor in the development of
the condition.
REFERENCE: Maffuli N, Ferran NA, Oliva F, et al: Recurrent subluxation of the peroneal tendons. Am J Sports Med 2006;34:986-992.

Question 70:

Osteochondritis dissecans of the capitellum is a source of elbow pain and most commonly occurs in what patient population?

Options:

Swimmers and divers
Football lineman
Rugby players
Gymnasts and throwing athletes
Cyclists

Correct Answer: Gymnasts and throwing athletes

Explanation:

DISCUSSION: The etiology of osteochondritis dissecans of the capitellum is somewhat unclear. However, trauma has been implicated in this disease process. Gymnasts who load their upper extremities during tumbling and throwing athletes with repetitive trauma during the throwing motion are common patient subgroups in which osteochondritis dissecans of the elbow is seen. This often occurs in the adolescent age population.
REFERENCES: Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520-523.
Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999;27:728-732.

Question 71:

Options:

physical therapy for quadriceps strengthening exercises.
a long leg cast with the knee fully extended.
excision of the fragment.
suture reattachment of the patellar tendon to the tibial tuberosity.
open reduction and tension band fixation.

Correct Answer: open reduction and tension band fixation.

Explanation:

Question 72:

Options:

Physiotherapy
Long-arm cast
Cannulated screw fixation
Plate fixation of the ulna
Hinged-elbow bracing

Correct Answer: Cannulated screw fixation

Explanation:

Question 73:

Options:

Reamed intramedullary nail
Unreamed intramedullary nail
Percutaneous plate fixation
Skeletal traction
External fixation

Correct Answer: External fixation

Explanation:

Question 74:

Which of the following conditions is considered a relative contraindication to interscalene nerve block for patients scheduled to undergo shoulder surgery?

Options:

Prior shoulder surgery
History of deep venous thrombosis
Controlled seizure disorder
Respiratory insufficiency
Obesity

Correct Answer: Respiratory insufficiency

Explanation:

DISCUSSION: A common side effect of interscalene nerve block for shoulder surgery is the blockade of the ipsilateral phrenic nerve. This, in turn, results in paresis of the diaphragm and up to a 30% reduction in pulmonary function volumes. Therefore, interscalene nerve block generally is not recommended for patients whose respiratory function is compromised. Other relative and absolute contraindications for interscalene nerve blocks include allergy to local anesthetics, infection at the injection site, uncontrolled seizure disorder, coagulation abnormality, and preexisting neurologic injury.
REFERENCES: Chelly JE: Indications for upper extremity blocks, in Chelly JE (ed): Peripheral Nerve Blocks, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 19-27.
Misamore GW, Sallay PI: A prospective analysis of the safety and efficacy of interscalene brachial plexus block anesthesia for shoulder surgery. J Shoulder Elbow Surg 2007;16:e39.

Question 75:

Options:

Technetium Tc 99m bone scan
Intravenous antibiotics
Oral antibiotics
CT of the hips
Aspiration of the left hip

Correct Answer: Aspiration of the left hip

Explanation:

DISCUSSION: Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mm
P
3
P
. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, et al: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Ann Emerg Med 1992;21:1418-1422.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.
Kocher MS, Zurakowski D, Kasser JR: Differentiating between septic arthritis and transient synovitis of the hip in children: An evidence-based clinical prediction algorithm. J Bone Joint Surg Am 1999;81:1662-1670.

Question 76:

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

Options:

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

Correct Answer: Adductor pollicis

Explanation:

Question 77:

Options:

0% if bracing is used
25%
50%
75%
90% or greater

Correct Answer: 90% or greater

Explanation:

Question 78:

Options:

Hamstring autograft
Revision ACL reconstruction and posterior cruciate ligament (PCL) reconstruction
Revision ACL reconstruction and posteromedial corner reconstruction
Revision ACL reconstruction and posterolateral corner reconstruction

Correct Answer: Revision ACL reconstruction and posterolateral corner reconstruction

Explanation:

Question 79:

Options:

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

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

Explanation:

Question 80:

Options:

His younger brother’s hip pain is almost certainly attributable to some other cause
His younger brother’s hip pain likely represents established osteoarthritis of the hip
His younger brother’s hip pain may be related to FAI
There is no known genetic influence in the etiology of FAI

Correct Answer: His younger brother’s hip pain may be related to FAI

Explanation:

DISCUSSION
Evidence suggests that FAI is more common in siblings of patients with FAI, particularly those with a CAM deformity. It is unlikely this patient has well-established osteoarthritis, even in the presence of FAI.
CLINICAL SITUATION FOR QUESTIONS 145 THROUGH 147
Figures 145a and 145b are the radiographs of a 56-year-old man who has had persistent pain in his right groin since undergoing primary total hip surgery 11 months ago. His erythrocyte sedimentation rate (ESR) is 38 mm/h (reference range [rr], 0-20 mm/h) and C-reactive protein (CRP) level is 28 mg/L (rr, 0.08-3.1 mg/L). A hip aspiration performed while the patient was taking antibiotics demonstrated 3200 white blood cells/µL with no growth. Treatment should consist of

Question 81:

Options:

Splinting, admission, and frequent neurovascular checks
Cylinder cast and discharge
Four-compartment calf fasciotomy
Non-weight-bearing, a knee immobilizer, and follow- up in 1 week

Correct Answer: Splinting, admission, and frequent neurovascular checks

Explanation:

Question 82:

Options:

Escherichia coli
Mycobacterium marinum
Pseudomonas
Clostridium

Correct Answer: Pseudomonas

Explanation:

DISCUSSION
Puncture wounds sustained through a shoe and sock increase risk for Pseudomonas infection. Clostridium are associated with soil-contaminated wounds. Mycobacterium marinum is associated with injuries sustained within water.
RECOMMENDED READINGS
DeCoster TA, Miller RA. Management of Traumatic Foot Wounds. J Am Acad Orthop Surg. 1994 Jul;2(4):226-230. PubMed PMID: 10709013.
View Abstract at PubMed
Raikin SM. Common infections of the foot. In: Richardson EG, ed. Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:199-205.

Question 83:

Options:

radiation therapy.
en bloc excision.
posterior fusion at C2-C3 with instrumentation.
CT-guided aspiration followed by IV antibiotics.
radiofrequency ablation.

Correct Answer: en bloc excision.

Explanation:

DISCUSSION: The CT scan shows an osteoblastic nidus pathognomic for an osteoid osteoma. Surgical treatment should include an en bloc excision of the lesion. Surgical treatment is not mandatory because the lesion often becomes asymptomatic over time. This lesion is not amenable to radiofrequency ablation due to its proximity to the spinal cord. A complete corpectomy is not necessary to adequately resect the lesion, as only the nidus needs to be removed. Radiation therapy and antibiotics are not appropriate treatments for an osteoid osteoma. Posterior C2-C3 fusion will not address the pathology.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
Hadjipavlou AG, Lander PH, Marchesi D, et al: Minimally invasive surgery for ablation of osteoid osteoma of the spine. Spine 2003;28:E472-E477.

Question 84:

Options:

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

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

Explanation:

Question 85:

- Which of the following factors is used to determine torsional rigidity of a long bone fracture under internal or external fixation?

Options:

Bone rotation versus torque applied
Bone deflection versus bending moment applied
Axial displacement versus tension applied
Lateral translation versus shear force applied
Fracture gap closing versus compressive force applied

Correct Answer: Bone rotation versus torque applied

Explanation:

Question 86:

The cervical disk herniation shown in the MRI scans in Figures 30a and 30b will most likely create which of the following constellations of symptoms?

Options:

Right thumb and index finger numbness and triceps weakness
Right thumb and index finger numbness and wrist extensor weakness
Right wrist extensor weakness and diminished triceps reflex
Right middle finger numbness and diminished brachioradialis reflex
Right little and ring finger numbness and diminished brachioradialis reflex

Correct Answer: Right thumb and index finger numbness and wrist extensor weakness

Explanation:

Question 87:

Options:

Injury to the anterior band of the medial collateral ligament
Injury to the radial nerve
Injury to the lateral ulnar collateral ligament
Injury to the lateral radial collateral ligament
Excessive dissection of the extensor carpi radialis brevis origin

Correct Answer: Injury to the lateral ulnar collateral ligament

Explanation:

Question 88:

Options:

Forward elevation in the scapular plane
External rotation and abduction
Flexion, adduction, and internal rotation
Flexion and abduction

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 89:

Figures 31a and 31b show the radiograph and MRI scan of an otherwise normal 3-month-old infant who has a spinal deformity. MRI reveals no intraspinal anomalies. What is the next step in management?

Options:

Posterior spinal fusion with instrumentation
Anterior-posterior hemiepiphysiodesis
Brace management
Cardiac and renal evaluation
Hemivertebrectomy and fusion

Correct Answer: Cardiac and renal evaluation

Explanation:

DISCUSSION: Congenital scoliosis in an infant warrants evaluation of the renal, cardiac, and neurologic systems because frequently there is concurrent pathology. Progression in this instance is possible but not certain; therefore, progression must be documented prior to any surgical intervention. Close observation with serial radiographs every 4 to 6 months is appropriate. All of the surgical options listed may be reasonable choices in the future, but cardiac evaluation is the most important issue at this time.
REFERENCES: Basu PS, Elsebaie H, Noordeen MH: Congenital spinal deformity:
A comprehensive assessment at presentation. Spine 2002;27:2255-2259.
Hedequist D, Emans J: Congenital scoliosis. J Am Acad Orthop Surg 2004;12:266-275.

Question 90:

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Options:

volar open reduction and pinning.
open reduction, ligament repair, and pinning.
closed reduction and splinting.
closed reduction and pinning.
dorsal open reduction and pinning.

Correct Answer: closed reduction and splinting.

Explanation:

Question 91:

Histologically, synovial chondromatosis is characterized by

Options:

exuberant synovitis (Pannus).
loose fragments of articular cartilage embedded in the synovium.
ossified cartilage nodules embedded in the synovium.
the presence of granulomas in the synovium.
hemosiderin deposition in the synovium.

Correct Answer: ossified cartilage nodules embedded in the synovium.

Explanation:

Question 92:

Figure 10 shows the radiograph of an 18-year-old woman who sustained a spinal cord injury in a motor vehicle accident. Based on the radiographic findings, her injury is best described as

Options:

distractive extension.
compressive extension.
lateral flexion.
distractive flexion.
compressive flexion.

Correct Answer: distractive flexion.

Explanation:

Question 93:

A 43-year-old woman has an enlarging mass in the left groin. A radiograph, CT scan, and a biopsy specimen are shown in Figures 42a through 42c. Treatment should consist of

Options:

wide resection of the ischiopelvic region and acetabulum with reconstruction.
wide resection of the ischiopelvic region inferior to the acetabulum.
observation.
external beam radiation.
classic hemipelvectomy.

Correct Answer: wide resection of the ischiopelvic region inferior to the acetabulum.

Explanation:

Question 94:

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Options:

Using commercially available antibiotic-loaded bone cement
Adding 0.5 g vancomycin to commercially available antibiotic-loaded bone cement
Adding 0.5 g tobramycin and 0.5 g vancomycin/unit of standard bone cement
Adding either 1.0 g vancomycin or 1.2 g tobramycin per 40 g of standard bone cement
Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Correct Answer: Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Explanation:

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.
High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 95:

An operating room intervention that should be undertaken by anesthesia staff during the cementing of a femoral stem is to

Options:

decrease the fraction of inspired oxygen (FiO2).
decrease the intravenous (IV) fluid rate.
have phenylephrine on standby.
redose epidural anesthesia.

Correct Answer: have phenylephrine on standby.

Explanation:

Question 96:

Options:

increasing the force to dislocation of the femoral head.
increasing the range of motion until impingement of the neck on the liner.
decreasing the resisting moment to dislocation of the femoral head.
decreasing the range of motion until dislocation of the femoral head.
decreasing the range of motion until impingement of the neck on the liner.

Correct Answer: increasing the range of motion until impingement of the neck on the liner.

Explanation:

Question 97:

Options:

Repeat wide excision of the tumor bed
Observation
Radiation therapy to the tumor bed only
Chemotherapy
Radiation therapy and chemotherapy

Correct Answer: Repeat wide excision of the tumor bed

Explanation:

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,
a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 98:

Options:

Fixation in the tibial tunnel
Fixation in the femoral tunnel
Posterior placement of the tibial tunnel
Anterior placement of the femoral tunnel
Size of the patellar autograft

Correct Answer: Anterior placement of the femoral tunnel

Explanation:

Question 99:

Options:

Ruptured biceps tendon
Subscapularis tear
Anterior subluxation
Internal impingement syndrome
Locked posterior dislocation

Correct Answer: Subscapularis tear

Explanation:

Question 100:

Options:

Peroneal spastic flatfoot
Flexible flatfoot with a short Achilles tendon
Calcaneonavicular coalition
Talocalcaneal coalition
Posterior tibial tendon dysfunction

Correct Answer: Talocalcaneal coalition

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

Orthopedic Surgery Board Review MCQs: Ligament, Nerve & Spine | Part 239

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 239

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index