OITE Orthopedic Board Review MCQs: Trauma Part 241

About This Board Review Set

This is Part 241 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 241

This module focuses heavily on: Fracture.

Sample Questions from This Set

Sample Question 1: What is the primary indication for performing an arthroscopic synovectomy on a patient with hemophilia that is the result of factor VIII deficiency? Review Topic...

Sample Question 2: -The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?...

Sample Question 3: A 25-year-old woman has lower leg pain during exercise without numbness, tingling, or weakness. The symptoms resolve by the following day. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19a (Table 1)....

Sample Question 4: Figures 37a and 37b show the clinical photographs of a 43-year-old patient with type I diabetes mellitus who has a stump ulcer after undergoing successful transtibial amputation 1 year ago. Which of the following is considered the most pred...

Sample Question 5: A 34-year-old man underwent open reduction and internal fixation of a closed both bones forearm fracture 11 months ago. The radiographs shown in Figures 32a and 32b reveal a 3-mm gap and loose screws. What is the best treatment option?...

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

What is the primary indication for performing an arthroscopic synovectomy on a patient with hemophilia that is the result of factor VIII deficiency? Review Topic

Explanation

Improved medical management has changed musculoskeletal outcomes for individuals with hemophilia. Patients with severe hemophilia receiving prophylactic administration of factor VIII may never develop a target joint that requires further orthopaedic intervention. Patients with moderate hemophilia and those patients with severe hemophilia not receiving prophylactic treatment will still develop joints that have recurrent hemarthroses. When recurrent hemarthrosis continues despite optimal medical management, synovectomy is indicated. While synovectomy is predictable in its ability to decrease joint bleeding, it does not necessarily improve joint range of motion or prevent the development of hemophilic arthropathy over time. It will not reverse articular damage to the joint once it has developed.

Question 2

-The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?

Explanation

Question 3

A 25-year-old woman has lower leg pain during exercise without numbness, tingling, or weakness. The symptoms resolve by the following day. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19a (Table 1). She undergoes anterior compartment fasciotomy with complete resolution of symptoms. Two years later, she has recurrent pain and tightness with exercise. Radiographs, a technetium bone scan, and noninvasive vascular study findings are normal. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19b (Table 2). What is the most likely etiology for her recurrent symptoms?

Explanation

DISCUSSION
Exertional compartment syndrome involves an increase in compartment pressure caused by exercise or sports activity that restricts blood flow in the compartment, resulting in pain with continued activity. Compartment pressures of at least 15 mm Hg measured at rest, at least 30 mm Hg measured 1 minute after exercise, and at least 20 mm Hg measured 5 minutes after exercise are diagnostic. Surgical fasciotomy for exertional compartment syndrome is successful for the majority of patients, but recurrence rates as high as 20% have been reported. Scar formation within the fascial defect can result in recurrent symptoms and/or nerve entrapment, and recurrence is typically observed after an initial symptom-free period. In a series of 18 patients, recurrent symptoms occurred at a mean of 23.5 months after the index procedure. Other potential causes of recurrence include inadequate fascial release, failure to recognize involvement of other compartments, nerve compression, and misdiagnosis. Surgical complications after fasciotomy include hemorrhage leading to excessive fibrosis, neurovascular injury, and hematoma or seroma formation.

Question 4

Figures 37a and 37b show the clinical photographs of a 43-year-old patient with type I diabetes mellitus who has a stump ulcer after undergoing successful transtibial amputation 1 year ago. Which of the following is considered the most predictable method of healing the ulcer and preventing recurrent ulceration?

Explanation

DISCUSSION: The ulcer occurred as the result of a mismatch between the shape of the residual limb and the prosthetic socket. With the mismatch, the residual limb pistoned and the tissue failed because of the applied shear forces. The most predictable short- and long-term solution is reconstruction of the residual limb. Refraining from use of the prosthesis will prevent the patient from walking for months. It is unlikely that prosthetic socket modification will allow resolution of this large ulcer.
REFERENCE: Hadden W, Marks R, Murdoch G, et al: Wedge resection of amputation stumps: A valuable salvage procedure. J Bone Joint Surg Br 1987;69:306-308.

Question 5

A 34-year-old man underwent open reduction and internal fixation of a closed both bones forearm fracture 11 months ago. The radiographs shown in Figures 32a and 32b reveal a 3-mm gap and loose screws. What is the best treatment option?

Explanation

DISCUSSION: In an atrophic nonunion with a good soft-tissue envelope, adequate plating with cancellous bone graft can be used to span defects of up to 6 cm. Cortical graft from the fibula or iliac crest is not necessary. BMP-7 is a bone graft substitute and should not be used alone in this patient because the hardware is loose.
REFERENCES: Ring D, Allende C, Jafarnia K, et al: Ununited diaphyseal forearm fractures with segmental defects: Plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004;86:2440-2445.

Question 6

A college athlete on a scholarship has a medical condition that you feel presents a life-threatening risk to him with participation in athletics. Because of the gravity of this decision and the potential effect it can have on the student/athlete's future, the college asks for your guidance. As the team physician for the college, what is your ethical obligation?

Explanation

There is legal precedent for banning a scholarship athlete from participation in college athletics if the physician feels that it presents a significant physical risk to the athlete. The courts have decided that the athlete has no constitutional right to participate in NCAA sports, and as a team physician you must advise your athlete and the school as to the best course of action. The athlete must be allowed to keep his or her college scholarship.

Question 7

Figure 177 is an intra-articular photograph taken while viewing from the anterior superior portal during arthroscopy of a right shoulder. Which of the following findings identified at the time of surgery would be the most predictive for recurrence following arthroscopic repair of the demonstrated pathology? Review Topic

Explanation

Anterior glenoid bone deficiency of 35% is most predictive of recurrence. Figure 177 shows an acute tear of the anterior inferior glenoid labrum consistent with a Bankart lesion. It has been clearly shown that there is a direct relationship between failure (ie, recurrent dislocation) of arthroscopic Bankart repair and anterior glenoid bone loss. Anterior glenoid bone loss of greater than 25% in the setting of anterior glenohumeral instability is a relative contraindication to performing arthroscopic stabilization and instead is an indication to perform a bony glenoid augmentation procedure to address the articular arc deficit. Therefore, an anterior bony defect of 35% is the most predictive finding at the time of surgery for recurrent dislocation. An engaging Hill-Sachs deformity has a significant effect on the rate of redislocation, but a nonengaging one should not. An intra-articular loose body, subacromial bursitis, and a partial-thickness articular-sided supraspinatous tear should not lead to an increased risk of recurrent dislocation following Bankart repair.

Question 8

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

Explanation

DISCUSSION: The radiograph shows a faux profil view of the hip. The primary purpose of this view is to evaluate anterior coverage of the femoral head.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Lequesne M, deSez S: Le faux profil du bassin: Nouvelle incidence radiographique pour l’etude de la hance. Son utilite dans les dysplasies et les differentes coxopathies. Rev Rhum Mal Osteoartic 1961;28:643.

Question 9

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Explanation

DISCUSSION: Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury.
REFERENCES: Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.
Ford KR, Meyer GD, Hewett TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exer 2003;35:1745-1750.

Question 10

Acetabular reconstruction followed by external beam irradiation The plain radiographs show a purely lytic destructive lesion that is poorly marginated. The technetium bone scan does not show any major uptake. The computerized tomography scan shows purely lytic bone destruction with breakthrough of the cortical bone. Complete destruction of the cortical bone is suggestive of a malignancy. The magnetic resonance image shows a lesion that is homogenously low on T1-weighted images and high on T2-weighted images. Surgeons cannot make a definitive diagnosis based upon the radiographic features. The most common malignancies in this age group are:

Explanation

Slide 1 Slide 2 Slide 3 Slide 4
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. The most likely diagnosis based upon the radiographs would be:

Question 11

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Explanation

DISCUSSION:
Obesity, a prior history of venous thromboembolism, and metabolic syndrome have all been associated with an increased risk of thromboembolism. A recent meta-analysis showed that diabetes had no significant relationship with venous thromboembolism following hip or knee arthroplasty. Tranexamic acid is an antifibrinolytic agent that has been shown to reduce blood loss substantially following hip and knee arthroplasty. It has also been shown to be safe in patients with severe medial comorbidities and a prior history of venous thromboembolism.

Question 12

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 13

A 36-year-old woman reports vague right shoulder pain. She denies any previous shoulder problems or any recent trauma. MRI scans are shown in Figures 81a and 81b. Weakness of which of the following is the most likely finding in her physical examination? Review Topic

Explanation

The MRI scans show a cyst formation within the suprascapular notch that can compress the suprascapular nerve. The suprascapular nerve innervates both the supraspinatus and the infraspinatus muscles. Therefore, patients with compression of this nerve may demonstrate weakness of shoulder abduction and external rotation with the arm at the side. If the nerve is compressed after its innervation of the supraspinatus muscle, however, patients will demonstrate weakness of shoulder external rotation only. Suprascapular nerve does not innervate muscles that control scapula motion or shoulder internal rotation.

Question 14

A 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 15

What is the structure indicated by the letter “A” in Figure A? Review Topic

Explanation

The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter “A” is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter “C” and the annular ligament is indicated by the letter “B.” The transverse ligament is a component of the medial collateral ligament complex.

Question 16

An 18-year-old boy has had pain in the right knee for the past 6 months. Examination reveals some fullness behind the knee but no significant palpable soft-tissue mass. There is no effusion, and he has full knee range of motion. The remainder of the examination is unremarkable. A radiograph and MRI scans are shown in Figures 33a through 33c, and biopsy specimens are shown in Figures 33d and 33e. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has parosteal osteosarcoma. The posterior aspect of the distal femur is the typical location for this variant of osteogenic sarcoma. The imaging studies indicate a surface lesion with no involvement of the adjacent intramedullary canal. The histologic appearance is that of a low-grade fibroblastic osteosarcoma, consisting of relatively mature bone and a bland fibroblastic stroma lacking cytologic atypia and mitotic activity. A cartilaginous component is also frequently seen. Classic osteosarcoma typically has a more aggressive radiologic and histologic appearance. Sessile osteochondromas, while common behind the knee, have a presence of hematopoietic marrow and fat. The cartilage found in the associated cartilaginous cap is oriented. Chondrosarcomas are more typical in an older age group and have a histologic pattern consisting of malignant chondroid.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 20-21.
Unni KK, Dahlin DC, Beabout JW, Ivins JC: Parosteal osteogenic sarcoma. Cancer 1976;37:2466-2475.

Question 17

40A B Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

Explanation

DISCUSSION
Ankle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearing
as tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.
RECOMMENDED READINGS
Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):368-77. Review. PubMed PMID: 9826420. View Abstract at PubMed
DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006 Oct;27(10):854-66. Review. PubMed PMID: 17054892. View Abstract at PubMed
Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604. View Abstract at PubMed

Question 18

The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

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

Question 19

What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

Explanation

DISCUSSION: When a recurrent neuroma forms at the end of the resected nerve, it does not retract far enough because either the transection was not proximal enough or it is tethered by plantar neural branches. The transverse intermetatarsal ligament may reform, but it is not associated with pathology. Synovial cysts and synovitis are part of the differential diagnosis but are not associated with neuroma excision. Complex regional pain syndrome may result from neuroma excision, but this is rare and the symptoms are different.
REFERENCES: Beskin JL: Recurrent interdigital neuromas, in Nunley JA, Pfeffer GB, Sanders RW, Trepman E (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 481-484.
Amis JA, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton’s neuroma excision. Foot Ankle 1992;13:153-156.

Question 20

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Explanation

The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 21

A non-communicative 16-year-old girl with spastic quadriplegic cerebral palsy and a 75-degree thoracolumbar scoliosis undergoes a successful posterior spinal fusion with instrumentation. What is the most predictable outcome of the surgical procedure?

Explanation

DISCUSSION: Surgical treatment of spinal deformity in a totally involved child with cerebral palsy has been shown on outcomes instruments to significantly improve the caregiver’s perception of the child’s comfort. The other parameters mentioned are difficult to measure and unpredictable.
REFERENCES: Tsirikos Al, Lipton G, Chang WN, et al: Surgical correction of scoliosis in pediatric patients with cerebral palsy using the unit rod instrumentation. Spine 2008;33:1133-1140.
Cassidy C, Craig CL, Perry A, et al: A reassessment of spinal stabilization in severe cerebral palsy. J Pediatr Orthop 1994;14:731-739.

Question 22

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Explanation

Minimally invasive methods used for stabilizing complex periarticular fractures continue to evolve. Encouraging results suggest a diminished threat to the soft tissues and enhanced preservation of osseous blood supply. Contemporary locking implants combined with indirect reduction lead to desirable biomechanical and biologic environments for osseous and soft-tissue healing. Deangelis and associates, in a cadaveric tibial study, demonstrated the superficial peroneal nerve to be at significant risk during percutaneous screw placement in very distal targeted holes (within laterally applied tibial locking plates). Use of a larger incision and cautious dissection to the plate in this region were encouraged to minimize risk to this structure.

Question 23

An 18-year-old high school basketball player is being treated for Achilles tendinitis. What type of strengthening exercise has been shown to be helpful in the later phases of rehabilitation?

Explanation

DISCUSSION: Eccentric strengthening for tendinopathies has proved most helpful in the later stages of rehabilitation. Although the exact mechanism of the effect on eccentric exercises is not known, the most widely accepted theory is that the absence of concentric stretching disrupts the normal lengthing/shorten- ing cycle which may cause shearing in the tendon and injury to the collagen. Isokinetic exercise maintains a constant angular velocity of joint motion. Isotonic exercise maintains a constant force of contraction while isometric contraction develops force without changing the length of the musculotendinous unit.
All three types of these exercises have not been shown to benefit Achilles tendinitis as much as eccentric exercise.
REFERENCES: Jonsson P, Alfredson H, Sunding K, et al: New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: Results of a pilot study. Br J Sports Med
2008;42:746-749.
Maffulli N, Walley G, Say ana MK, et al: Eccentric calf muscle training in athletic patients with Achilles tendinopathy. Disabil Rehabil 2008;30:1677-1684.

Question 24

A patient with a grade 2 L5-S1 isthmic spondylolisthesis reports low back pain and bilateral lower extremity pain. Nonsurgical management has failed to provide relief, and the patient is now a candidate for surgical intervention. The

Explanation

The L5 nerve root is especially vulnerable and prone to injury after the reduction of spondylolisthesis in patients with mid-and high-grade isthmic spondylolisthesis. The genitofemoral nerve is more commonly injured during anterior retroperitoneal approaches to the lumbar spine. Injury to the cauda equina often leads to bowel and bladder dysfunction and lower extremity weakness and is uncommon after reduction maneuvers.

Question 25

A 2-week-old infant has been referred for evaluation of nonmovement of the left hip. History reveals that the patient was delivered 6 weeks premature by cesarean section. Examination reveals no fever, and there is mild swelling of the thigh. Passive movement of the hip appears to elicit tenderness and very limited hip motion. A radiograph of the pelvis shows mild subluxation of the left hip. The next step in evaluation should consist of

Explanation

DISCUSSION: The diagnosis of bone and joint sepsis in a newborn is difficult because of the relative lack of obvious signs and symptoms. Fever is usually absent. A study of 34 newborns with osteomyelitis identified prematurity and delivery by cesarean section as predisposing factors. In that study, the most common clinical findings were pseudoparalysis, local swelling, and pain on passive movement. Because early diagnosis is so important, any infant who exhibits these findings should be suspected as having bone or joint sepsis. Once the area of involvement is identified, aspiration is mandatory. In newborns who have an infection about the hip, radiographs may reveal subluxation. In this patient, septic arthritis must be ruled out by aspiration of the hip. Developmental dysplasia of the hip is not painful and is not accompanied by localized swelling. If no purulent material is obtained at the time of hip aspiration, an arthrogram should be obtained to rule out epiphysiolysis of the proximal femur. Because the area of involvement has been identified by clinical examination, a gallium scan or MRI scan of the spine is not indicated.
REFERENCES: Knudsen CJ, Hoffman EB: Neonatal osteomyelitis. J Bone Joint Surg Br 1990;72:846-851.
Morrissy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 579-624.

Question 26

Which of the following factors is most closely associated with early postoperative migration of “stand-alone” lumbar interbody fusion cages?

Explanation

DISCUSSION: Postoperative migration of lumbar interbody fusion cages is a rare complication. It is most commonly seen after placement of the cages through a posterior approach, with instability of the final construct. It is not associated with the design of the cage, the type of graft used, or a resultant pseudarthrosis.
REFERENCES: McAfee PC: Interbody fusion cages in reconstructive operations on the spine. J Bone Joint Surg Am 1999;81:859-880.
McAfee PC, Cunningham BW, Lee GA, et al: Revision strategies for salvaging or improving failed cylindrical cages. Spine 1999;24:2147-2153.

Question 27

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

Explanation

DISCUSSION: There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding. The patient has a lateral compression Burgess-Young type I pelvic ring injury. This injury does not increase the pelvic volume because it is not unstable in external rotation. Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern. Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization. If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography. Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated.
REFERENCES: Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols. J Trauma 1990;30:848-856.
Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management. Arch Surg 1989;124:422-424.
Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture. Ann Surg 1990;211:703-707.

Question 28

What is the most common presenting problem in patients with cauda equina syndrome? Review Topic

Explanation

In one recent retrospective cohort study of 42 patients with cauda equina syndrome, 83% had low back pain at presentation, 90% had radicular lower extremity pain, 60% had urinary retention, and 55% had urinary incontinence. Objective findings at presentation included 55% with leg weakness, 62% with sensory deficit, 62% with absent ankle jerk reflexes, 76% with perianal sensory deficit, and 50% with decreased rectal tone.

Question 29

Which of the following regions in the growth plate is commonly affected in a Salter-Harris type II injury? Review Topic

Explanation

A type II injury consists of a fracture along the hypertrophic zone of the growth plate with an attached metaphyseal bony fragment. The hypertrophic zone is the metaphyseal fragment and is located on the compressive or concave side, whereas periosteum is torn on the tensile or convex side. The reserve and proliferative zones remain with the epiphysis and the circulation is usually preserved.

Question 30

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 31

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 32

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Explanation

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 33

Figure 10 shows patellar radiographs of a 68-year-old woman who underwent bilateral total knee arthroplasty 2 months ago. Following a recent fall onto the left side, she now reports anterior pain in the left knee. A CT scan shows that the femoral and tibial components are appropriately externally rotated and radiographs show acceptable axial alignment and no evidence of loosening. What is the most appropriate treatment option?

Explanation

DISCUSSION: Treatment of patellofemoral instability after total knee arthroplasty (TKA) is directed by its etiology. In instances of component malpositioning, revision of one or both components is indicated.
If the components are determined to be in satisfactory position, soft-tissue procedures can be pursued. Lateral retinacular release is usually the first soft-tissue procedure used to improve patellofemoral mechanics. In this patient, the patellar fracture fragment is so small that it can be excised. Distal realignment is not usually used as the first line of treatment for patellar maltracking following TKA.
REFERENCES: Fehring TK, Christie MJ, Lavemia C, et al: Revision total knee arthroplasty: Planning, management, and controversies. Instr Course Lect 2008;57:341-363.
Patel J, Ries MD, Bozic KJ: Extensor mechanism complications after total knee arthroplasty. Instr Course Lect 2008;57:283-294.

Question 34

A 15-year-old high school soccer player collides with an opponent and is unconscious when the trainer arrives on the field. He is conscious within 15 seconds, breathing appropriately, and denies any headache, neck pain, or nausea. It is his first head injury. Provided that the athlete is free of symptoms, when should he be allowed to return to athletic activity?

Explanation

DISCUSSION: The loss of consciousness indicates a grade 2 concussion, which necessitates a
week period out of sport. The last week prior to return must be symptom-free and the athlete should not have symptoms in practice.
REFERENCES: Cantu RC: Return to play guidelines after a head injury. Clin Sports Med 1998;17:45-60.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 35

When performing elbow arthroscopy, it is often necessary to evaluate the posterior compartment. When entering the posterior compartment of the elbow, what are the two safest and most commonly used portals? Review Topic

Explanation

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the "workhorse" portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

Question 36

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?

Explanation

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 37

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

Explanation

DISCUSSION: Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustration A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.
Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.
Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.
Incorrect
2:
This
describes
an
APC-II
injury
3:
This
describes
an
APC-III
injury
4:
This
describes
and
LC-I
injury

Question 38

A 52-year-old woman with a 2-year history of a flexible (stage II) adult-acquired flatfoot deformity has failed to respond to nonsurgical management consisting of immobilization, custom orthotics, nonsteroidal anti-inflammatory drugs, and physical therapy. The patient is unable to perform a single limb heel rise. Weight-bearing radiographs are shown in Figures 30a through 30c. What is the most appropriate surgical correction?

Explanation

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 39

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Explanation

DISCUSSION: The lesion is typical of a subungual exostosis, which is most often found on the medial aspect of the great toe in children and young adults. The diagnosis is confirmed on radiographs and usually requires excision for relief.
REFERENCES: Lokiec F, Ezra E, Krasin E, Keret D, Wientraub S: A simple and efficient surgical technique for subungual exostosis. J Pediatr Orthop 2001;21:76-79.
Letts M, Davidson D, Nizalik E: Subungual exostosis: Diagnosis and treatment in children. J Trauma 1998;44:346-349.
Davis DA, Cohen PR: Subungual exostosis: Case report and review of the literature. Pediatr Dermatol 1996;13:212-218.

Question 40

-Figure 162 is the CT scan of a 74-year-old woman who struck her head during a ground-level fall and has severe neck pain. Examination reveals normal strength and sensation in her upper and lower extremities.What is the most appropriate treatment option?

Explanation

Question 41

A 35-year-old man has had progressive right knee pain for the past 2 months. An AP radiograph, bone scan, MRI scan, and photomicrograph are shown in Figures 34a through 34d. What is the most appropriate treatment of this lesion?

Explanation

DISCUSSION: This is a classic case of giant cell tumor of bone. The radiograph and the MRI scan reveal a purely lytic lesion in the medial femoral condyle. The lesion is well-demarcated without a rim of sclerotic bone. It is eccentrically located and abuts the subchondral bone. The lesion demonstrates increased uptake on a technetium TC 99m bone scan. These imaging studies are highly suggestive of giant cell tumor arising in its most common location. The photomicrograph confirms the diagnosis of giant cell tumor. Based on these findings, the most widely accepted treatment is extended curettage plus a local adjuvant such as polymethylmethacrylate bone cement, argon beam coagulation, liquid nitrogen, and/or phenol.
REFERENCES: Lackman RD, Hosalkar HS, Ogilvie CM, et al: Intralesional curettage for grades II and III giant cell tumors of bone. Clin Orthop Relat Res 2005;438:123-127.
Ward WG Sr, Li G III: Customized treatment algorithm for giant cell tumor of bone: Report of a series. Clin Orthop Relat Res 2002;397:259-270.

Question 42

A 39-year-old competitive cyclist sustains an injury to her left hip in a fall. Gadolinium arthrography, with an accompanying MRI scan, is shown in Figure 31. A cleft, or defect, identified by the arrow, indicates a detachment of the

Explanation

DISCUSSION: The area indicated by the arrow represents gadolinium contrast extending into a separation between the lateral labrum and its acetabular attachment. This can be a traumatic detachment, but occasionally a cleft may be present as a normal variant of the labral morphology. The capsular attachment of the iliofemoral ligament is peripheral to the labrum. The pulvinar is the common name applied to the fat and overlying synovium contained within the acetabular fossa above the ligamentum teres. The zona orbicularis is a circumferential thickening of the capsule around the femoral neck, and the retinacular vessels travel within the capsular synovium up the femoral neck to supply the femoral head.
REFERENCES: Petersilge CA, Haque MA, Petersilge WJ, Lewin JS, Lieberman JM, Buly R: Acetabular labral tears: Evaluation with MR arthrography. Radiology 1996;200:231-235.
Czerny C, Hofmann S, Neuhold A, et al: Lesions of the acetabular labrum: Accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200:225-230.
Byrd JWT: Indications and contraindications, in Byrd JWT (ed): Operative Hip Arthroscopy. New York, NY, Thieme, 1998, pp 7-24.

Question 43

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

Explanation

CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9

Question 44

A 65-year-old woman with rheumatoid arthritis is undergoing revision total knee arthroplasty (TKA) during which the medial collateral ligament (MCL) is damaged. Suture anchors are used to attempt primary repair, and a varus-valgus constrained insert also is used. Postsurgically she experiences instability that does not respond to bracing with a 3+ opening to valgus stress (Figure 120). What is the most appropriate surgical option?

Explanation

DISCUSSION
MCL repair or reconstruction may be considered in younger, more active patients, but this intervention is technically demanding and produces variable results. Rotating-hinge TKA is associated with good results in a number of small series that include cases performed with MCL insufficiency or absence. A rotating hinge is preferable over a fixed hinge because of decreased stresses on implants imposed by fixed-hinge devices.

Question 45

Figures 51a and 51b show subluxation of the

Explanation

DISCUSSION: The extensor carpi ulnaris tendon is shown subluxated from its tunnel at the ulnar head; this requires disruption of the tendon’s subsheath.
REFERENCES: Rowland SA: Acute traumatic subluxation of the extensor carpi ulnaris tendon at the wrist. J Hand Surg Am 1986;11:809-811.
Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1026-1027.

Question 46

At revision, the stem is retained and a new head with a polyethylene bearing is selected. The best option for the head is

Explanation

DISCUSSION
Ceramic-on-ceramic is a controversial bearing surface typically reserved for younger patients such as this one. Some studies have suggested that the bearing is more expensive and does not really prolong the service life of the implant, although a recent meta-analysis of high-quality trials showed that there is a decreased revision rate with ceramic-on-ceramic, so its use may be justified. Complications of intraoperative bearing fracture and squeaking are more common than with conventional bearings, but pain and function scores are equivalent. Stripe wear associated with a vertical cup and morbid obesity are related to an increased risk for liner fracture. Concerns about head fractures with a new ceramic head and a damaged trunnion have led investigators to conclude that using a harder bearing than the initial bearing surface with a built-in titanium sleeve is probably the best solution when a stem is retained during revision surgery.

Question 47

-What is the most common metatarsal fracture in a 3-year-old?

Explanation

CLINICAL SITUATION FOR QUESTIONS 77 AND 78
Figures 77a through 77c are the preoperative and postoperative radiographs of a 13-year-old boy who had sudden worsening of left hip pain following many months of mild pain. He was unable to walk because of his pain and underwent screw fixation.

Question 48

Which of the following patients with cerebral palsy is considered the ideal candidate for a selective dorsal rhizotomy?

Explanation

DISCUSSION: The enthusiasm with which dorsal rhizotomy was received led to the broadening of selection criteria with poorer results. The ideal candidate is an ambulatory 4- to 8-year-old child with spastic diplegia who does not use assistive devices or have joint contractures. The child must be old enough to actively participate in the rigorous postoperative physical therapy program. The use of the procedure in an ambulatory 16-year-old patient is less desirable because joint contractures will most likely have developed to a varying degree. The hemiplegic child is best treated by orthopaedic interventions.
REFERENCES: Oppenheim WL: Selective posterior rhizotomy for spastic cerebral palsy: A review. Clin Orthop 1990;253:20-29.
Renshaw TS, Green NE, Griffin PP, Root L: Cerebral palsy: Orthopaedic management. J Bone Joint Surg Am 1995;77:1590-1606.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 19-27.

Question 49

A child born with myelomeningocele is expected to be an ambulator with bracing. Examination by the consulting orthopaedic surgeon reveals rigid clubfeet in addition to the neurologic issues. Management should consist of

Explanation

DISCUSSION: In a child with myelomeningocele, the guiding principle of treatment is to achieve a plantigrade foot by the time the child is ready to stand. The standard clubfoot protocol should be followed, but these children will require an aggressive surgical release to obtain a sufficient correction.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 65-78.
Kasser JE (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 503-514.

Question 50

A 48-year-old woman has knee pain that is worse with weight bearing. She reports no night pain or pain at rest. History reveals that she underwent total knee arthroplasty with cementless components 2 years ago. Examination reveals tenderness along the medial joint line. Figures 12a through 12c show radiographs and a bone scan. What is the most likely cause of the patient’s pain?

Explanation

DISCUSSION: The radiographs show a halo-like sclerotic margin around the tibial stem and lucency under the baseplate. The bone scan shows markedly increased uptake under the tibial component, particularly on the medial side (not diffusely through the knee as seen with infection). These studies indicate lack of bone ingrowth fixation of the cementless porous-coated tibial component. The recent report of Fehring and associates has identified failure of ingrowth of a porous-coated implant as a dominant mode of early failure of total knee arthroplasties.
REFERENCES: Fehring TK, Odum S, Griffin WL, Mason B, Nadaud M: Early failures of total knee arthroplasty. Clin Orthop 2001;392:315-318.
Fehring TK: Revision TJA corrects flexion extension gap imbalance. Orthop Today 2002;22:44.

Question 51

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

Explanation

DISCUSSION: The use of intramuscular botulinum type A toxin has been shown to be a useful adjuvant in the management of dynamic deformity in patients with cerebral palsy. Botulinum type A toxin is a neurotoxin produced by Clostridium botulinum that works by interfering with presynaptic acetylcholine release at cholinergic nerve terminals. At the cellular level, the mechanism involves endocytosis of the intact botulinum toxin molecule by cells in the end plate, followed by disulfide cleavage and translocation of the light chain into the cytosol where it disrupts the normal binding of the synaptosomal vesicles to the axon terminal membrane. Neither the nerve terminal nor the neuromuscular junction is damaged. The muscle paralysis is reversible and dose-dependent. Baclofen is a neuropharmacologic agent that functions as a GABA agonist. Dorsal rhizotomy is a neurosurgical procedure that reduces spasticity by dividing afferent (excitatory) fibers in the posterior rootlet of the spinal nerves.
REFERENCES: Koman LA, Mooney JF III, Smith B, Goodman A, Mulvaney T: Management of cerebral palsy with botulinum-A toxin: Preliminary investigation. J Pediatr Orthop 1993;13:489-495.
Brin MF: Botulinum toxin: Chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl 1997;6:S146-168.

Question 52

Figures 3a through 3c show the radiographs and bone scan of a patient who reports increasing pain associated with activity for the past several months. Laboratory studies show an erythrocyte sedimentation rate of 14 mm/h and a C-reactive protein level of 0.4. Aspiration is negative for infection. Management should consist of

Explanation

DISCUSSION: The radiographs show polyethylene wear, but exchange of this will not necessarily provide pain relief. The presence of pain suggests the possibility of occult loosening, and the surgeon must be prepared for this option intraoperatively. There is little evidence of infection.
REFERENCES: Rand JA, Peterson LF, Bryan RS, Ilstrup DM: Revision total knee arthroplasty, in Anderson LD (ed): Instructional Course Lectures XXXV. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1986, pp 305-318.
Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 317-322.

Question 53

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

Explanation

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

Question 54

What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?

Explanation

DISCUSSION: The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.
The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.
The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).

Question 55

The AP radiograph of a 5-year-old boy shows a 20-degree left thoracic scoliosis. He was noted by his pediatrician to have asymmetry on a forward bend test. On examination he is neurologically intact except for decreased sensation on the lateral aspect of both flanks and to pinprick in both hands. He has no pain. What is the best initial step in treatment at this time? Review Topic

Explanation

This patient has atypical scoliosis, given his young age and left thoracic curve. In addition, he has abnormal neurologic findings. MRI scan to evaluate for neural axis abnormalities is indicated. Abnormal MRI findings are present in 2% to 3.8% of all patients with presumed idiopathic scoliosis. Abnormal MRI findings are more likely if specific clinical factors are present, such as absence of thoracic apical segment lordosis, atypical curve pattern, an abnormal neurologic examination, male gender, and age younger than 11. In a patient with an atypical curve and neurologic indicators, the yield of MRI scan for a neuraxis abnormality has been shown to be 25%. This patient had both syringomyelia and a Chiari malformation that were treated neurosurgically. Observation would have missed these findings. Bracing or spinal instrumentation may eventually be treatment options for scoliosis given his young age, but establishing a diagnosis first with an MRI scan of the spine is the most appropriate initial step.

Question 56

A 4-year-old boy with arthrogryposis has little active motion of his knees or elbows. Both elbows are in full extension with good triceps strength, but he is unable to bring his hand to his face or feed himself. Management should consist of

Explanation

DISCUSSION: Elbow release and triceps transfer to restore motion can be performed in children who are age 4 years and older. The ability to flex the elbow either actively or passively is of great assistance in activities of daily living.
REFERENCES: Van Heest A, Waters PM, Simmons BP: Surgical treatment of arthrogrypsosis of the elbow. J Hand Surg Am 1998;23:1063-1070.
Caroll RE, Hill NA: Triceps transfer to restore elbow flexion: A study of fifteen patients with paralytic lesions and arthrogryposis. J Bone Joint Surg Am 1970;52:239-244.

Question 57

2010 Pediatric Orthopaedic Examination Answer Book • 9 A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis?

Explanation

DISCUSSION: The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta.
There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.
REFERENCES: Goldberg MJ, Yassir W, Sadeghi-Nejad A: Clinical analysis of short stature. J Pediatr Orthop 2002;22:690-696.
Parmar VS, Stanitski DF, Stanitski CL: Interpretation of radiographs in a pediatric limb deformity practice: Do
radiologists contribute? J Pediatr Orthop 1999;19:732-734. Question 4
Patients with slipped capital femoral epiphysis are more likely to experience a delay in definitive diagnosis if they initially present to a physician reporting which of the following problems?
L Limp
Hip pain
Knee pain
Proximal thigh pain
Buttock pain
DISCUSSION: A delay in diagnosis of slipped capital femoral epiphysis (SCFE) can lead to significant worsening of the deformity or even progression from a stable to an unstable SCFE. Those patients that report knee pain as their primary complaint are most likely to experience significant delay. Other variables associated with this delay include Medicaid insurance and stable SCFE.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis.
AL-Madena Copy
10 • American Academy of Orthopaedic Surgeons
Pediatrics 2004;113:e322-e325.
Rahme D, Comley A, Foster B, et al: Consequences of diagnostic delays in slipped capital femoral epiphysis. J Pediatr Orthop B 2006;15:93-97.

Question 58

Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes

Explanation

DISCUSSION: The use of gamma radiation to sterilize polyethylene will result in the formation of free radicals in the material that increase the susceptibility of the material to oxidation and wear. The packaging can also have an impact. If the polyethylene is packaged in air, the oxygen in the packaging can significantly oxidize the material on the shelf prior to clinical use. Gas plasma and ethylene oxide sterilization do not appear to increase oxidation of polyethylene.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 449-486.
Wright TM: Ultra-high molecular weight polyethylene, in Morrey BF (ed): Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991, pp 37-46.
Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
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Question 59

A 10-month-old infant has a deformity of the right foot. Radiographs, including simulated weight-bearing AP and lateral views and a maximum plantar flexion lateral view, are shown in Figures 57a through 57c. Initial management of the foot should consist of Review Topic

Explanation

The radiographs show a congenital vertical talus. This is confirmed on the maximum plantar flexion lateral view which shows failure of the long axis of the first metatarsal to align with the long axis of the talus. This finding is caused by a fixed dorsal dislocation of the navicular on the head of the talus. The initial treatment should consist of manipulation and serial cast application in an attempt to elongate the contracted dorsolateral tendons, joint capsules, and skin. Surgery is always required to complete the correction. Traditionally, surgical treatment consisted of lengthening of the dorsolateral tendons, release of the talonavicular joint capsule, and lengthening of the Achilles tendon. Recently, Dobbs and associates reported the successful use of manipulation and cast immobilization, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. There are no studies documenting the effectiveness of orthoses for the treatment of this condition. Lateral column lengthening may be indicated in older individuals with a symptomatic flexible flatfoot, especially those with neurologic conditions. Observation may be indicated in a young child with a painless flexible flatfoot.

Question 60

A 24-year-old woman has a spleen laceration and hypotension. Radiographs reveal a pulmonary contusion and a displaced mid-diaphyseal fracture of the femur. The trauma surgeon clears her for stabilization of the femoral fracture. What technique will offer the least potential for initial complications?

Explanation

DISCUSSION: A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Recent evidence has shown that the presence of a lung injury is the most important determining factor in future deterioration. However, despite the lung injury and its potential consequences, this patient’s femur fracture needs stabilization. Because damage control in the multiply injured patient requires a technique that can be performed rapidly and consistently, the treatment of choice is application of an external fixator. By placing two pins above and below the fracture and with longitudinal traction, the fracture is quickly realigned and stabilized. This allows the patient to be resuscitated and treated at a later date when definitive management of the fracture can be carried out. There is little difference between plate fixation and intramedullary nailing.
REFERENCES: Bosse MJ, MacKenzie EJ, Riemer BL, et al: Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated with either intramedullary nailing with reaming or with a plate: A comparative study. J Bone Joint Surg Am 1997;79:799-809.
Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN: External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: Damage control orthopedics. J Trauma 2000;48:613-623.
Pape HC, Auf’m’Kolk M, Puffrath T, et al: Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion: A cause of posttraumatic ARDS? J Trauma 1993;34:540-548.

Question 61

A 6-year-old boy has had increasing pain and a mass in the suprapatellar region of the right femur for the past week. Examination of the mass reveals it may be firm, immobile, and tender to palpitation. The patient has no systemic symptoms. Laboratory studies show a WBC of 7000 per cubic millimeter, a hematocrit of 40%, and an erythrocyte sedimentation rate of 10 mm/hr. radiographs are normal. Figures 64a and 64b show saggital and axial T1-weighted MRI scans. Figure 64c shows frozen section pathology of the biopsy specimen. What is the most likely diagnosis?

Explanation

Multiple hints in this history, MRI and pathology section leads to the diagnosis of soft tissue abscess. The sarcomas are slow growing and mostly are asymptomatic. The mass is tender and enlarging over the past week. PVNS would give the patient a painful boggy joint and this mass is supracondyler. Esinophilic granuloma would give a punched-out lesion in the long bones on the plain radiographs. The best clue is the slide given which shows inflammatory cells. PVNS would show hemosiderin stained giant cells, synovial sarcoma would reveal a biphasic pattern of spindle cells, E.G. would show eosinophils and histiocytes, and rhabdomyosarcoma would have cross striation within the tumor cells.

Question 62

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

Explanation

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

Question 63

Figures 1 and 2 are the radiographs of a 40-year-old woman who sustained a twisting injury to her lower extremity. What additional information or studies are important in determining treatment options?

Explanation

Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is
displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:

Question 64

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic

Explanation

Bone bruises are often noted on MRI after anterior cruciate and medial collateral ligament injuries. The significance of these injuries awaits long-term follow-up studies. The areas of increased signal on T2-weighted images represent areas of acute hemorrhage and are secondary to microfractures of the adjacent medullary trabeculae.

Question 65

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 66

Tendon fibroblasts detect applied strain through what mechanism?

Explanation

The primary cilium is a cellular extension present in nearly every cell of the body, and has been shown to have critical importance in numerous functions. Emerging evidence in tendon mechanobiology suggests that mechanotransduction signaling is also mediated by the deflection of the primary cilium in response to tendon loading. "Induced apoptosis from tendon loading" would infer that each time a tendon was loaded and a portion of the tenocytes apoptosed, there would be fewer cells left, and no hope for a hypertrophy response to the loads applied. Tendon loading-mediated cell pressurization and cell elongation were previously suggested as possible means for a mechanism to mediate mechanotransduction.

Question 67

-A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms?

Explanation

Question 68

A 37-year-old man pulled his hamstring playing softball 3 weeks ago. The patient had not noted any mass prior to his injury. MRI scans of the posterior thigh are shown in Figures 4a and 4b. Figure 4c shows the biopsy specimen from a needle biopsy. What is the most likely diagnosis?

Explanation

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T₂-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 965-981.

Question 69

A 21-year-old man has had posterior neck discomfort for the past 6 months. A whole-body bone scan and a cervical single-photon emission CT reveal increased activity at the C7 spinous process. MRI reveals multifocal involvement of the spinous process lamina and facet of C7. A CT-directed needle biopsy reveals osteoblastoma. What is the best course of action?

Explanation

DISCUSSION: En bloc excision is the recommended treatment of osteoblastoma. Treatment should consist of en bloc removal of the lamina, facet, and spinous process. Facet removal would necessitate fusion. Radiation therapy is not recommended. Intralesional curettage has a high rate of recurrence.
REFERENCES: Bridwell KH, Ogilvie JW: Primary tumors of the spine, in Bridwell KH, DeWald RL (eds): The Textbook of Spinal Surgery. Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1143-1174.
Ozaki T, Liljenquist U, Hillmann A, et al: Osteoid osteoma and osteoblastoma of the spine: Experience with 22 patients. Clin Orthop 2002;397:394-402.

Question 70

A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. Management should consist of

Explanation

DISCUSSION: Open reduction and internal fixation is the treatment of choice for accurate reduction of the disrupted intercarpal ligaments. In addition, the displaced scaphoid fracture will require open reduction and internal fixation and possible bone grafting. Closed reduction and long arm casting will not allow accurate reduction of the dislocated intracarpal intervals, and it is unlikely to allow accurate reduction of the scaphoid. The maneuver required to effect closed reduction of a displaced scaphoid fracture will most likely cause the scaphoid lunate interval to displace. Closed reduction with percutaneous pin fixation or with an external fixator is unable to effect anatomic reduction of the injury. Proximal row carpectomy is used as a salvage procedure for a variety of degenerative and posttraumatic problems of the wrist.
REFERENCES: Kozin SH: Perilunate injuries: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120.
Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.
Sotereanos DG, Mitsionis GJ, Ginnakopoulos PN, Tomaino MM, Herndon JH: Perilunate dislocation and fracture dislocation: A critical analysis of the volar-dorsal approach. J Hand Surg Am 1997;22:49-56.

Question 71

A 27-year-old woman sustained a bilateral C5-6 facet subluxation in a motor vehicle accident. Neurologic evaluation reveals normal motor, sensory, and reflex functions. She is awake, alert, and cooperative. Initial management should consist of

Explanation

DISCUSSION: As long as the patient is alert and cooperative, an attempt can be made to reduce the dislocation. This should not be attempted in a patient who is obtunded, comatose, or uncooperative. If any neurologic changes are noted during the reduction maneuver, the attempt should be stopped, appropriate radiographic studies obtained, and open reduction and stabilization planned in the operating room.
REFERENCE: Eismont FJ, Arena MJ, Green BA: Extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets: Case reports. J Bone Joint Surg Am 1991;73:1555-1560.

Question 72

In total knee arthroplasty, in vitro testing has shown that cross-linking can diminish the rate of polyethylene wear by 30% to 80%. What other change in material properties is possible when polyethylene is highly cross-linked?

Explanation

DISCUSSION:
The most important concern regarding highly cross-linked polyethylene relates to decreased mechanical properties. Cross-linking results in reduced ductility, tensile strength, and fatigue crack propagation resistance. These problems have not been shown to cause implant failure in the most recent clinical trials, but they remain the most important mechanical issues associated with current material processing methods.

Question 73

What is the most common benign bone tumor in childhood?

Explanation

DISCUSSION: The most common benign bone tumor in childhood is a nonossifying fibroma. It is estimated that 30% of children have a nonossifying fibroma. In most patients, the lesion is not identified until a radiograph is obtained for unrelated reasons. Similarly, most identified cases of fibrous cortical defect are not biopsied because the radiographic and clinical presentations are diagnostic.
REFERENCES: Aboulafia AJ, Kennon RE, Jelinek JS: Benign bone tumors of childhood. J Am Acad Orthop Surg 1999;7:377-388.
Biermann JS: Common benign lesions of bone in children and adolescents. J Pediatr Orthop 2002;22:268-273.

Question 74

Which of the following is an FDA approved adjunctive treatment for an acute open tibia fracture being treated with an intramedullary nail?

Explanation

rhBMP-2 has FDA approval for use when treating acute open tibia fractures with an intramedullary nail.
Open tibial shaft fractures can present many treatment challenges. Although its use remains somewhat controversial, rhBMP-2 has been shown to have many positive effects when used to treat acute open tibia fractures. These benefits include accelerated early fracture healing, decreased rates of hardware failure, decreased need for subsequent bone grafting procedures, and decreased infection rates. rhBMP-2 does have FDA approval specifically for use in open tibia fractures being treated with an intramedullary nail.
Alt et al. present a comparison of patients with Grade III open tibia fractures treated
with un-reamed nails with or without rhBMP-2. They found significant decreases in need for secondary interventions such as bone grafting or nail exchange. Mean time to fracture healing was less in the rhBMP-2 group, but this difference was not statistically significant.
Govender et al. present a prospective randomized study of 450 patients with open tibia fractures treated with an intramedullary nail with or without rhBMP-2. They found statistically significant decreases in need for secondary intervention, hardware failure, and infection as well as faster wound healing and faster time to fracture union.
Wei et al. provide a meta analysis regarding use of rhBMP-2 in open tibia fractures. Due to decreased rates of secondary interventions they estimated a net savings of
$6,000 per case when rh-BMP2 was used. They found no significant difference in rates of infection, postoperative pain, hardware failure, or fracture healing at 20 weeks.
Incorrect answers:

Question 75

Which of the following factors is most likely to contribute to pseudarthrosis in a patient who has undergone a single-level anterior decompression and fusion procedure for the treatment of cervical radiculopathy? Review Topic

Explanation

Various factors affect the pseudarthrosis rate in patients who undergo anterior cervical decompression and fusion. Patient factors, including history of smoking and history of
diabetes mellitus, have been shown to significantly increase pseudarthrosis rates. The literature has been mixed with regard to fusion rates for allograft versus autograft, especially for one-level fusions; in that category, there is minimal, if any, difference. Similarly, several authors have shown higher rates of fusion with uninstrumented single-level rather than instrumented anterior cervical decompressions and fusions. The level (ie, cranial or caudal) of fusion and sagittal alignment have not been correlated with fusion rates.

Question 76

An otherwise healthy 65-year-old man has had chronic pain in his prosthetic knee for the past 9 months. Repeated aspirations reveal a coagulase-negative staphylococcus infection. To eradicate the infection while maintaining the best possible joint function, management should consist of

Explanation

Postoperative wound infections following total joint arthroplasty are generally classified as acute or chronic. The time period is either 2 or 4 weeks from the time of implantation depending on whom you read. This will, generally, determine if you can attempt a one-stage procedure. The other considerations are the bacteria’s resistance to antibiotics and whether or not it produces glycocalyx. If the microorganism elaborates glycocalyx it is highly likely that it will remain after surgical removal of the implants and debridement of the joint.
Present recommendations are to avoid a one-stage reconstruction in a patient in whom a glycocalyx elaborating microorganism has been isolated. In one study 52% of the isolates of S. epidermidis and 28% of the isolates of S. aureus elaborated glycocalyx. The microbiology laboratory can be asked to determine if the microorganisms elaborate glycocalyx. In the present case it should be assumed that the staphylococci elaborate glycocalyx and are resistant to antibiotics. A two-stage procedure is indicated for these reasons alone.
Antibiotic therapy alone has been used for a select group of patients who could not medically tolerate either a one-stage or a two-stage arthroplasty. The patient in this case is listed as otherwise healthy.
The decision to perform a resection arthroplasty as a definitive procedure without reimplantation is based on the bacteria’s resistance to antibiotics, quality of the local soft tissues, the complexity of the reconstruction, the patient’s refusal to have another operation, the patient’s overall health, or a combination of these factors. None of which appear to be present in this case.

Question 77

-Figure is the clinical photograph of a 70-year-old woman with squamous cell cancer on her thumb.Resection and reconstruction is planned and requires soft-tissue coverage. Thumb region coverage is best obtained with

Explanation

Question 78

Figure 33 shows the oblique radiograph of an 11-year-old boy who has a mild left flatfoot deformity. Examination reveals that subtalar motion is limited and painful. Despite casting for 6 weeks, the patient reports foot pain that limits participation in sport activities. A CT scan shows no subtalar joint abnormalities. Management should now include

Explanation

DISCUSSION: The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening

has been described for treatment of the peroneal spastic flatfoot without demonstrable

tarsal coalition.
REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Luhmann SJ, Rich MM, Schoenecker PL: Painful idiopathic rigid flatfoot in children and adolescents. Foot Ankle Int 2000;21:59-66.

Question 79

A 25-year-old male involved in a motor vehicle accident sustains multiple injuries. He undergoes operative treatment for his humeral shaft fracture. Figures A and B show his preoperative and postoperative radiographs. The distal interlocks for this implant place which of the following nerves at risk?

Explanation

With intramedullary (IM) nailing of the humerus, the distal anterior-to-posterior interlocking screws place the musculocutaneous nerve at high risk for injury as it goes through the coracobrachialis muscle and courses anteriorly along the brachialis (of which it innervates the medial half).
Rupp et al performed a cadaveric study with IM nails utilizing either lateral-to-medial or anterior-to-posterior distal interlocking screws. They showed that anterior-to-posterior screws placed the musculocutaneous nerve at high risk, while lateral-to-medial screws placed the radial nerve at high risk as it courses laterally distally along the humerus.
OrthoCash 2020

Question 80

A 12-year-old child falls from his bicycle and injures his right knee. Evaluation in the emergency department reveals knee effusion and pain with extremes of range of motion. Radiographs are shown in Figures 13a and 13b. Attempts at closed reduction are made and he is placed in a long leg cast with the knee flexed at 10 to 20 degrees. At follow-up, repeat radiographs continue to show anterior displacement of the fracture. What structure is most likely entrapped under the fragment?

Explanation

Lowe J, Chaimsky G, Freedman A, et al: The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 2002;84:1933-1938.
Figure 14a Figure 14b Figure 14c Question 14
A 14-year-old boy underwent in situ screw fixation for a left slipped capital femoral epiphysis 8 months ago. He
noted 3 months of intermittent right hip pain but is presently asymptomatic. The last episode of pain was 2 days prior to this office visit. He reports that he has pain approximately once a week over the past 3 months. Examination of the right hip is normal, and includes pain-free internal rotation. Radiographs and an MRI scan are shown in Figures 14a through 14c. Treatment should consist of which of the following?
In situ screw fixation of the right hip
Physical therapy
Limitation of activities and return to the clinic if pain persists
Biopsy of the femoral neck lesion
Irrigation and debridement of the right hip PREFERRED RESPONSE: 1
DISCUSSION: The patient history is concerning for a pre-slip slipped capital femoral epiphysis (SCFE) of the right hip. In one study, nearly 40% of patients with SCFE had bilateral involvement, and of that 40%, half presented initially with a unilateral SCFE but had a subsequent SCFE on the contralateral limb. Radiographs are normal, but the MRI scan shows increased signal about the proximal femoral physis. Treatment should include prophylactic screw fixation of the right hip.
REFERENCES: Aronsson DD, Loder RT, Breur GJ, et al: Slipped capital femoral epiphysis: Current concepts. J Am Acad Orthop Surg 2006;14:666-679.
Loder RT, Aronson DD, Greenfield ML: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg Am 1993;75:1141-1147.

Loder RT: Controversies in slipped capital femoral epiphysis. Orthop Clin North Am 2006;37:211-221, vii.
Figure 15a Figure 15b

Question 81

A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Explanation

There are many causes of rickets and osteomalacia. Renal osteodystrophy is a common complication of chronic renal failure and is one of the most common causes of osteomalacia. Pure osteomalacia is caused by the aluminum in phosphate binders used to treat hyperphosphatemia in renal failure. Desferoxamine is an effective chelator of aluminum in patients with biopsy documented aluminum-associated osteomalacia. Pure osteomalacia also can be caused by hypophosphatemia. The other choices are part of the mechanism of bone changes in renal osteodystrophy.

Question 82

A 58-year-old woman who underwent a successful total hip replacement for degenerative arthritis 8 years ago reports groin pain for the past 6 months. A radiograph of the hip is shown in Figure 32. At revision, severe deficiency of the posterior column is noted. What reconstructive option would be most appropriate for the acetabulum?

Explanation

DISCUSSION: The radiograph shows medial migration of the cementless acetabular component, strongly suggesting acetabular discontinuity with a combined segmental and cavitary medial deficiency. The treatment of choice is a morcellized or structural graft, supported with a reconstructive cage bridging the pelvic discontinuity, and a cemented cup.
REFERENCES: Whiteside LA: Selection of acetabular component, in Steinberg ME, Garino JP (eds): Revision Total Hip Arthroplasty. Philadelphia, PA, Lippincott Williams and Wilkins, 1999, pp 209-220.
Berry DJ, Muller ME: Revision arthroplasty using an anti-protrusio cage for massive acetabular bone deficiency. J Bone Joint Surg Br 1992;74:711-715.

Question 83

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.
RECOMMENDED READINGS
McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.
View Abstract at PubMed
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58
Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 84

A 45-year-old man sustained the injury seen in Figure 130a 6 weeks ago. He denies any prior injury to his shoulder. After treatment of the injury in the emergency department, he was noted to have significant weakness with empty can testing and external rotation at the side. He has full passive range of motion with forward flexion, abduction, and internal and external rotation, but has difficulty initiating abduction with his arm at his side. He has negative apprehension and relocation signs. A detailed neurologic examination shows no deficits. A coronal image from a follow-up MRI scan is seen in Figure 130b. Follow-up radiographs reveal no fractures. What is the most appropriate next step in his treatment? Review Topic

Explanation

The most likely concern, in a patient older than age 40 having a first-time shoulder dislocation, is a rotator cuff tear. The MRI scan shows a tear of the supraspinatus tendon. Recurrent instability is less likely to be a problem, so an external rotation brace for an extended period of time is unnecessary. The patient already has good passive range of motion, and with a full-thickness rotator cuff tear, physical therapy alone is unlikely to return him to full function. The MRI scan shows no labral tear, so arthroscopic or open repair is not indicated.

Question 85

An 81-year-old man with severe low back pain reports right extensor hallucis longus and anterior tibialis weakness and difficulty urinating over the past 24 hours. He has a temperature of 101 degrees F (38.3 degrees C). MRI scans are shown in Figures 31a and 31b. Management should consist of

Explanation

DISCUSSION: An epidural abscess with neurologic deficit represents a medical and surgical emergency. The prognosis is related to the timeliness of diagnosis and treatment. Once identified, the primary treatment is surgical decompression of the abscess, followed by organism-specific antibiotics. In the absence of a significant anterior process such as diskitis or vertebral osteomyelitis, lumbar epidural abscesses generally can be drained through a posterior approach. Delayed stabilization usually is not required unless, in the course of decompression, removal of too much of the facets creates an instability; this is an uncommon occurrence.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Reihsaus E, Waldbaur H, Seeling W: Spinal epidural abscess: A meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204.

Question 86

A 16-year-old right-hand dominant pitcher has had pain with throwing for the past 6 months but denies any history of trauma. Figures 9a and 9b show noncontrast MRI scans of the involved shoulder. What is the most likely diagnosis? Review Topic

Explanation

Internal impingement differs from standard, or outlet, impingement because instability of the glenohumeral joint is commonly the primary etiology. Sports with repetitive stress of the glenohumeral joint, such as swimming, volleyball, and baseball, are most often associated with this problem. Pathology identified with diagnostic imaging and arthroscopy include: posterolateral humeral head edema, undersurface partial tearing of the rotator cuff, and increased anterior capsular volume. In throwing athletes, prevention and treatment centers on directed posterior capsular stretching and dynamic strengthening of the rotator cuff musculature.

Question 87

Which of the following agents increases the risk for a nonunion following a posterior spinal fusion?

Explanation

DISCUSSION: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to increase the risk of pseudarthrosis. In a controlled rabbit study, nonunions were reported with the use of toradol and indomethacin. NSAIDs are commonly used medications with the potential to diminish osteogenesis. Studies clearly have demonstrated inhibition of spinal fusion following the postoperative administration of several NSAIDs, including ibuprofen. Cigarette smoking is another potent inhibitor of spinal fusion.
REFERENCES: Glassman SD, Rose SM, Dimar JR, et al: The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine 1998;23:834-838.
Martin GJ Jr, Boden SD, Titus L: Recombinant human bone morphogenetic protein-2 overcomes the inhibitory effect of ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), on posterolateral lumbar intertransverse process spine fusion. Spine 1999;24:2188-2193.

Question 88

Spondyloepiphyseal dysplasia congenita and tarda, precocious osteoarthropathy, and Stickler syndrome are caused by a mutation in the gene coding for

Explanation

Precocious osteoarthropathy is due to a mutation at 12q13.11-q13.2. It causes type-II collagen disorders. Spondyloepiphyseal dysplasia congenita and tarda are autosomal dominant and recessive disorders, respectively. They also affect the gene site for coding for type-II collagen (12q13.11-q13.2). Stickler syndrome, or hereditary arthro-ophthalmopathy, is secondary to changes in type-II collagen. Stickler syndrome without eye involvement is due to mutations in type-XI collagen. Achondroplasia involves a mutation in FGFR3. Alpert syndrome is due to defects with FGFR2. Ehler-Danlos is an example of type-I collagen mutations. Type I Multiple epiphyseal dysplasia and Pseudoachondroplasia involves a defect in cartilage oligomeric protein.

Question 89

Figure 23 shows the radiograph of a 7 year-old girl with a low thoracic-level myelomeningocele. She has a history of skin ulcers over the apex of the deformity, but her current skin condition is good. Management of the spinal deformity should consist of

Explanation

DISCUSSION: This form of severe kyphosis results in intractable difficulties with sitting position, compression of internal organs, and chronic skin breakdown. Kyphectomy and posterior fusion with instrumentation, while associated with a high rate of complications, provides one of the best solutions to this clinical dilemma. The other choices are either completely ineffective or inadequate in managing this degree of deformity.
REFERENCES: Lindseth RE: Spine deformity in myelomeningocele. Instr Course Lect 1991;40:273-279.
Sharrard J, Drennan JC: Osteotomy excision of the spine for lumbar kyphosis in older children with myelomeningocele. J Bone Joint Surg Br 1972;54:50-60.

Question 90

A patient has pain 2 years after undergoing a metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis in the setting of reaction to metal debris?

Explanation

Figures 1 and 2 are the recent radiographs of an 82-year-old man with rheumatoid arthritis who underwent total knee arthroplasty (TKA) 18 years ago. These radiographs reveal osteolysis with loosening of the tibial component. Aspiration and laboratory study findings for infection are negative. During the revision TKA, treatment of tibial bone loss should consist of

Question 91

A 55-year-old patient with rheumatoid arthritis reports increasing elbow pain and swelling for the past 2 months. She underwent a cemented, semiconstrained elbow arthroplasty 8 years ago. Laboratory studies show a normal peripheral white blood cell count; however, the erythrocyte sedimentation rate and C-reactive protein level are elevated. Radiographs are shown in Figures 48a and 48b. Which of the following organisms is most difficult to eradicate? Review Topic

Explanation

The patient's history and radiographs are suspicious for a relatively aggressive infection. Staphylococcus epidermidis is difficult to eradicate because of its encapsulation. The lytic area surrounding both the ulnar and humeral components suggests that the prosthesis is also loose. This revision will require component removal, antibiotic spacer placement, and parenteral antibiotics.

Question 92

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Explanation

DISCUSSION: Temporary bed rest (less than 4 days) with gradual resumption of activities can be efficacious. Epidural steroid injections may be indicated for acute low back pain with radiculopathy. Acupuncture, facet joint injections, or ligamentous (sclerosant) injections are not indicated.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, Appendix A15.
Helfgott SM: Sensible approach to low back pain. Bull Rheum Dis 2001;3:50.

Question 93

A 21-year-old woman with Marfan syndrome is seeking evaluation of her scoliosis. She reports no back or leg pain, and the neurologic examination is normal. Lateral and bending radiographs are shown in Figures 7a through 7e. Management should consist of

Explanation

DISCUSSION: Because the patient’s thoracolumbar scoliosis is of a large enough magnitude, observation or bracing is not recommended. The thoracolumbar curve is flexible enough and L4 corrects well enough to the pelvis to consider anterior spinal fusion from T10 to L4.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 161-171.
Turi M, Johnston CE II, Richards BS: Anterior correction of idiopathic scoliosis using TSRH instrumentation. Spine 1993;18:417-422.
Moskowitz A, Trommanhauser S: Surgical and clinical results of scoliosis surgery using Zielke instrumentation. Spine 1993;18:2444-2451.

Question 94

Which of the following is the most stable construct for fixation of an unstable transforaminal sacral fractures?

Explanation

DISCUSSION: The referenced article by Schildhauer et al is a cadaveric study that examined the biomechanical properties of different fixation constructs under cyclic loading and demonstrates that triangular osteosythesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in-vitro cyclical loading. The illustration below shows the radiographic appearance of triangular osteosynthesis.

Question 95

What is the main biologic effect of aggrecan in cartilage? Review Topic

Explanation

Aggrecan binds hyaluronic acid to attract water, which accounts for its hydrophilic property.
Aggrecan is the predominant proteoglycan in cartilage. It contains a large number of negatively charged sequences that attract water called sulfated glycosaminoglycan (GAG) chains. Its the N-terminal globular domain of aggrecan that binds hyaluronan to form huge aggregates. Together with its chondroitin sulfate chains, they help to create a hydrophilic viscous gel that decreases the coefficient of friction as well as to help absorb compressive loads.
Ulrich-Vinthe et al. reviewed the biology of articular cartilage. They report that matrix metalloproteinases and aggrecanases play a major role in aggrecan degradation and their production is upregulated by mediators associated with joint inflammation and overloading.
Illustration A shows a depiction of the function of aggrecan in articular cartilage. In the relaxed state, the aggregates draw water into cartilage. With compressive loads, the water is displaced to cushion the load. Upon removal of the load, the water content is restored.
Incorrect Answers:

Question 96

Hip pain of month duration has developed in a year-old man with a previous total hip arthroplasty. He underwent dental work 6 weeks ago. Aspiration shows a white blood cell count of more than 6,000 cells/μL (reference range 4,500 to 11,000 cells/μL) and the presence of gram-positive cocci in clusters on Gram stain. The orthopaedic surgeon recommends urgent debridement and irrigation. Fixation of the components is judged to be stable, and the surgeon elects to retain the implants. What is this patient's prognosis for infection resolution?

Explanation

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin- resistant Staphylococcus epidermidis organisms treated with a two-stage protocol, the failure rate was
21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 97

A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension?

Explanation

DISCUSSION: An important hemodynamic consideration in the pregnant trauma patient is the potential hypotensive effect of supine positioning. This effect, which is caused by aortocaval compression by the enlarged uterus, may decrease cardiac output by 25%. Use of a right hip wedge, manual displacement of the uterus, or lateral tilt positioning of the patient may help avoid this situation. Patient positioning must be determined with a focus on the well-being of the fetus. To avoid compression of the inferior vena cava in the patient who is in her second or third trimester, the left lateral decubitus position (left side down) should be used. The referenced review article by Flik et al
reviews the appropriate physiological changes of pregnancy and covers the treatment of orthopedic trauma in the face of pregnancy.

Question 98

During an anterior retroperitoneal approach to the low lumbar spine, the iliac vessels are mobilized along the lateral side, allowing them to be retracted toward the midline. To gain adequate mobility of the common iliac vein for exposure of L5, it is important to identify which of the following structures?

Explanation

DISCUSSION: The iliolumbar vein is a large tributary that sits along the lateral surface of the common iliac vein. It can be quite substantial in size and must be identified prior to mobilizing the common iliac vein toward the midline. The other structures are not of surgical significance in performing this exposure.
REFERENCE: Gray H: Anatomy of the Human Body. Philadelphia, PA, Lea & Febiger,

1918, 2000.

Question 99

A baseball player reports a dull pain in the posterior aspect of his throwing arm. Examination reveals decreased internal rotation and prominence of the inferomedial corner of the scapula. An MRI scan suggests a partial-thickness tear of the posterior supraspinatus tendon. Successful treatment would most likely include which of the following? Review Topic

Explanation

Internal impingement is related to an internal rotation contracture (GIRD-glenohumeral internal rotation deficit) and an increase in external rotation caused by repetitive overhead throwing. Most patients can be successfully treated with rehabilitation that focuses on internal rotation stretches along with anti-inflammatory medication and strengthening as symptoms improve. SLAP repair and rotator cuff debridement may be considered in refractory cases. Rotator cuff repair is not typically
required, and capsulolabral imbrication is more consistent with the surgical treatment for multidirectional instability.

Question 100

What is the most common clinical presentation of a patient with a malignant bone tumor?

Explanation

DISCUSSION: The most common clinical presentation of a patient with a malignant bone tumor is pain. Malignant bone tumors rarely are diagnosed as an incidental finding or pathologic fracture. In patients who have a pathologic fracture on initial presentation, a history of increasing pain prior to the fracture is typical. While 90% of malignant bone tumors are associated with a soft-tissue mass, in many patients the soft-tissue component of the tumor is not clinically apparent.
REFERENCES: Buckwalter JA: Musculoskeletal neoplasms and disorders that resemble neoplasms, in Weinstein SL, Buckwalter JA (eds): Turek’s Orthopaedics: Principles and Their Application, ed 5. Philadelphia, PA, JB Lippincott, 1994, pp 290-295.
Mehlman CT, Crawford AH, McMath JA: Pediatric vertebral and spinal cord tumors: A retrospective study of musculoskeletal aspects of presentation, treatment, and complications. Orthopedics 1999;22:49-55.

Full Question & Answer Text (for Search Engines)

Question 1:

What is the primary indication for performing an arthroscopic synovectomy on a patient with hemophilia that is the result of factor VIII deficiency? Review Topic

Options:

Joint pain with radiographic evidence of joint space narrowing
Joint stiffness that has not improved with physiotherapy and bracing
Recurrent joint bleeding despite optimal medical management
Prophylaxis for joint preservation in severe hemophilia (factor VIII level <1%)
Decreasing ambulatory endurance despite optimal medical management

Correct Answer: Recurrent joint bleeding despite optimal medical management

Explanation:

Question 2:

-The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?

Options:

year risk for hip fracture
year risk for distal radius fracture
year risk for any fragility fracture
year risk for hip fracture
year risk for distal radius fracture

Correct Answer: year risk for hip fracture

Question 3:

Options:

Misdiagnosis
Hematoma formation
Postsurgical fibrosis
Failure to recognize involvement of other compartments

Correct Answer: Postsurgical fibrosis

Explanation:

Question 4:

Options:

Refrain from using the prosthesis until the ulcer heals.
Refrain from using the prosthesis and apply platelet-derived growth factor daily until the ulcer heals.
Have a prosthetist relieve the area of the anterior-distal tibia to eliminate pressure and allow the ulcer to heal.
Replace the prosthetic socket liner with a thick silicone liner.
Perform a wedge resection of the infected tissue, create a soft-tissue envelope with muscle covering the bone, and allow primary healing of the skin.

Correct Answer: Perform a wedge resection of the infected tissue, create a soft-tissue envelope with muscle covering the bone, and allow primary healing of the skin.

Explanation:

Question 5:

Options:

Vascularized fibular graft
Locked intramedullary rodding
Tricortical iliac crest grafting and compression plating
Cancellous autograft and plating
BMP-7

Correct Answer: Cancellous autograft and plating

Explanation:

Question 6:

Options:

Ban the athlete from sports participation.
Allow the athlete to participate as it is his constitutional right to do so.
Advise the college to revoke the athlete's college scholarship.
Offer no opinion as it is a matter strictly between the college and the athlete.
Recuse yourself from all decision making and advise the athlete to get an opinion from a third-party physician who is not employed by the college or university.

Correct Answer: Ban the athlete from sports participation.

Explanation:

Question 7:

Options:

Nonengaging Hill-Sachs deformity
Intra-articular loose body
Anterior glenoid bone deficiency of 35%
Subacromial bursitis
10% partial-thickness, articular side tear of the supraspinatous

Correct Answer: Anterior glenoid bone deficiency of 35%

Explanation:

Question 8:

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

Options:

the anterior column of the acetabulum.
the acetabular rim.
the os acetabulae.
anterior coverage of the femoral head.
femoral anteversion.

Correct Answer: anterior coverage of the femoral head.

Explanation:

Question 9:

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Options:

Males have greater total valgus knee loading.
Females have greater total valgus knee loading.
Males have greater total varus knee loading.
Females have greater total varus knee loading.
There is no gender difference in total varus or valgus knee loading.

Correct Answer: Females have greater total valgus knee loading.

Explanation:

Question 10:

Options:

Metastatic bone disease
Multiple myeloma
Lymphoma
Chondrosarcoma
Malignant fibrous histiocytoma The biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease. The treatment of metatastic bone disease is either internal fixation with postoperative external beam irradiation or external beam irradiation alone. In this case, there is extensive destruction and fracture is imminent. The treatment of choice is acetabular reconstruction followed by external beam irradiation.

Correct Answer: Malignant fibrous histiocytoma The biopsy specimen shows round, epithelial-like cells that are grouped in clusters. The cells are arranged in a fibrous background. The diagnosis is metastatic bone disease. The treatment of metatastic bone disease is either internal fixation with postoperative external beam irradiation or external beam irradiation alone. In this case, there is extensive destruction and fracture is imminent. The treatment of choice is acetabular reconstruction followed by external beam irradiation.

Explanation:

Slide 1 Slide 2 Slide 3 Slide 4
A 50-year-old woman has had severe hip pain for 4 months. Her plain radiographs (Slide 1), technetium bone scan (Slide 2), computerized tomography scan (Slide 3), and coronal T1- and T2-weighted magnetic resonance images (Slide 4) are presented. The most likely diagnosis based upon the radiographs would be:

Question 11:

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Options:

a BMI lower than 30.
diabetes mellitus, with a hemoglobin A1c test result less than 7.
tranexamic acid use.
metabolic syndrome.

Correct Answer: metabolic syndrome.

Explanation:

Question 12:

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 13:

Options:

Shoulder abduction and internal rotation
Shoulder external rotation and scapula protraction
Shoulder external rotation with the arm at the side
Shoulder internal rotation with the arm at the side
Scapula protraction

Correct Answer: Shoulder external rotation with the arm at the side

Explanation:

Question 14:

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 15:

What is the structure indicated by the letter “A” in Figure A? Review Topic

Options:

Annular ligament
Lateral ulnar collateral ligament
Accessory collateral ligament
Radial collateral ligament
Transverse ligament

Correct Answer: Radial collateral ligament

Explanation:

Question 16:

Options:

Parosteal osteosarcoma
Classic osteogenic sarcoma
Ewing’s sarcoma
Osteochondroma
Chondrosarcoma

Correct Answer: Parosteal osteosarcoma

Explanation:

Question 17:

40A B Figures 40a and 40b are this patient's intraoperative arthroscopic images. The abnormality seen here illustrates which of the patient's clinical findings?

Options:

Instability on unlevel ground
Ankle pain and swelling
Anterior laxity on lateral radiographs
Osteochondral lesion of the talus on MR imaging

Correct Answer: Ankle pain and swelling

Explanation:

DISCUSSION
Ankle sprains are the most common musculoskeletal injury; however, most of these sprains do not progress to chronic instability. Initial injuries are treated with RICE (rest, ice, compression, elevation), range of motion, weight bearing
as tolerated, and proprioceptive therapy. Lace-up ankle braces are most effective during the subacute period after a sprain. Structured physical therapy focused on proprioception is recommended for 6 weeks. Examination findings for ankle ligament instability are unreliable because of associated subtalar joint motion. Casting is not as effective as functional rehabilitation. Stress radiographs are recommended, but a clear pathologic range of measurements is not defined. Generalized ligament laxity can result in false-positive findings of instability; therefore, contralateral stress radiographs are often necessary for comparison. The difference in anterior drawer measurement between both ankles should not exceed 5mm. Likewise, the difference in talar tilt measurement between both ankles should be 5 or fewer degrees. Patients with mechanical symptoms, a joint effusion, or continued pain may have an intra-articular pathology such as a loose body or osteochondral lesion. Ankle instability can exist without ligamentous laxity. Symptoms of chronic instability can result from osteochondral lesions of talus, peroneal tendon pathology, loose bodies, anterior ankle impingement, and fracture nonunions. Although there is not sufficient evidence to recommend arthroscopy prior to all ligament reconstructions, arthroscopy is recommended when other pathology is suspected.
RECOMMENDED READINGS
Colville MR. Surgical treatment of the unstable ankle. J Am Acad Orthop Surg. 1998 Nov-Dec;6(6):368-77. Review. PubMed PMID: 9826420.
View Abstract at PubMed
DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006 Oct;27(10):854-66. Review. PubMed PMID: 17054892.
View Abstract at PubMed
Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008 Oct;16(10):608-15. Review. PubMed PMID: 18832604.
View Abstract at PubMed

Question 18:

Options:

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

Correct Answer: no differences in long-term results.

Explanation:

Question 19:

What is the most likely cause of recurrent symptoms following excision of a third web space neuroma?

Options:

Traumatic neuroma tethered by plantar neural branches
Regeneration of the transverse intermetatarsal ligament
Development of an intermetatarsal synovial cyst
Complex regional pain syndrome
Metatarsophalangeal joint synovitis

Correct Answer: Traumatic neuroma tethered by plantar neural branches

Explanation:

Question 20:

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Options:

Inferior glenohumeral ligament
Superior glenohumeral ligament
Rotator cuff interval
Subscapularis recess
Interior recess

Correct Answer: Rotator cuff interval

Explanation:

Question 21:

Options:

Improved cognitive function
Improved caregiver satisfaction
Improved nutrition
Decreased pain
Improved mobility

Correct Answer: Improved caregiver satisfaction

Explanation:

Question 22:

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Options:

Sural
Saphenous
Superficial peroneal
Deep peroneal
Posterior tibial

Correct Answer: Superficial peroneal

Explanation:

Question 23:

An 18-year-old high school basketball player is being treated for Achilles tendinitis. What type of strengthening exercise has been shown to be helpful in the later phases of rehabilitation?

Options:

Eccentric
Isokinetic
Concentric
Isometric
Isotonic

Correct Answer: Eccentric

Explanation:

Question 24:

Options:

L4 nerve root
L5 nerve root
S1 nerve root
Genitofemoral nerve
Cauda equina

Correct Answer: L5 nerve root

Explanation:

Question 25:

Options:

aspiration of the left hip.
application of a Pavlik harness.
a gallium scan.
an MRI scan of the spine.
modified Bryant traction.

Correct Answer: aspiration of the left hip.

Explanation:

Question 26:

Which of the following factors is most closely associated with early postoperative migration of “stand-alone” lumbar interbody fusion cages?

Options:

Pseudarthrosis
Placement of the cage through a posterior approach
Placement of the cage laparoscopically through an anterior approach
Use of tapered rather than cylindrical cages
Use of BMP-2 rather than autograft in the cage

Correct Answer: Placement of the cage through a posterior approach

Explanation:

Question 27:

Options:

Inflation of the abdominal portion of the PASG
Application of a pelvic clamp
Application of a pelvic external fixator
Rapid infusion of 4 more units of blood
Angiography and embolization

Correct Answer: Angiography and embolization

Explanation:

Question 28:

What is the most common presenting problem in patients with cauda equina syndrome? Review Topic

Options:

Urinary retention
Urinary incontinence
Saddle numbness
Lower extremity numbness and weakness
Back and leg pain

Correct Answer: Back and leg pain

Explanation:

Question 29:

Which of the following regions in the growth plate is commonly affected in a Salter-Harris type II injury? Review Topic

Options:

Reserve zone
Proliferative zone
Hypertrophic zone
Primary spongiosa
Epiphyseal zone

Correct Answer: Hypertrophic zone

Explanation:

Question 30:

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Options:

Enchondroma
Nonossifying fibroma
Chondromyxoid fibroma
Osteosarcoma
Chondrosarcoma

Correct Answer: Chondromyxoid fibroma

Explanation:

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 31:

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 32:

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Options:

Correct Answer: L2

Explanation:

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 33:

Options:

Fracture fixation and bracing
Lateral retinacular release with proximal realignment
Tibial component revision
Distal realignment by medialization of the tibial tubercle
Revision of the patellar component

Correct Answer: Lateral retinacular release with proximal realignment

Explanation:

Question 34:

Options:

Immediately
After 30 minutes
After 24 hours
After 4 weeks
Next season

Correct Answer: After 4 weeks

Explanation:

Question 35:

Options:

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps
The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and medial to the triceps and the posterior lateral portal created 3 cm from the tip of the olecranon and lateral to the triceps
The posterior medial portal created 3 cm from the tip of the olecranon and the lateral portal made through the anconeus
The posterior portal created at the tip of olecranon and the posterior medial portal just medial to the triceps

Correct Answer: The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps

Explanation:

Question 36:

Options:

Vigorous physical therapy
Manipulation under anesthesia
Arthroscopic capsular release
Hemiarthroplasty
Arthroscopic capsular plication

Correct Answer: Hemiarthroplasty

Explanation:

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 37:

Options:

Crescent fracture located on the side of impact
Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments
Complete SI disruption with lateral displacement
Sacral compression fracture on side of impact with transverse pubic rami fractures
Open-book injury with contralateral sacral compression fracture

Correct Answer: Open-book injury with contralateral sacral compression fracture

Explanation:

Question 38:

Options:

Tendon transfer, lateral column lengthening, and heel cord lengthening
Triple arthrodesis and heel cord lengthening
Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening
Tendon transfer, spring ligament repair, and heel cord lengthening
Tendon repair, medial displacement calcaneal osteotomy, and heel cord lengthening

Correct Answer: Tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening

Explanation:

DISCUSSION: The patient has an atypical adult flatfoot deformity. The radiographs reveal forefoot abduction, mild loss of calcaneal pitch, and marked plantar flexion sag through the naviculocuneiform joint. The inability to perform a single limb heel rise indicates that the posterior tibial tendon is nonfunctional; however, the deformity remains flexible. In this patient, surgical treatment should include a tendon transfer, lateral column lengthening, medial column arthrodesis, and heel cord lengthening. Because a substantial portion of the deformity stems from the naviculocuneiform joint in this instance, tendon transfer and lateral column lengthening alone provide insufficient deformity correction. Triple arthrodesis and heel cord lengthening is best reserved for fixed flatfoot deformities. Soft-tissue procedures alone are associated with a high failure rate, as are attempted tendon repairs.
REFERENCES: Greisberg J, Assal M, Hansen ST Jr, et al: Isolated medial column stabilization improves alignment in adult-acquired flatfoot. Clin Orthop Relat Res 2005;435:197-202.
Greisberg J, Hansen ST Jr, Sangeorzan BJ: Deformity and degeneration in the hindfoot and midfoot joints of the adult acquired flatfoot. Foot Ankle Int 2003;24:530-534.

Question 39:

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Options:

Fungal infection
Ingrowth of the medial nail
Benign exostosis
Malignant neoplasm
Reactive pyogenic granuloma

Correct Answer: Benign exostosis

Explanation:

Question 40:

Options:

Cervical traction
Halo-vest orthosis
Anterior single-level fusion
Posterior single-level fusion
Posterior multilevel fusion

Correct Answer: Posterior multilevel fusion

Question 41:

Options:

Observation
Extended curettage with adjuvant treatment
Wide resection
Radiation therapy
Multimodal treatment including chemotherapy and surgery

Correct Answer: Extended curettage with adjuvant treatment

Explanation:

DISCUSSION: This is a classic case of giant cell tumor of bone. The radiograph and the MRI scan reveal a purely lytic lesion in the medial femoral condyle. The lesion is well-demarcated without a rim of sclerotic bone. It is eccentrically located and abuts the subchondral bone. The lesion demonstrates increased uptake on a technetium TC 99m bone scan. These imaging studies are highly suggestive of giant cell tumor arising in its most common location. The photomicrograph confirms the diagnosis of giant cell tumor. Based on these findings, the most widely accepted treatment is extended curettage plus a local adjuvant such as polymethylmethacrylate bone cement, argon beam coagulation, liquid nitrogen, and/or phenol.
REFERENCES: Lackman RD, Hosalkar HS, Ogilvie CM, et al: Intralesional curettage for grades II and III giant cell tumors of bone. Clin Orthop Relat Res 2005;438:123-127.
Ward WG Sr, Li G III: Customized treatment algorithm for giant cell tumor of bone: Report of a series. Clin Orthop Relat Res 2002;397:259-270.

Question 42:

Options:

acetabular labrum.
zona orbicularis.
iliofemoral ligament.
acetabular pulvinar.
retinacular vessels.

Correct Answer: acetabular labrum.

Explanation:

Question 43:

Options:

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

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

Explanation:

CLINICAL SITUATION FOR QUESTIONS 7 THROUGH 9

Question 44:

Options:

Femoral revision with distal augment
MCL allograft reconstruction
Ultracongruent insert
Rotating-hinge TKA

Correct Answer: Rotating-hinge TKA

Explanation:

Question 45:

Figures 51a and 51b show subluxation of the

Options:

extensor carpi ulnaris.
distal radioulnar joint.
extensor carpi radialis longus.
extensor digiti minimi.
extensor pollicis longus.

Correct Answer: extensor carpi ulnaris.

Explanation:

Question 46:

At revision, the stem is retained and a new head with a polyethylene bearing is selected. The best option for the head is

Options:

ceramic with a metal sleeve.
ceramic alone.
metal with a metal sleeve.
metal alone.

Correct Answer: ceramic with a metal sleeve.

Explanation:

Question 47:

-What is the most common metatarsal fracture in a 3-year-old?

Options:

Proximal first metatarsal
Proximal fifth metatarsal
Distal second metatarsal
Distal fifth metatarsal DISCUSSION -In children 5 years of age and younger, the proximal first metatarsal is the most common site for metatarsal fractures; the fractures are usually caused by a fall. In children older than age 5, injury to the fifth metatarsal is most common and is sustained during play or sports. Many fractures in children under age 5 are not initially visible on radiograph. Knowing where to look for common injuries is mandatory when treating young children and nonverbal patients.

Correct Answer: Proximal first metatarsal

Explanation:

CLINICAL SITUATION FOR QUESTIONS 77 AND 78
Figures 77a through 77c are the preoperative and postoperative radiographs of a 13-year-old boy who had sudden worsening of left hip pain following many months of mild pain. He was unable to walk because of his pain and underwent screw fixation.

Question 48:

Which of the following patients with cerebral palsy is considered the ideal candidate for a selective dorsal rhizotomy?

Options:

An ambulatory 6-year-old patient with spastic diplegia
An ambulatory 10-year-old patient with spastic right hemiplegia
An ambulatory 16-year-old patient with spastic diplegia
A nonambulatory 8-year-old patient with spastic quadriplegia
A nonambulatory 18-year-old patient with rigid quadriplegia

Correct Answer: An ambulatory 6-year-old patient with spastic diplegia

Explanation:

Question 49:

Options:

immediate casting with the expectation of a satisfactory correction.
immediate casting with the expectation that surgical correction will be needed.
immediate surgery to correct the deformity.
delayed casting and corrective bracing.
therapeutic and frequent physical therapy to stretch the soft tissues and observe the skin.

Correct Answer: immediate casting with the expectation that surgical correction will be needed.

Explanation:

Question 50:

Options:

Deep infection
Malalignment
Fibrous ingrowth of the femoral component
Fibrous ingrowth of the tibial component
Patellar component loosening

Correct Answer: Fibrous ingrowth of the tibial component

Explanation:

Question 51:

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

Options:

Blocks the release of presynaptic acetylcholine release at the neuromuscular junction and end plate
Acts as a g -aminobutyric acid (GABA) agonist
Inhibits afferent fibers in the dorsal root of the spinal nerve
Competitively blocks the acetylcholine receptor
Destroys the neuromuscular junction

Correct Answer: Blocks the release of presynaptic acetylcholine release at the neuromuscular junction and end plate

Explanation:

Question 52:

Options:

antibiotics for 6 weeks.
use of an unlocked brace.
revision arthroplasty.
resection of the implants.
two-stage reimplantation.

Correct Answer: revision arthroplasty.

Explanation:

Question 53:

Options:

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

Correct Answer: Flattening of the femoral condyles

Explanation:

Question 54:

What muscles are responsible for the most common deformity after antegrade intramedullary nailing for a subtrochanteric femur fracture?

Options:

Hip abductors and iliopsoas muscle
Hip internal rotators and iliopsoas muscle
Quadriceps and iliopsoas muscle
Hamstring and iliopsoas muscle
Quadriceps and hip adductors

Correct Answer: Hip abductors and iliopsoas muscle

Explanation:

Question 55:

Options:

Observation
Initiate bracing
MRI scan of the entire spine
Spinal instrumentation with growing rod construct

Correct Answer: MRI scan of the entire spine

Explanation:

Question 56:

Options:

observation.
serial casting.
flexion osteotomy of the distal humerus.
posterior soft-tissue elbow release and anterior triceps transfer.
adaptive equipment.

Correct Answer: posterior soft-tissue elbow release and anterior triceps transfer.

Explanation:

Question 57:

Options:

Renal osteodystrophy
Diastrophic dysplasia
Metaphyseal dysplasia
Osteogenesis imperfecta
Fibrous dysplasia

Correct Answer: Metaphyseal dysplasia

Explanation:

DISCUSSION: The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta.
There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.
REFERENCES: Goldberg MJ, Yassir W, Sadeghi-Nejad A: Clinical analysis of short stature. J Pediatr Orthop 2002;22:690-696.
Parmar VS, Stanitski DF, Stanitski CL: Interpretation of radiographs in a pediatric limb deformity practice: Do
radiologists contribute? J Pediatr Orthop 1999;19:732-734. Question 4
Patients with slipped capital femoral epiphysis are more likely to experience a delay in definitive diagnosis if they initially present to a physician reporting which of the following problems?
L Limp
Hip pain
Knee pain
Proximal thigh pain
Buttock pain
DISCUSSION: A delay in diagnosis of slipped capital femoral epiphysis (SCFE) can lead to significant worsening of the deformity or even progression from a stable to an unstable SCFE. Those patients that report knee pain as their primary complaint are most likely to experience significant delay. Other variables associated with this delay include Medicaid insurance and stable SCFE.
REFERENCES: Kocher MS, Bishop JA, Weed B, et al: Delay in diagnosis of slipped capital femoral epiphysis.
AL-Madena Copy
10 • American Academy of Orthopaedic Surgeons
Pediatrics 2004;113:e322-e325.
Rahme D, Comley A, Foster B, et al: Consequences of diagnostic delays in slipped capital femoral epiphysis. J Pediatr Orthop B 2006;15:93-97.

Question 58:

Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes

Options:

gamma radiation in air.
gamma radiation in nitrogen.
gamma radiation in argon.
gas plasma exposure.
ethylene oxide exposure.

Correct Answer: gamma radiation in air.

Explanation:

Question 59:

Options:

manipulation and cast application.
basic orthopaedic shoes with a scaphoid pad and reinforced medial counter.
open reduction of the talonavicular joint and Achilles tendon lengthening.
lateral column lengthening osteotomy.
observation.

Correct Answer: manipulation and cast application.

Explanation:

Question 60:

Options:

External fixation
Plate fixation
Unreamed unlocked intramedullary nailing
Reamed statically locked intramedullary nailing
Reamed unlocked nailing

Correct Answer: External fixation

Explanation:

Question 61:

Options:

Synovial sarcoma
Soft-tissue abcess
Rhabdomyosarcoma
Eosinophilic granuloma
Nodular pigmented villonodular synovitis

Correct Answer: Soft-tissue abcess

Explanation:

Question 62:

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

Options:

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

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

Explanation:

Question 63:

Options:

Full-length tibia-fibula radiographs
Inability to bear weight
History of recurrent ankle sprains
Presence or absence of medial tenderness
MRI scan

Correct Answer: Full-length tibia-fibula radiographs

Explanation:

The radiographs reveal a medial ankle injury with a widened medial clear space. No fibula fracture is visualized on this view; therefore, full-length radiographs looking for a proximal fibula fracture are required to determine treatment. The presence or absence of medial tenderness has been shown to not be a good predictor of unstable injuries. A history of previous injuries or ankle instability is typically lateral instability, which would not present with this radiographic appearance. An MRI scan can be used to evaluate subtle syndesmotic injuries, but there is a clear widening of the medial clear space in this case. The inability to bear weight is not helpful in determining the treatment options.
(SBQ12TR.24) In each of the following scenarios, atrophic fracture nonunion occurred after initial treatment with intramedullary nail fixation. Which scenario has shown to have the highest rate of osseous union if treated with exchange intramedullary nailing?
Oligotrophic nonunion of a comminuted humeral shaft fracture
Oligotrophic nonunion of a transverse humeral shaft fracture
Oligotrophic nonunion of an oblique distal femur fracture
Oligotrophic nonunion of a comminuted tibial shaft fracture
Oligotrophic nonunion of an oblique tibial shaft fracture
Reamed exchange nailing is recommended for the management of aseptic nonunions of noncomminuted tibial shaft fractures. Union rates have been reported between 76-96% in large studies.
Tibial exchange nailing promotes osseous bone healing of non-unions by providing biological and mechanical support. The biological support is provided by reaming the medullary canal. This increases periosteal blood flow and stimulates periosteal new-bone formation. The mechanical support is provided by a larger-diameter intramedullary nail, which increases the rigidity and strength of the nail.
Brinker et al. reviewed the concept of exchange nailing of nonunited long bone fractures. They showed that exchange nailing is the most successful in the treatment of nonunions following closed or open fractures without substantial bone loss. Aseptic, noncomminuted diaphyseal femoral and tibial shaft fractures showed the highest rates of union with exchange nailing, which were found to be 76-100% and 72-96%, respectively.
Illustration A shows a heterotrophic non-union of the tibia after intramedullary nailing. The patient was treated with exchange nailing with a larger nail. On the right shows a 4 month post-op radiograph after exchange nailing showing osseous union at the fracture site.
Incorrect Answers:
(SBQ12TR.79) A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2 weeks. Which of the following would be an indication for surgical management?
Age greater than 70 years.
Fracture pattern in Figure A
Significant medical comorbidities.
Fracture pattern in Figure B
Fracture pattern in Figure C
The patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.
Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity is
displaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.
Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.
Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.
Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.
Incorrect Answers:

Question 64:

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic

Options:

Osteosarcoma
Bucket-handle medial meniscal tear
Lateral collateral ligament tear
Bone bruise
Tibial spine avulsion

Correct Answer: Bone bruise

Explanation:

Question 65:

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 66:

Tendon fibroblasts detect applied strain through what mechanism?

Options:

Induced apoptosis from tendon loading
Induced cell elongation from tendon loading
Tendon loading-mediated cell pressurization
Deflection of cell-cilia from tendon loading

Correct Answer: Deflection of cell-cilia from tendon loading

Explanation:

Question 67:

Options:

Early cocking
Late cocking
Acceleration
Deceleration DISCUSSION --This patient is experiencing soreness over his medial (ulnar) collateral ligament. Valgus overload is likely to reproduce his symptoms and is most pronounced during the late cocking phase of the throwing cycle.In wind up, very little elbow torque is required. In early cocking, the arm is getting loaded and maximum valgus is not yet achieved at the elbow. In acceleration and deceleration, more force is generated at the level of the shoulder joint.

Correct Answer: Late cocking

Question 68:

Options:

Intramuscular hematoma
Lipoma
Myositis ossificans
Malignant fibrous histiocytoma
Liposarcoma

Correct Answer: Malignant fibrous histiocytoma

Explanation:

DISCUSSION: Malignant fibrous histiocytoma (MFH) is the most common soft-tissue sarcoma. MFH typically presents as a large mass, deep to the fascia with heterogeneous signal on MRI. The MRI scans show a heterogeneous lesion in the posterior thigh. There is significant high signal uptake on the T
2
-weighted image. The histology shows malignant histiocytic cells with marked atypia and pleomorphism. Histology of a hematoma would show only old hemorrhage and some granulation tissue. Lipoma and liposarcoma are both seen as a fat-containing lesion on histology. No significant fat tissue is seen in this histologic specimen. Histology of myositis ossificans would show bone formation.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 965-981.

Question 69:

Options:

Observation
Radiation therapy
Curettage
En bloc excision with stabilization
En bloc excision followed by radiation therapy

Correct Answer: En bloc excision with stabilization

Explanation:

Question 70:

Options:

closed reduction and a long arm cast.
closed reduction, percutaneous pin fixation, and a long arm cast.
closed reduction and an external fixator.
open reduction and internal fixation and soft-tissue repair.
proximal row carpectomy.

Correct Answer: open reduction and internal fixation and soft-tissue repair.

Explanation:

Question 71:

Options:

halo application.
skeletal traction and attempted closed reduction.
a soft cervical collar.
immediate transfer to the operating room for closed reduction.
immediate transfer to the operating room for open reduction and stabilization posteriorly.

Correct Answer: skeletal traction and attempted closed reduction.

Explanation:

Question 72:

Options:

Increased ductility
Increased wettability
Diminished fatigue strength
Decreased resistance to abrasive wear

Correct Answer: Diminished fatigue strength

Explanation:

Question 73:

What is the most common benign bone tumor in childhood?

Options:

Unicameral bone cyst
Fibrous dysplasia
Nonossifying fibroma
Aneurysmal bone cyst
Chondromyxoid fibroma

Correct Answer: Nonossifying fibroma

Explanation:

Question 74:

Which of the following is an FDA approved adjunctive treatment for an acute open tibia fracture being treated with an intramedullary nail?

Options:

Calcitonin
rhBMP-2
rhBMP-7
Teraparatide
Bisphosphonates

Correct Answer: Calcitonin

Explanation:

Question 75:

Options:

Sagittal alignment
History of diabetes mellitus and tobacco use
Performance of an uninstrumented fusion (ie, no plate and screws)
Use of allograft (instead of autograft)
Fusion at the C3-C4 level

Correct Answer: History of diabetes mellitus and tobacco use

Explanation:

Question 76:

- An otherwise healthy 65-year-old man has had chronic pain in his prosthetic knee for the past 9 months. Repeated aspirations reveal a coagulase-negative staphylococcus infection. To eradicate the infection while maintaining the best possible joint function, management should consist of

Options:

Long-term administration of IV and oral antibiotics
Open soft-tissue debridement, retention of prosthetic components, and IV antibiotics
Immediate exchange arthroplasty with antibiotic-impregnated cement
Two-stage surgical prosthetic exchange and IV antibiotics
Resection arthroplasty and IV antibiotics

Correct Answer: Two-stage surgical prosthetic exchange and IV antibiotics

Explanation:

Question 77:

Options:

the Moberg flap.
a third dorsal metacarpal artery flap.
a first dorsal metacarpal artery flap.
a full-thickness skin grafting.
a reverse cross-finger flap from the index finger with full-thickness skin grafting.

Correct Answer: a first dorsal metacarpal artery flap.

Question 78:

Options:

manipulation of the foot under general anesthesia.
peroneal lengthening.
coalition resection with interposition of fat or muscle.
distal calcaneal lengthening osteotomy.
triple arthrodesis.

Correct Answer: coalition resection with interposition of fat or muscle.

Explanation:

DISCUSSION: The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening
has been described for treatment of the peroneal spastic flatfoot without demonstrable
tarsal coalition.
REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Luhmann SJ, Rich MM, Schoenecker PL: Painful idiopathic rigid flatfoot in children and adolescents. Foot Ankle Int 2000;21:59-66.

Question 79:

Options:

Radial
Ulnar
Anterior interosseous
Axillary
Musculocutaneous

Correct Answer: Musculocutaneous

Explanation:

Question 80:

Options:

Anterior fat pad
Anterior cruciate ligament
Posterior cruciate ligament
Anterior horn of the medial meniscus
Anterior horn of the lateral meniscus

Correct Answer: Anterior horn of the medial meniscus

Explanation:

DISCUSSION: Avulsion fractures of the tibial spine are a relatively rare injury in children. Historically, the most common cause of this fracture was falls from bicycles, but with the increased participation in competitive sports, the etiology is changing. Most fractures occur in children ages 8 to 14 years, and they typically present with a painful hemarthrosis and refusal to bear weight. The Meyers and McKeever classification is based on degree of displacement, where type I is minimally displaced, type II is anteriorly displaced with an intact posterior hinge, and type III is completely displaced. The Ilia and Illb modifications have been added to account for fragment comminution and rotation, respectively. Long leg casting is advocated for type I fractures, though there is debate whether the knee should be maintained in full extension or in 10 to 20 degrees of flexion. Management of type II and III fractures is much more controversial. Type II fractures can be treated closed if adequate reduction can be achieved, but if not, surgical management is indicated. Surgery is also indicated for type III fractures, and results of open versus arthroscopic procedures are similar long term. Kocher and associates examined 80 consecutive skeletally immature patients with type II or III tibial eminence fractures that were treated surgically. They found that the anterior hom of the medial meniscus was entrapped beneath the displaced fracture fragment in 36 of 80 cases, whereas the lateral meniscus was only entrapped in 1 of 80 cases. This is not to be confused with the data
from Lowe and associates in JBJS 2002 where they found the lateral meniscus to be involved in blocking reduction. This was not thought due to entrapment of the lateral meniscus. Rather, with the anterior cruciate
ligament and lateral meniscus still being attached to the avulsed fracture fragment, they felt the two structures were pulling in opposite directions and therefore blocking reduction of the fragment.
REFERENCES: Falstie-Jensen S, Sondergard-Petersen PE: Incarceration of the meniscus in fractures of the intercondylar eminence of the tibia in children. Injury 1984;15:236-238.
Kocher MS, Micheli LJ, Gerbino P, et al: Tibial eminence fractures in children: Prevalence of meniscal entrapment. Am J Sports Med 2003;31:404-407.
Accousti WK, Willis RB: Tibial eminence fractures. Orthop Clin North Am 2003;34:365-375.
Lowe J, Chaimsky G, Freedman A, et al: The anatomy of tibial eminence fractures: arthroscopic observations following failed closed reduction. J Bone Joint Surg Am 2002;84:1933-1938.
Figure 14a Figure 14b Figure 14c Question 14
A 14-year-old boy underwent in situ screw fixation for a left slipped capital femoral epiphysis 8 months ago. He
noted 3 months of intermittent right hip pain but is presently asymptomatic. The last episode of pain was 2 days prior to this office visit. He reports that he has pain approximately once a week over the past 3 months. Examination of the right hip is normal, and includes pain-free internal rotation. Radiographs and an MRI scan are shown in Figures 14a through 14c. Treatment should consist of which of the following?
In situ screw fixation of the right hip
Physical therapy
Limitation of activities and return to the clinic if pain persists
Biopsy of the femoral neck lesion
Irrigation and debridement of the right hip PREFERRED RESPONSE: 1
DISCUSSION: The patient history is concerning for a pre-slip slipped capital femoral epiphysis (SCFE) of the right hip. In one study, nearly 40% of patients with SCFE had bilateral involvement, and of that 40%, half presented initially with a unilateral SCFE but had a subsequent SCFE on the contralateral limb. Radiographs are normal, but the MRI scan shows increased signal about the proximal femoral physis. Treatment should include prophylactic screw fixation of the right hip.
REFERENCES: Aronsson DD, Loder RT, Breur GJ, et al: Slipped capital femoral epiphysis: Current concepts. J Am Acad Orthop Surg 2006;14:666-679.
Loder RT, Aronson DD, Greenfield ML: The epidemiology of bilateral slipped capital femoral epiphysis: A study of children in Michigan. J Bone Joint Surg Am 1993;75:1141-1147.
Loder RT: Controversies in slipped capital femoral epiphysis. Orthop Clin North Am 2006;37:211-221, vii.
Figure 15a Figure 15b

Question 81:

- A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Options:

Secondary hyperparathyroidism
Phosphate retention secondary to uremia
Insufficient renal synthesis of 1, 25 dihydroxy vitamin D
Aluminum deposition in bone from oral phosphate binders
Persistent acidosis aggravating the negative calcium balance

Correct Answer: Aluminum deposition in bone from oral phosphate binders

Explanation:

Question 82:

Options:

Cementless cup without graft
Cemented cup without graft
Cemented cup with structural bone graft
Bone graft, reconstruction cage, and cemented cup
Bilobed cementless acetabular component

Correct Answer: Bone graft, reconstruction cage, and cemented cup

Explanation:

Question 83:

Options:

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

Correct Answer: MTP arthrodesis

Explanation:

Question 84:

Options:

Coracoid transfer
Rotator cuff repair
Reverse total shoulder arthroplasty
Arthroscopic anteroinferior labral repair
Physical therapy for range of motion and strength improvements

Correct Answer: Rotator cuff repair

Explanation:

Question 85:

Options:

hospital admission for IV antibiotics and observation.
an epidural steroid.
anterior diskectomy and fusion with autologous bone graft.
laminectomy for decompression and debridement.
laminectomy for decompression with an instrumented posterolateral fusion.

Correct Answer: laminectomy for decompression and debridement.

Explanation:

Question 86:

Options:

Rotator cuff tear
Epiphyseal stress fracture
Bicipital tendinitis
Internal impingement
Loose body

Correct Answer: Internal impingement

Explanation:

Question 87:

Which of the following agents increases the risk for a nonunion following a posterior spinal fusion?

Options:

Ibuprofen
Intranasal calcitonin
Simvastatin
Gentamycin
Tamoxifen

Correct Answer: Ibuprofen

Explanation:

Question 88:

Spondyloepiphyseal dysplasia congenita and tarda, precocious osteoarthropathy, and Stickler syndrome are caused by a mutation in the gene coding for

Options:

type-I collagen
type-II collagen
cartilage oligomeric protein (COMP)
fibroblast growth factor 2 (FGFR2)
fibroblast growth factor 3 (FGFR3)

Correct Answer: type-II collagen

Explanation:

Question 89:

Options:

physical therapy for hip stretching exercises.
kyphectomy and posterior fusion with instrumentation.
anterior release and fusion using a rib strut graft.
anterior release and strut grafting and posterior fusion with instrumentation.
bracing.

Correct Answer: kyphectomy and posterior fusion with instrumentation.

Explanation:

Question 90:

A patient has pain 2 years after undergoing a metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis in the setting of reaction to metal debris?

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
MRI with metal artifact reduction sequence (MARS)
CT of pelvis Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Correct Answer: MRI with metal artifact reduction sequence (MARS)

Explanation:

Question 91:

Options:

Streptococcus viridans
Staphylococcus epidermidis
Escherichia coli
Vibrio parahaemolyticus
Clostridium difficile

Correct Answer: Staphylococcus epidermidis

Explanation:

Question 92:

Which of the following forms of nonsurgical management is considered best for acute low back pain without radiculopathy?

Options:

Acupuncture
Epidural steroid injections
Facet joint injections
Sclerosant injections
Bed rest

Correct Answer: Bed rest

Explanation:

Question 93:

Options:

observation and regular follow-up.
a custom-molded thoracolumbar orthosis.
anterior spinal fusion from T10 to L4.
anterior and posterior spinal fusion from T10 to L4.
posterior spinal fusion from T4 to L4.

Correct Answer: anterior spinal fusion from T10 to L4.

Explanation:

Question 94:

Which of the following is the most stable construct for fixation of an unstable transforaminal sacral fractures?

Options:

external fixation
iliosacral osteosynthesis
combined iliosacral and lumbopelvic fixation (triangular osteosynthesis)
anterior pelvic ring plating
transiliac bars

Correct Answer: external fixation

Explanation:

Question 95:

What is the main biologic effect of aggrecan in cartilage? Review Topic

Options:

Extracellular matrix protein involved in the organization of collagen
Proteoglycan involved in the hydrophilic behaviour of cartilage
Cartilage matrix protein that plays a role in cartilage tissue organization
Collagen component responsible for stability
Non-collagenous extracellular matrix protein that regulates chondrocyte proliferation

Correct Answer: Extracellular matrix protein involved in the organization of collagen

Explanation:

Question 96:

Options:

Good because it is a gram-positive organism
Good because it is an acute infection
Poor because it is a gram-positive organism
Poor because it is a late infection

Correct Answer: Poor because it is a late infection

Explanation:

DISCUSSION:
The patient has a late infection of at least 4 weeks symptomatic duration that most likely is hematogenous in etiology. This infection is not an acute hematogenous infection that can successfully be treated with irrigation and debridement. Retention of the implants with debridement and irrigation alone has been associated with a poor prognosis. In a recent study, the success rate was only 44% in a series of 104 patients at a mean 5.7-year follow-up. In one study of 50 infections attributable to MRSA or methicillin- resistant
Staphylococcus epidermidis
organisms treated with a two-stage protocol, the failure rate was
21%. Patients who experienced successful infection treatment had lower functional outcome measures using the Western Ontario and McMaster Universities Osteoarthritis Index, the University of California Los Angeles Activity Score, and the 12-item Oxford Knee Score, however.

Question 97:

A 21-year-old pregnant female arrives in the trauma bay with a closed head injury as well as an open ankle injury. During evaluation, what positioning is recommended to limit positional hypotension?

Options:

Reverse trendelenburg
Trendelenburg
Left lateral decubitus
Right lateral decubitus
Supine

Correct Answer: Reverse trendelenburg

Explanation:

Question 98:

Options:

Obturator artery
Central sacral vessels
Internal iliac vein
Ascending lumbar vein
Iliolumbar vein

Correct Answer: Iliolumbar vein

Explanation:

Question 99:

Options:

Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening
SLAP repair
Debridement of the partial-thickness rotator cuff tear
Rotator cuff repair
Imbrication of the labrum and anterior capsule

Correct Answer: Anti-inflammatory medication, posterior capsular stretching, and rotator cuff strengthening

Explanation:

Question 100:

What is the most common clinical presentation of a patient with a malignant bone tumor?

Options:

Incidental finding
Pain
Pathologic fracture
Deformity
Presence of a mass

Correct Answer: Pain

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

Orthopedic Board Review MCQs: Trauma & Sports Medicine | Part 241

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 241

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index