OITE Orthopedic Board Review MCQs: Shoulder & Foot

About This Board Review Set

This is Part 243 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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Topics Covered in Part 243

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

Sample Questions from This Set

Sample Question 1: An obese 4-year-old boy has infantile Blount’s disease. Radiographs reveal a metaphyseal-diaphyseal angle of 18 degrees and a depression of the medial proximal tibial physis. Management should consist of...

Sample Question 2: A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side, but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear nor...

Sample Question 3: An active 66-year-old man who underwent total shoulder arthroplasty 3 years ago now reports pain. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein. Intraoperative frozen section reveals greater tha...

Sample Question 4: A 36-year-old man has a 2-day history of acute lower back pain with severe radicular symptoms in the left lower extremity. The patient has a positive straight leg test at 40 degrees on the left side and mild decreased sensation on the dorsu...

Sample Question 5: Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory stud...

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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

An obese 4-year-old boy has infantile Blount’s disease. Radiographs reveal a metaphyseal-diaphyseal angle of 18 degrees and a depression of the medial proximal tibial physis. Management should consist of

Explanation

DISCUSSION: The deformity is too severe for observation, and at age 4 years, the child is too old for orthotic treatment. To prevent recurrence, surgery should be performed before irreversible changes occur in the medial physis. A proximal tibial osteotomy should overcorrect the mechanical axis to 10 degrees of valgus. Bar resection has not been shown to be as effective in this severe deformity, especially without a concomitant osteotomy.
REFERENCES: Raney EM, Topoleski TA, Yaghoubian R, Guidera KJ, Marshall JG: Orthotic treatment of infantile tibia vara. J Pediatr Orthop 1998;18:670-674.
Loder RT, Johnston CE: Infantile tibia vara. J Pediatr Orthop 1987;7:639-646.

Question 2

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side, but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

Explanation

DISCUSSION
This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 3

An active 66-year-old man who underwent total shoulder arthroplasty 3 years ago now reports pain. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein. Intraoperative frozen section reveals greater than 10 white blood cells per high power field on two slides and the Gram stain reveals gram-positive cocci in clusters. What is the most appropriate surgical treatment to eradicate the infection and maintain function? Review Topic

Explanation

The prosthesis is grossly infected. Removal of the components and placement of an antibiotic spacer is necessary to eradicate the infection and allow for a second stage reimplantation. Resection arthroplasty is an option to treat the infection but the functional outcome would be limited. Bone grafting with concurrent infection is not likely to heal and should be delayed until the second stage. Humeral head exchange and debridement or arthroscopic debridement alone is unlikely to eradicate the infection.

Question 4

A 36-year-old man has a 2-day history of acute lower back pain with severe radicular symptoms in the left lower extremity. The patient has a positive straight leg test at 40 degrees on the left side and mild decreased sensation on the dorsum of the left foot. What is the most appropriate management at this time? Review Topic

Explanation

In the absence of any severe progressive neurologic deficits or other red flags, the most appropriate management for an acute lumbar disk herniation is nonsurgical care. Conservative treatments such as limited bed rest, anti-inflammatory medications, and judicious use of pain medications are appropriate in this clinical situation. Up to 90% of patients will experience a resolution of symptoms without the need for surgical intervention within a 3-month window. In the acute setting, with no neurologic deficits, immediate MRI of the lumbar spine is neither beneficial nor warranted. Likewise, without signs of an acute deficit, emergent surgical intervention and caudal epidural steroid injections are not needed.

Question 5

Figures 29a and 29b show the AP and lateral radiographs of a 30-year-old man who has increasingly worse back pain and stiffness. Examination shows painful, limited spinal range of motion. There is no neurologic deficit. What laboratory study would be most helpful in confirming the diagnosis?

Explanation

DISCUSSION: The radiographs show ankylosing spondylitis with sclerosis of the sacroiliac joints and a “bamboo spine” in the lumbar region. HLA-B27 is positive in 80% to 90% of patients with ankylosing spondylitis and in about 8% of the general population. The findings do not represent diffuse idiopathic skeletal hyperostosis (DISH), which is a radiographic diagnosis in which there are three consecutive levels of nonmarginated osteophytes without disk degeneration.
REFERENCES: Calin A: Ankylosing spondylitis. Clin Rheum Dis 1985;11:41-60.
Booth R, Simpson J, Herkowitz H: Arthritis of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 431.
van der Linden S, Valkenburg H, Cats A: The risk of developing ankylosing spondylitis in HLA-B27 positive individuals: A family and population study. Br J Rheumatol 1983;22:18-19.

Question 6

After full healing from this injury, which option most likely will help to optimize this patient's activities?

Explanation

DISCUSSION
Midfoot fracture dislocations typically occur after a fall from a height or a motor vehicle collision involving severe dorsiflexion loading of the foot from a brake pedal or the floorboards. The deformity that results may be subtle because the subluxation may be a valgus or varus rotation around the midfoot rather than pure dorsiflexion. Early recognition and reduction is indicated to minimize secondary complications such as nerve injury or vascular compromise. Closed reduction usually necessitates formal anesthesia in an operating room to permit adequate relaxation and reduction. In many cases, satisfactory reduction can be accomplished closed, but the surgeon must be prepared to perform an open reduction if needed. The most common reason for failed closed reduction is that the talar head is caught by the tibialis posterior tendon (under which the talar head has protruded). This acts as a Chinese finger trap, preventing relocation by the usual distraction followed by
a plantar flexion maneuver. In these cases, open reduction is performed through a dorsomedial incision through which the tibialis posterior is retracted medially, allowing reduction of the talonavicular joint. The joints usually require pinning to maintain stability during healing. The long-term prognosis for these injuries is guarded because many patients develop degenerative changes in the Chopart joint. If symptomatic arthritis develops, helpful external supports are designed to limit sagittal motion at the joint (for example, carbon fiber inserts or rocker-bottom soles).
RECOMMENDED READINGS
Swords MP, Schramski M, Switzer K, Nemec S. Chopart fractures and dislocations. Foot Ankle Clin. 2008 Dec;13(4):679-93, viii. Doi: 10.1016/j.fcl.2008.08.004. Review. PubMed PMID: 19013402.View Abstract at PubMed
Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int. 2004 May;25(5):340-8. PubMed PMID: 15134617. View Abstract at PubMed

Question 7

A 21-year-old woman is struck by a car and sustains a Gustillo IIIB fracture of the tibia. The wound was debrided and immobilized with an external fixator. Radiographs are shown in Figure A. The soft tissue defect was covered with a free flap. Her recovery was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli. One month after her injury, she underwent intramedullary nailing and placement of an antibiotic spacer measuring 15cm in length. Radiographs are shown in Figure B. At the next stage of surgery 6 weeks later, the surgeon should plan to do all of the following:

Explanation

The second stage of the Masquelet technique requires removal of the cement bolus, incision into the induced membranes and bone grafting. The existing hardware is preserved where possible as the fracture is still not stable. Bone graft is inserted INTO the membranous cavity, AROUND the nail.
The Masquelet staged technique of induced membranes is an option for filling large bone defects up to 25cm in length. This technique protects against autograft resorption, stimulates mesenchymal cell-to-osteoblast differentiation, maintains graft position, and prevents soft tissue interposition. Cement impregnation achieves high local antibiotic concentration without risk of systemic toxicity.
Ashman et al. discussed the techniques of addressing bone defects. Options include:
(1) acute limb shortening (up to 4cm in the tibia and humerus, and 7cm in the femur);
(2) distraction osteogenesis for defects up to 10cm long (at 1mm/day with consolidation period of 5days per mm, or total treatment time of up to 60days/cm), (3) autograft (up to 25cm of vascularized fibula, or 3cm of nonvascularized iliac crest),
and (4) Masquelet technique.
Taylor et al. reviewed the induced membranes technique. They found that the membrane is well vascularized and composed of type I collagen with fibroblasts with an inner epithelial cell layer. There is a high concentration of VEGF, RUNX2 (CBFA1), TGFß1, and BMP2. The membrane is sutured over bone graft to create a closed pouch. When a nail is present, they note a second internal membrane around the nail, potentially increasing local vascularity and osteoinductive factor concentration.
Figure A shows a Gustillo IIIB tibia fracture with a large bone defect held in a temporizing external fixator. Figure B shows the same defect following intramedullary nailing and with a cement spacer placed circumferentially around the nail in the defect.
Incorrect Answers

Question 8

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Explanation

Articular cartilage in the knee adapts to exercise by increasing the glycosaminoglycan (GAG) content. Increased GAG content is important to cartilage health. There is a higher glycosaminoglycan content in the lateral femoral cartilage compared to the medial femoral cartilage. Using T1 gadolinium enhanced MRI, the GAG content is seen to be increased in moderate distance runners. Moderate exercise may be a good treatment, not only to improve joint symptoms and function, but also to improve the knee cartilage GAG content in patients at high risk of developing osteoarthritis.

Question 9

A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve?

Explanation

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstay of treatment for medial scapular winging.

Question 10

A 42-year-old man with a history of renal cell carcinoma has progressive weakness in the lower extremities for the past 3 weeks. The patient desires intervention. A sagittal T 2 -weighted MRI scan is shown in Figure 9a, and a sagittal contrast enhanced T 1 -weighted MRI scan is shown in Figure 9b. He currently ambulates minimal distances with a walker. His life expectancy is 8 months. Treatment of the spine lesion should consist of

Explanation

DISCUSSION: The MRI scans show a metastatic lesion in two contiguous vertebral bodies in the lower thoracic spine. Posterior laminectomy is not indicated because this does not adequately decompress the neural elements and will lead to progressive kyphosis. A posterior fusion may prevent progressive kyphosis but will not decompress the spinal cord. Renal cell carcinoma is not radiosensitive; therefore, radiation therapy would not be helpful in relieving neurologic compression. The lesion should be treated by an anterior corpectomy and reconstruction. This will allow for complete decompression as well as reconstruction of the anterior column. Kyphoplasty is not indicated in a lesion with disruption of the posterior cortex and neurologic impairment.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
White AP, Kwon BK, Lindskog DM, et al: Metastatic disease of the spine. J Am Acad Orthop Surg 2006;14:587-598.

Question 11

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Explanation

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not

require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am

2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 12

A 40-year-old man has had hip pain with increased activity over the past year. Examination reveals restriction of motion and tenderness with combined hip flexion, adduction, and internal rotation. An AP radiograph is shown in Figure 34. What is the most likely diagnosis?

Explanation

DISCUSSION: Femoral acetabular impingement (FAI) is a pathologic entity leading to pain, reduced range of motion in flexion and internal rotation, and development of secondary arthritis of the hip. There are two types of FAI: cam impingement and pincher impingement. Cam impingement is seen when a nonspherical femoral head produces a cam effect when the prominent portion to the femoral head rotates into the joint. This mechanism produces shear forces that damage articular cartilage. Radiographs reveal early joint degeneration and flattening of the head neck junction (the so-called “pistol grip deformity”) as seen in this image. The pincher type of impingement involves abnormal contact between the femoral head neck junction and the acetabulum, in the presence of a spherical femoral head.
REFERENCES: Beall DP, Sweet CF, Martin HD, et al: Imaging findings of femoraoacetabular impingement syndrome. Skeletal Radiol 2005;34:691-701.
Mardones RM, Gonzalez C, Chen Q, et al: Surgical treatment of femoroacetabular impingement: Evaluation of the effect of the size of the resection. J Bone Joint Surg Am 2006;88:84-91.

Question 13

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: A ganglion cyst compressing the suprascapular nerve results in poorly localized pain in the shoulder girdle. Sensation is intact, with weakness of external rotation and abduction. Supraspinatus and infraspinatus atrophy is often noted when viewed from behind. These cysts are typically associated with labral tears. Deltoid weakness is associated with an axillary nerve injury, and scapular winging results from injury to the long thoracic nerve.
REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Inokuchi W, Ogawa K, Horiuchi V: Magnetic resonance imaging of suprascapular nerve palsy.

J Shoulder Elbow Surg 1998;7:223-227.

Question 14

Examination of the shoulder seen in Figure 52 shows atrophy and tenderness of the infraspinous fossa and profound weakness in external rotation. The supraspinous fossa shows normal muscle bulk. What is the most likely cause of this condition?

Explanation

DISCUSSION: Compression of the suprascapular nerve by a ganglion cyst is a well-documented cause of pain and weakness in the shoulder. Isolated involvement of the infraspinatus indicates that the area of entrapment is at the spinoglenoid notch and not the suprascapular notch. The majority of ganglion cysts found in the shoulder are related to tears of the labrum. When such a compressive lesion is found, decompression can be accomplished through either an open or arthroscopic approach. Several authors have shown the value of arthroscopy in the treatment of this condition. It has been shown that it is technically possible to decompress a paralabral ganglion cyst using arthroscopy; this method is usually followed by repair of the torn labrum. Alternatively, arthroscopic repair of the labrum can be performed and the cyst may be aspirated at the time of surgery. Open cyst excision through a posterior approach is also an acceptable method of treatment.
REFERENCES: Schickendantz MS, Ho CP: Suprascapular nerve compression by a ganglion cyst: Diagnosis by magnetic resonance imaging. J Shoulder Elbow Surg 1993;2:110-114.
Thompson RC, Schneider W, Kennedy T: Entrapment neuropathy of the inferior branch of the suprascapular nerve by ganglia. Clin Orthop 1982;166:185-187.
Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 15

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

Explanation

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.
REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy. Tech Hand Up Extrem Surg 1999;3:32-36.

Question 16

Figure 2 shows the radiograph of a 72-year-old woman who reports pain after a fall. History includes several years of increasing thigh pain and limb shortening. Management consisting of an extensive work-up for infection reveals normal laboratory studies, a positive bone scan, and a negative hip aspiration. What is the most likely etiology of this complication?

Explanation

DISCUSSION: The patient has a midstem periprosthetic fracture, which commonly results in loosening of the prosthesis. Patients who have a large amount of bone loss may require an allograft with the surgical reconstruction. Although the patient reported a fall, her history is also consistent with preexisting loosening of the prosthesis. Chronic infection has been shown in up to 16% of these fractures; however, the patient’s work-up revealed no infection.
REFERENCES: Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Bethea JS III, DeAndrade JR, Fleming LL, Lindenbaum SD, Welch RB: Proximal femoral fractures following total hip arthroplasty. Clin Orthop 1982;170:95-106.
Kelley SS: Periprosthetic femoral fractures. J Am Acad Orthop Surg 1994;2:164-172.

Question 17

Acetaminophen is an antipyretic medication. It exerts its pharmacologic effects by inhibiting which of the following enzymes?

Explanation

DISCUSSION: Acetaminophen inhibits prostaglandin E2 production via IL-1 β, without affecting cyclooxygenase-2 enzymatic activity. The therapeutic concentrations of acetaminophen induce an inhibition of IL-1 β-dependent NF-kappa β nuclear translocation. The selectivity of this effect suggests the existence of an acetaminophen-specific activity at the transcriptional level that may be one of the mechanisms through which the drug exerts its pharmacologic effects. Acetaminophen does not affect any of the other enzymes named above.
REFERENCE: Mancini F, Landolfi C, Muzio M, et al: Acetaminophen down-regulates interleukin-1beta-induced nuclear factor-kappaB nuclear translocation in a human astrocytic cell line. Neurosci Lett 2003;353:79-82.

Question 18

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Explanation

RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 19

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Explanation

Fixation of pelvic and acetabular fractures in pregnancy is not contraindicated. However, both maternal and fetal morbidity and mortality is increased in this patient subset. Factors shown to be associated with increased fetal mortality include: injury severity, mechanism of injury, and maternal hemorrhage. Surgical approach, fracture classification, fetal position, and the trimester of pregnancy have not been shown to affect fetal morbidity or mortality.

Question 20

What is the most serious complication that may occur with a ceramic-on-ceramic bearing in a total hip prosthesis?

Explanation

Fortunately, due to improvements in strength and quality control, fracture of a modern ceramic hip bearing is very rare. However, when a ceramic bearing does fracture, numerous fragments may become embedded in the capsular tissues. During revision, the surgeon must make every reasonable effort to locate and remove these fragments. Among other complications, fragments that remain behind can become entrapped between the bearing surfaces of the new implant and initiate severe wear. In normal use, ceramic bearings have excellent wear resistance. Squeaking may be extremely annoying to the patient, but is not inherently dangerous and sometimes resolves spontaneously. Dislocation is a serious complication regardless of the type of bearing, but it sometimes may be treated without requiring a reoperation and, if revision is required, it typically is not as problematic as with a fractured ceramic bearing. Infection is to be avoided, but it is not a complication directly related to the use of a ceramic bearing.

Question 21

Which of the following findings is a contraindication to isolated percutaneous pinning of a distal radius fracture?

Explanation

DISCUSSION: Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex. Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution. Simple intra-articular fractures can also be treated with pinning alone. Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening. When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended.
REFERENCES: Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23:381-394.
Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases. J Bone Joint Surg Br 1995;77:797-801.
Weil WM, Trumble TE: Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization. Hand Clin 2005;21:317-328.

Question 22

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

Explanation

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

Question 23

Figures 81a through 81c show the MRI scans of a 53-year-old man who has experienced a long history of progressively worsening right-sided back pain with radiation to the buttocks and right lower extremity. Examination reveals weakness and hyperreflexia in the right lower extremity. He reports intermittent episodes of urinary incontinence. What is the most appropriate surgical approach? Review Topic

Explanation

The presence of stenosis in the thoracic region with its related clinical manifestations has only recently been appreciated. The pathogenesis of thoracic stenosis is similar to that found in the cervical or lumbar spine. Two distinct clinical syndromes of thoracic stenosis have been identified, the most common being associated with degenerative changes of the spine. Clinical manifestations include development of unilateral or bilateral symptoms of pseudoclaudication. Focal radicular pain or paresthesias may also be present. The neurologic examination initially may be normal, but as the degree of neural compression progresses, posterior column dysfunction and long tract signs appear. If allowed to progress untreated, the patient may develop significant difficulty with gait and bowel/bladder function. Thoracic spinal cord stenosis secondary to congenital narrowing of the spinal canal is associated with a more abrupt onset of symptoms. The typical clinical manifestations of myelopathy may commence following minor or moderate trauma. Radicular symptoms are rare in congenital thoracic stenosis. One indication for thoracic laminectomy is a patient in whom imaging has demonstrated evidence of spinal canal stenosis secondary to hypertrophy of the posterior elements. A laminectomy should not be the primary approach when stenosis results from a significant ventral epidural osteophyte or herniated disk; these lesions are more effectively and safely managed by a posterolateral (transpedicular, transfacetal, or costotransversectomy) or an anterior approach.

Question 24

Figures below show the radiographs, and the CT obtained from a 58-year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

Explanation

DISCUSSION:
Groin pain after total hip replacement has a number of possible causes, and an exact diagnosis may remain elusive in some patients. Infection should be ruled out with laboratory studies and, if indicated, diagnostic aspiration of the hip joint. Implant loosening should be evaluated by plain radiograph and bone scan, if indicated. Synovitis resulting from wear debris should be considered in patients with polyethylene liners who experience late-onset symptoms or in any patient with a metal-on-metal bearing. This patient's symptoms are classic for iliopsoas tendonitis. Physical examination usually reveals pain and weakness with resisted hip flexion. A cross-table lateral radiograph and CT show that the anterior edge of the acetabulum protrudes beyond the anterior wall, thereby acting as a source of iliopsoas tendon irritation. In such cases, acetabular component revision and repositioning are indicated. Fluoroscope-guided iliopsoas cortisone injection can help to establish the diagnosis and relieve groin pain. If the acetabular component is well positioned, then iliopsoas tenotomy should be considered.

Question 25

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Explanation

Figure A shows a minimally displaced Weber B ankle fracture. The need for operative treatment would be dependent on fracture stability. A gravity stress test would best demonstrate fracture displacement, syndesmotic injury and medial sided ligamentous integrity.
In patients who present with no medial widening on standard ankle radiographs and no clinical symptoms of deltoid ligament injury, the integrity of the deltoid ligament remains unknown. The gravity stress radiograph may be used to help identify a deltoid ligament injury in association with an isolated distal fibular fracture. Stage-IV supination-external rotation fractures, which involve the deltoid ligament, are more likely to be treated operatively as they are often considered unstable ankle fractures.
Egol et al. reviewed 101 patients with isolated fibular fracture and an intact mortise. They found that medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. Interestingly, they report that good functional results can be obtained in patients with widening of the medial clear space on a stress radiograph in the absence of medial signs.
Gill et al. compared the effectiveness of gravity stress radiograph as compared to manual stress radiograph for the detection of deltoid ligament injury in isolated fibular fracture. A total of twenty-five patients with SER type-II fracture and SER Type IV-equivalent fractures were enrolled. They found the gravity stress radiograph was equivalent to the manual stress radiograph for determining deltoid ligament injury.
Figure A shows a mortise radiograph displaying a minimally displaced Weber B ankle fracture. Illustration A shows the positioning for a gravity stress radiograph. The patient is in the lateral decubitus position with the injured leg dependent and off the end of the table, a mortise view is taken in 10° of internal rotation of the tibia.
Incorrect Answers:

Question 26

A 12-year-old Little League pitcher has had pain in the dominant shoulder for the past week that prevents him from pitching. Examination reveals normal strength, full range of motion, normal stability, and mild tenderness about the proximal humerus. Radiographs with comparison views of the opposite shoulder show widening of the proximal humerus physis. Management should include

Explanation

Little League’s shoulder is a stress fracture of the proximal humeral epiphyseal plate. The classic history is the adolescent pitcher who has increased his pitching level and now has poorly localized aching shoulder pain after attempts to throw. PE will show discomfort at the proximal humerus and weakness. Early x-ray may show no pathology. Later it shows physis widening, fragmentation, demineralization, periosteal stripping, callus.
Treatment requires cessation of repetitive physeal stress. There is no long-term sequelae. The athlete can return to same sports in the following season with emphasis on preseason conditioning.

Question 27

The initiating cellular event in development of posttraumatic osteoarthritis is attributed to which of the following?

Explanation

A relatively large percentage of patients sustaining intra-articular fractures develop posttraumatic arthritis despite surgical restoration of joint incongruity and alignment. Fracture-related chondrocyte death (apoptosis) concentrated along matrix cracks in the superficial layer of cartilage has been linked to the pathogenesis of posttraumatic osteoarthritis. Apoptosis is accentuated by a series of aspartate-specific cysteine proteases. Inhibition of this cascade is a target of emerging pharmacological treatment options.

Question 28

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

Explanation

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

Question 29

Figure 11 shows the radiograph of a 2-year-old child with marked genu varum and tibial bowing. Based on these findings, what is the best initial course of action?

Explanation

The radiograph shows multiple wide physes, consistent with a diagnosis of rickets. A low serum phosphorous level and an elevated alkaline phosphatase level are the hallmarks in diagnosing familial hypophosphatemic Vitamin D-resistant rickets. Serum calcium is usually normal or low normal. This disease is inherited as an X-linked dominant trait and usually presents at age 18 to 24 months. The disease results from a poorly defined problem with renal phosphate transport in which normal dietary intake of vitamin D is insufficient to achieve normal bone mineralization. Renal tubular dysfunction is associated with urinary phosphate wasting. Treatment involves oral phosphate supplementation, which can cause hypocalcemia and secondary hyperparathyroidism. To prevent associated problems, high doses of Vitamin D are administered. While obtaining a scanogram may be clinically indicated in an associated limb-length discrepancy, and subsequent corrective surgery may be indicated, either of these choices would not be the first course of action. An orthosis may slow the progression of genu varum in this disorder but is less important than establishing the correct diagnosis to begin pharmacologic treatment. This amount of varum and tibial bowing far exceeds the normal limits of physiologic genu varum. Skeletal dysplasias usually are not associated with abnormal laboratory values.

Question 30

What nerve is most likely to be injured during the anterior exposure of C2-3?

Explanation

DISCUSSION: The hypoglossal nerve exits from the ansa cervicalis at approximately the C2-3 level and can be injured during retraction up to the C2 level. The superior laryngeal nerve lies at about C4-5. The facial nerve is much higher. The vagus nerve runs with the internal jugular and carotid much more laterally. The phrenic nerve exits posteriorly.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-54.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 31

A 20-year-old collegiate pitcher has had a 5-month history of shoulder pain while throwing, decreased velocity, and difficulty with location of his pitches despite multiple attempts at rest. He reports no traumatic event. Examination with his throwing arm abducted at 90 degrees reveals external rotation to 110 degrees and internal rotation to 70 degrees when compared with his nonthrowing shoulder which has external rotation to 95 degrees and internal rotation to 85 degrees. He has a positive O'Brien's sign, positive modified Jobe's relocation test, full rotator cuff strength, no obvious muscular atrophy, and no scapular winging. Radiographs of the affected shoulder show no abnormalities. What is the next most appropriate step in management? Review Topic

Explanation

The study of choice to evaluate the superior labrum is an MR arthrogram. The patient has symptoms suspicious for superior labral pathology (ie, positive O'Brien's test, Jobe's relocation test, pain with throwing, loss of velocity and location). Whereas he does have increased external rotation and decreased internal rotation of his throwing arm compared with his non-throwing arm, the total arc of motion is 180 degrees and this is considered a normal adaptive change in the overhead throwing athlete; therefore, ultrasound is not considered appropriate management. There are no signs of weakness or rotator cuff pathology to suggest suprascapular nerve compression or a full-thickness rotator cuff tear; therefore, electrodiagnostic testing or physical therapy are inappropriate. There are also no signs or symptoms suggesting infection or rheumatologic issues; therefore, laboratory studies are unnecessary. If the MR arthrogram shows a labral tear, the initial management would include posterior capsular stretching and rotator cuff strengthening.

Question 32

A 13-year-old girl has had increasing left hip pain for the past 4 months. A radiograph, bone scan, MRI scan, and photomicrograph are shown in Figures 1a through 1d. Which of the following immunohistochemistry results would confirm the most likely diagnosis?

Explanation

DISCUSSION: The imaging studies show a permeative lesion of the left hemipelvis with a large soft-tissue mass. The photomicrograph demonstrates a small blue cell tumor with pseudorosettes. The most likely diagnosis is primitive neuroectodermal tumor (Ewing’s sarcoma family of tumors). MIC-2 is a highly sensitive and specific marker for this family of tumors. Cytokeratin is an epithelial marker. Vimentin is a mesenchymal marker. Thus, Ewing’s sarcomas are cytokeratin negative and vimentin positive. Before discovery of the MIC-2 antigen, PAS and reticulin stains were commonly used to help differentiate Ewing’s sarcoma from lymphoma. In contrast to lymphoma, Ewing’s sarcomas are typically PAS positive and reticulin negative.
REFERENCES: Halliday BE, Slagel DD, Elsheikh TE, et al: Diagnostic utility of MIC-2 immunocytochemical staining in the differential diagnosis of small blue cell tumors. Diagn Cytopathol 1998;19:410-416.
Llombart-Bosch A, Navarro S: Immunohistochemical detection of EWS and FLI-1 proteins is Ewing sarcoma and primitive neuroectodermal tumors: Comparative analysis with CD99

(MIC-2) expression. Appl Immunohistochem Mol Morphol 2001;9:255-260.

Question 33

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 34

What is the most common behavioral effect of anabolic steroid use in athletes? Review Topic

Explanation

Users of anabolic steroids often display increased feelings of hostility and aggression. Although reports of psychotic, depressive, and manic behavior have been reported with the use of steroids, they are rare. Drug dependence, such as seen with narcotics, is not a feature of steroid use.

Question 35

-A collegiate offensive football lineman has decreased bench-press strength and shoulder pain as off-season workouts begin. Examination revealed no atrophy, and deltoid and rotator cuff strength testing findings were normal. Translational testing was difficult to achieve because of his large size.Apprehension and relocation test findings were negative. An O’Brien’s active compression test result was negative. Jerk testing was positive on the affected side. Which diagnosis is most likely revealed on an MRI arthrogram?

Explanation

Question 36

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

Explanation

EXPLANATION:
Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and paresthesias, are not supported by the evidence.

Question 37

An 80-year-old right-hand dominant male presents to clinic with 1 month of left shoulder pain. He has crepitance as well as a positive drop arm test on exam. Radiographs are significant for moderate glenohumeral arthritis and MRI demonstrates Goutallier Stage IV fatty infiltration of the rotator cuff. Which of the following is NOT an appropriate option for treatment of this condition? Review Topic

Explanation

This patient has moderate glenohumeral arthritis with an irreparable rotator cuff tear. Rotator cuff tears with fatty infiltration are considered to be "irreparable", with arthroscopic repair not indicated as an appropriate option for treatment.
The optimal management of patients with irreparable rotator cuff tears with glenohumeral osteoarthritis is not well defined in literature. Initial management should involve conservative measures, including injection of corticosteroids, physical therapy, activity modification, and NSAIDs, with consideration of operative intervention in those that fail a trial of nonoperative management.
Laudicina et al review the management of irreparable rotator cuff tears in the setting of glenohumeral osteoarthritis(OA). NSAIDs, corticosteroid injection, activity modification, and physical therapy are mainstays of nonoperative treatment. Failure of conservative management may lead to operative intervention. The authors endorse that hemiarthroplasty is currently the procedure of choice for patients with moderate to severe glenohumeral OA and irreparable cuff tears.
Izquierdo et al provide a clinical practice guideline of the treatment of glenohumeral osteoarthritis based on systematic review. Nine of 16 addressed recommendations were inconclusive, illustrating that the management of glenohumeral osteoarthritis remains controversial. The single moderate-rated recommendation was for the use of total shoulder arthroplasty (TSA) rather than hemiarthroplasty. The two recommendations reached by consensus include use of perioperative mechanical and/or chemical DVT prophylaxis for shoulder arthroplasty patients and that TSA should be avoided in patients with glenohumeral OA with irreparable rotator cuff tear.
Illustration A demonstrates the Goutallier staging system of rotator cuff tears.
Incorrect Answers:

Question 38

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

Explanation

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

Question 39

What structure is located at the tip of the arrow in Figure 18? Review Topic

Explanation

The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.

Question 40

Decreased risk of shoulder and elbow injury in a throwing athlete has been demonstrated with which of the following? Review Topic

Explanation

Posterior capsular contracture has been demonstrated to significantly impair the ability of the humeral head to translate anterior and inferiorly during the late cocking and early acceleration phases of the throwing motion. This results in an obligatory posterosuperior translation of the humeral head that may contribute to posterior superior glenohumeral internal impingement with posterosuperior labral and articular-sided rotator cuff pathology. Posterior capsular stretching in throwing athletes has been demonstrated to decrease the likelihood of clinically significant shoulder or elbow injury. Periscapular muscle and rotator cuff strengthening are important for optimal scapulothoracic rhythm, stable scapular position for throwing, and rotator cuff function but less directly established to result in a decreased risk of shoulder and elbow injury than posterior capsular stretching. Partial-thickness rotator cuff repair and superior labral repair may be necessary for treatment of symptomatic lesions unresponsive to nonsurgical management, but these do not necessarily correlate with decreased shoulder and elbow injury risk.

Question 41

A 55-year-old man who runs on the weekends reports a 1-year history of continued pain directly posteriorly in the heel. Management consisting of anti-inflammatory drugs, icing techniques, a heel-counter in his shoe split, and physical therapy consisting of stretching, contrast baths, custom orthotics, and iontophoresis has failed to provide relief. Not only is his lifestyle disrupted with respect to running, but he now has pain with normal ambulation with all forms of shoe wear. He is not necessarily concerned with returning to running; he is primarily seeking pain relief. A lateral radiograph and clinical photograph are shown in Figures 32a and 32b. Treatment should now consist of

Explanation

DISCUSSION: The patient has severe calcifications at the insertion of the Achilles tendon. Failure to address the Haglund’s exostosis and the calcifications will leave the patient with persistent pain. Steroids should not be injected directly into the tendon because of the increased risk of tendon rupture. Shock wave treatment may have some value in treating plantar fasciitis, but its efficacy has not been documented with insertional calcifications and Haglund’s exostosis treatment. Brisement is injection of saline solution around the Achilles tendon in an attempt to decompress the peritenon. This may be valuable in intrasubstance Achilles tendinosis or peritendinitis but has no value with insertional disease. Symptoms persisting beyond 6 months are difficult to treat nonsurgically; therefore, the appropriate treatment protocol is aggressive and must address all pathology. The patient may not be able to run at the level achieved prior to surgery, but the goal of the surgery is pain relief.
REFERENCES: Clain M, Baxter D: Achilles tendinitis. Foot Ankle 1992;13:482-487.
Schepsis A, Wagner C, Leach R: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.
Schepsis A, Leach R: Surgical management of Achilles tendinitis. Am J Sports Med 1987;15:308-315.
Keck S, Kelly P: Bursitis of the posterior part of the heel: Evaluation of surgical treatment of eighteen patients. J Bone Joint Surg Am 1965;47:267-273.

Question 42

Figure 61 shows the current radiograph of a 69-year-old woman who fell getting out of bed 10 months ago. At the time of injury she was diagnosed with a nondisplaced humeral surgical neck fracture. After 2 weeks of sling immobilization, physical therapy was started for range of motion. She continues to have pain and is unable to elevate her arm. What is the most likely diagnosis?

Explanation

The patient has a nonunion at the fracture site. The humeral head fragment has the rotator cuff musculature attached but the head is not united to the humeral shaft. There is no evidence of glenohumeral arthritis or a rotator cuff tear. Given the history, she has no evidence of a shoulder infection at this time. In review of the radiographs, there is an established nonunion; therefore, examination for post fracture stiffness is not possible because the motion is occurring at the nonunion site.
(SBQ12TR.96) Interleukin-6 levels have been shown to be a reliable measure of which of the following?
Osteoporosis
Severity of injury
Sarcomatous tumor burden
Bone turnover
Hyperparathyroidism
Interleukin-6 (IL-6) is a proinflammatory cytokine that is increased according to the level of injury sustained and acts to activate the host immune system. In addition, new literature exists to indicate its high sensitivity and specificity for detecting infection in total joint arthroplasty.
Overactivation of the immune system and cytokines can lead to systemic inflammatory response syndrome (SIRS), which results in end-organ damage, including small-vessel vascular damage; this would lead to parenchymal cell death from hypoxic insult.
Keel et al. report that immediate and early trauma deaths are determined by brain injuries or significant blood loss, while late mortality is caused by secondary brain injuries and host defense failure. The secondary effects are characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators.
Pape et al. investigated the effect of surgeries as a "second-hit" phenomenon. They found that surgery on days 2-4 was associated with a greater amount of postoperative organ dysfunction than if the secondary surgery was done on days 5-8. They also found a significant association between IL-6 values above 500pg/dL at the time of surgery and development of multiple organ failure.
Sears et al. review the effect of the inflammatory response to trauma and the development of complications (death, multiple organ failure). They report that IL-6 and the HLA-DR2 molecules currently appear to have the most potential for use in predicting outcomes in trauma patients.
Illustration A is a diagram that shows some of the effects of IL-6 production. Incorrect Answers:
1,3-5: IL-6 levels are not known to be reliably altered by these factors.

Question 43

A 36-year-old woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with open reduction and internal fixation. What is the most common complication?

Explanation

DISCUSSION: The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs. Fusion is reserved for failure of nonsurgical management. Hardware failure may occur, but it is clinically unimportant.
REFERENCES: Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Arntz CT, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173-181.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 44

A 45-year-old man reports a history of a popping sensation and pain in the right shoulder while lifting boxes 6 months ago. The pain has persisted with loss of motion of the shoulder. Radiographs and MRI scans are shown in Figures 47a through 47d. Which of the following studies is likely to produce a significant positive result? Review Topic

Explanation

The patient has a neuropathic joint secondary to syringomyelia that can be seen on a cervical MRI scan. The patient sustained minimal trauma that lead to a chronic anterior glenohumeral dislocation. He did not seek treatment for several months and has a massive rotator cuff tear and hygroma on MRI in addition to the chronic dislocation. Rheumatoid arthritis does not present with a neuropathic picture, except theoretically as the result of numerous intra-articular cortisone injections. This Charcot picture is inconsistent with ankylosing spondylitis or gout. Cannabis use is not typically associated with seizures that could produce anterior as well as posterior shoulder dislocations.

Question 45

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

Explanation

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

Question 46

..Figures 107a through 107c are the radiograph, CT, and bone scan of a 68-year-old man. While walking, he collapsed and was unable to ambulate because of pain and deformity in his right leg. What is the most appropriate next step?

Explanation

RESPONSES FOR QUESTIONS 108 THROUGH 111
Glomus tumor
Diffuse pigmented villonodular synovitis (PVNS)
Extra-abdominal fibromatosis
Schwannoma
Hemangioma
Please match the characteristics below to the condition listed above.

Question 47

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Explanation

DISCUSSION: Aneurysmal bone cysts typically present as radiolucent lesions with an expansile remodeled cortex. The histologic appearance consists of blood-filled lakes surrounded by a benign lining that contains fibroblasts, giant cells, and hemosiderin. Although the other lesions are in the radiographic differential diagnosis, these histologic findings indicate an aneurysmal bone cyst.
REFERENCES: Bieselker JL, Marcove RC, Huvos AG, Mike V: Aneurysmal bone cyst: A Clinico-pathologic study of 66 cases. Cancer 1973;26:615.
Martinez V, Sissons HA: A review of 123 cases including primary lesions and those secondary to other bone pathology. Cancer 1988;61:2291.

Question 48

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 49

In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if Review Topic

Explanation

With the notable exception of fusion for degenerative spondylolisthesis and scoliosis, there is a paucity of evidence on the indications for spinal fusion in patients undergoing laminectomy for spinal stenosis. However, it is generally recommended that if the spine is destabilized (for example by removal of one complete facet joint or by an iatrogenic pars fracture), spinal fusion should be considered. Although fusion can be considered for a very long laminectomy, a two-level laminectomy does not represent, by itself, a clear indication for the addition of a spinal fusion. The repair of a dural tear and the use of nicotine by the patient play no role in the determination of whether or not to add fusion to a laminectomy procedure.

Question 50

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 51

50%

Explanation

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 52

A 32-year-old patient reports progressively increasing pain and stiffness after undergoing arthroscopic shoulder stabilization 1 year ago. The stabilization procedure was a Bankart repair with anchor fixation and supplemented with the heat probe. Radiographs are shown in Figures 45a and 45b. What is the most likely diagnosis?

Explanation

DISCUSSION: Postshoulder stabilization chondrolysis is a rare but devastating complication. It has been implicated with the use of the radiofrequency heat probe in some patients.
REFERENCES: Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Petty DH, Jazrawi LM, Estrada LS, et al: Glenohumeral chondrolysis after shoulder arthroscopy: Case reports and review of the literature. Am J Sports Med 2004;32:509-515.

Question 53

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Explanation

Success of a meniscal allograft transplantation is strongly dependent on accurate graft sizing, typically within 5% of the native meniscus. Previous studies have established that donor cell viability is not mandatory for the survival of these grafts since they are replaced by the recipient’s cells (at least peripherally) within several weeks. Thus,
cryopreservation of the graft to ensure cell viability is not necessary. There is a limited immune response to musculoskeletal allografts; therefore, immunosuppression, as is required for visceral organ transplantation, is not indicated.

Question 54

03 A 64 year old man who underwent revision total knee arthroplasty 6 months ago has leg pain after walking. AP and lateral radiographs are shown in Figures 39a and 39b. The cause of pain is most likely related to

Explanation

Barrack RL, Rorabeck C, Burt M. Sawhney J: Pain at the end of the stem after revision total knee arthroplasty. Clin Orthop 1999:367:216225.
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Question 55

A B C Figures 63a through 63c are the radiographs of a 19-year-old woman who sustained injuries in a motorcycle collision. Which initial treatment will result in the best functional outcome and lowest pain scores at 2 years?

Explanation

DISCUSSION
Ligamentous injuries to the tarsometatarsal and intermetatarsal joints are commonly a result of high-energy mechanisms. These injuries have resulted in worse outcomes following ORIF than Lisfranc injuries, which involve fractures. Multiple injury patterns may occur, with some injuries involving mostly the ligamentous structures. Ligamentous Lisfranc injuries treated with primary arthrodesis have been shown to result in improved American Orthopaedic Foot & Ankle Society scores and lower Visual Analog Scale pain scores at 2-year follow-up than injuries treated with ORIF. ORIF with either plate or screw fixation has resulted in higher rates of secondary surgeries and lower functional scores. Nonsurgical management is not recommended for displaced injuries. Cast placement is recommended for patients with midfoot sprains with displacement of less than 2 mm. Nonanatomic reductions have been associated with poor results. Closed reduction and percutaneous pinning is unlikely to achieve an anatomic reduction and stable fixation.
RECOMMENDED READINGS
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583.View
Abstract at PubMed
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816. View Abstract at PubMed
Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000 Nov;82-A(11):1609-18. PubMed PMID: 11097452. View Abstract at PubMed Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002 Nov-Dec;30(6):871-8. PubMed PMID: 12435655. View Abstract at PubMed

Question 56

Figures 15a through 15c show the radiographs of a 23-year-old football player who was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Management should consist of

Explanation

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,

pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 57

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

Explanation

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

Question 58

A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Explanation

Number four is the correct answer because the flexor digitorum longus tendon will give excellent plantar support when transferred to the dorsum of the toe and this removes the main dynamic deforming force. Number one is incorrect because the planter plate will stretch in time and be insufficient. Number two is incorrect because the radiographs show a normal second metatarsophalangeal joint surface and it is not a fixed/dislocated joint and it is in a young patient. Number three is incorrect because it is not a frank dislocation. Number five is incorrect as this is reserved for mild deformity and would not be sufficient correction in this case.

Question 59

A 47-year-old man comes for evaluation of his dominant right elbow, which has been bothering him with activity for the past 3 months, especially with activities requiring wrist extension. He is an active squash player and has been unable to continue this sport. Examination shows tenderness at the common extensor origin. What is the next best step? Review Topic

Explanation

This patient has tennis elbow or lateral epicondylitis. First line treatment is conservative.
Lateral epicondylitis is a common problem with numerous non-operative treatments available. There is little scientific evidence to support any of these treatments however and the quality of most reports is low and their conclusions limited by bias and/or study design. Tennis elbow often resolves with time regardless of which conservative treatment is chosen.
Coombes et al. randomized patients with unilateral tennis elbow to receive either (1) corticosteroid injection, (2) placebo injection, (3) corticosteroid injection plus physical therapy or (4) placebo injection plus physical therapy. They found that
corticosteroid resulted in worse clinical outcome and recurrence rate compared to placebo injection. Use of physical therapy did not produce any significant differences.
Dines et al. review the diagnosis and of tennis injuries, including lateral epicondylitis. Although they acknowledge that there is "no long term benefit with regard to tendon healing," they note that steroid injection may be useful to control acute symptoms.
Boyer et al. review the myths surrounding lateral epicondylitis. They note that despite widespread use, corticosteroid injection has repeatedly been shown to have no long term benefit. They conclude based on their review of the literature that if there is any benefit to steroid injection, it is of short duration, and in patients whose symptoms have been of short duration, without any previous treatment.
Incorrect answers:

Question 60

A 40-year-old woman who is an avid tennis player reports the insidious onset of progressive left shoulder pain for the past 2 months. Examination reveals full range of motion with a positive impingement sign. Strength in the supraspinatus and infraspinatus muscles is normal, although stress testing is painful. An earlier subacromial cortisone injection provided good, but only temporary relief. An AP radiograph of the left shoulder is shown in Figure 10. Management should now consist of

Explanation

DISCUSSION: The radiograph shows calcific deposits within the substance of the supraspinatus tendon. Patients with this condition are prone to recurrent bouts of acute inflammation in the shoulder. While the response to cortisone injection is often dramatic, repeated injections are not recommended because of injury to the collagen fibers. Good results have been obtained with arthroscopic evacuation of the calcium deposits. In one study, the addition of a subacromial decompression did not improve the results.
REFERENCES: Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 1998;7:30-37.
Ark JW, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8:183-188.

Question 61

below depict the radiographs obtained from a year-old woman with a painful total knee arthroplasty. She describes an uneventful recovery with no wound-healing issues and was pain free for the first 10 years. Although reporting no trauma or inciting event, she now describes pain in the entire knee that is most severe with her first few steps. She has begun to notice night pain and, more recently, constant swelling. What is the most appropriate work-up at this time?

Explanation

DISCUSSION:
An evaluation of the painful total knee must be supported by an understanding of the potential etiologies of pain. They may include, aseptic loosening, infection, osteolysis, gap imbalance, referred pain, stiffness, and complex regional pain syndrome. In this case, the patient demonstrates start-up pain and had no prior history of infections. Her radiographs show subsidence of the tibia, indicating a loose prosthesis. Knowing that the prosthesis is already loose precludes the need for a bone scan. It is, however, important to rule out infection in this case; therefore, CRP and ESR testing is essential. Aspiration is also recommended when going into knee arthroplasty, and infection is a concern.

Question 62

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Explanation

DISCUSSION: The treatment of choice for pelvic chondrosarcoma is wide resection via an internal hemipelvectomy. Chondrosarcoma requires surgical resection for control and does not respond to traditional chemotherapy or external beam radiation. Hip arthroplasty with acetabular reconstruction and curettage and cementation of the lesion are intralesional procedures that result in a higher incidence of local recurrence of tumor.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Sheth DS, Yasko AW, Johnson ME, Ayala AG, Murray JA, Romsdahl MM: Chondrosarcoma of the pelvis: Prognostic factors for 67 patients treated with definitive surgery. Cancer 1996;78:745-750.

Question 63

Explanation

The Essex-Lopresti reduction technique is a useful method for the treatment of tongue type calcaneal fractures. With this technique, a steinman pin is inserted percutaneously into the posterior facet fragment. This pin is then used to disimpact the fragment and reduce the fracture.

Question 64

You are studying a single continuous variable after administration of a defined treatment intervention. Your statistician informs you the data are not normally distributed. What is the best test to analyze the data?

Explanation

The Mann-Whitney U test is used when data are nonparametric, meaning either not normally distributed or variances are not equal among groups. Both the Student t test and ANOVA are used with parametric, normally distributed data. A regression analysis is a statistical model that allows for control of potentially confounding variables. It is used to assess the relationship between a dependent variable and (usually) multiple independent variables.

Question 65

A 67-year-old retired steelworker was involved in a motor vehicle accident and sustained a midcervical spinal cord injury. Radiographs and MRI scans reveal severe cervical stenosis and spondylosis without fractures or dislocations. Neurologic examination reveals an ASIA C spinal cord impairment with greater motor involvement of the upper extremities than the lower extremities. What is the probability that the patient eventually will become ambulatory?

Explanation

DISCUSSION: The patient sustained an incomplete spinal cord injury known as central cord syndrome. Central cord syndrome characteristically has disproportionate involvement of the upper extremities with the lower extremities being relatively spared. It is most commonly seen after cervical injuries in elderly patients with spondylosis and spinal stenosis, often without fracture. Penrod and associates noted that 23 of 59 patients with central cord syndrome

(ASIA C and D) ultimately walked. The poorest prognosis, however, was in ASIA C patients older than age 50, in which only 40% walked.
REFERENCES: Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.
Northrup BE: Acute injuries to the spine and spinal cord: Evaluation and early treatment, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, p 735.

Question 66

Figure 16 shoes the AP radiograph of a 32-year-old man with a fracture cephalad to the fovea of the femoral head. A CT scan shows a single head fragment. After closed reduction of the hip, there is 5 mm of residual articular incongruity. Management should now include

Explanation

There seems to be no controversy in treating Pipkin 3 and 4 femoral head fractures. These are treated with an ORIF in concert with the femoral neck fracture or the acetabular fracture respectively. The difficulty stems in how to treat types land 2. In their review the authors recommend that residual joint incongruity of >2mm or an unstable hip requires and ORIF; their preferred approach was anterior. Swiontkowski Thorp Hansen Operative management of displaced femoral head fractures. J Orthopaedic Trauma. 1992 Vol 6 No 4; 437442

Question 67

A 2-year-old child is being evaluated for limb-length and girth discrepancy. As a newborn, the patient was large for gestational age and had hypoglycemia. Current examination shows enlargement of the entire right side of the body, including the right lower extremity and foot. The skin shows no abnormal markings, and the neurologic examination is normal. The spine appears normal. Radiographs confirm a 2-cm discrepancy in the lengths of the lower extremities. Additional imaging studies should include

Explanation

DISCUSSION: The patient may have Beckwith-Wiedemann syndrome (BWS), which consists of exophthalmos, macroglossia, gigantism, visceromegaly, abdominal wall defects, and neonatal hypoglycemia. Hemihypertrophy develops in approximately 15% of patients with BWS. Patients with hemihypertrophy that is the result of BWS have a 40% chance of developing malignancies such as Wilms’ tumor or hepatoblastoma; therefore, frequent ultrasound screening is recommended until about age 7 years. The absence of nevi and vascular markings helps to rule out other causes of hemihypertrophy, such as neurofibromatosis, Proteus syndrome, and Klippel-Trenaunay syndrome. Bone age estimations are not accurate at this young age but may become more useful later to help predict the timing of epiphysiodesis procedures.
REFERENCES: DeBaun MR, Tucker MA: Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry. J Pediatr 1998;132:398-400.
Ballock RT, Wiesner GL, Myers MT, et al: Hemihypertrophy concepts and controversies.

J Bone Joint Surg Am 1997;79:1731-1738.
Carpenter CT, Lester EL: Skeletal age determination in young children: Analysis of three regions of the hand/wrist film. J Pediatr Orthop 1993;13:76-79.

Question 68

Which of the following nutraceuticals has been associated with perioperative bleeding?

Explanation

DISCUSSION: Ginkgo biloba is a popular nutraceutical for patients who have early dementia, intermittent claudication secondary to peripheral vascular disease, vertigo, and tinnitus. It is reported to improve mental alertness and cognitive deficiency. It has antiplatelet properties as a result of one of its components, ginkgolide B, which displaces platelet-activating factor from its receptor binding sight. Rowin and Lewis reported on spontaneous bilateral subdural hematomas associated with chronic ginkgo biloba ingestion. Vale also reported on subarachnoid hemorrhage associated with ginkgo biloba. Bebbington and associates reported on persistent postoperative bleeding after total hip arthroplasty secondary to ginkgo biloba usage. Furthermore, the use of ginkgo biloba with aspirin or other antiplatelet agents or anticoagulants represents a relative contraindication. Physicians should be aware not only of prescribed medications but also alternative nutraceuticals that are used by the patient.
REFERENCES: Rowin J, Lewis SL: Spontaneous bilateral subdural hematomas associated with chronic ginkgo biloba ingestion. Neurology 1996;46:1775-1776.
Vale S: Subarachnoid hemorrhage associated with ginkgo biloba. Lancet 1998;352:36.
Bebbington A, Kulkarni R, Roberts P: Ginkgo biloba: Persistent bleeding after total hip arthroplasty caused by herbal self-medication. J Arthroplasty 2005;20:125-126.

Question 69

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Explanation

DISCUSSION: Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis.
REFERENCES: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.
Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.

Question 70

During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs. An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis. At this point, the surgeon should

Explanation

DISCUSSION: The risk of intraoperative fracture in osteopenic rheumatoid bone is significant. Fractures may occur with dislocation of the head and canal reaming, especially while extending and externally rotating the shoulder. If the fracture occurs at the distal tip of the prosthesis, the use of a long-stemmed prosthesis to bypass the fracture site and supplementation with wire cables has been reported with good results.
REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. J Bone Joint Surg Am 1995;77:1340-1346.
Boyd AD Jr, Thornhill TS, Barnes CL: Fractures adjacent to humeral protheses. J Bone Joint Surg Am 1992;74:1498-1504.
Petersen SA, Hawkins RJ: Revision of failed total shoulder arthroplasty. Orthop Clin North Am 1998;29:519-533.

Question 71

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O’Brien’s active compression test. What is the next most appropriate step in the diagnosis of this patient?

Explanation

DISCUSSION: MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct.
REFERENCES: Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963.
Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.
Nam EK, Snyder SJ: The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med 2003;31:798-810.

Question 72

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Explanation

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 73

When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?

Explanation

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

Question 74

Which component is most common to both simple and complex elbow dislocations?

Explanation

DISCUSSION: Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.

Question 75

What type of muscle contraction occurs while the muscle is lengthening?

Explanation

DISCUSSION: A muscle that lengthens as it is activated is an eccentric contraction. Isometric contraction involves no change in length. Concentric contraction occurs while the muscle is shortening. In isotonic contraction, the force remains constant through the contraction range. Isokinetic muscle contraction occurs at a constant rate of angular change of the involved joint.
REFERENCES: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000,

pp 12-13.
Lieber RL: Form and function of skeletal muscle, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 76

A hip compression screw is placed in a test jig and a bending load is applied to the tip of the screw. After the load is released, the screw returns completely to its original shape. What is this type of deformation called?

Explanation

When an implant is loaded below the yield point, by definition, it undergoes elastic deformation, meaning that all of the deformation recovers when the load is removed. If it is loaded above the yield point, then plastic or permanent deformation occurs. Fatigue is the gradual accumulation and progression of cracks in the material, which, after many cycles of loading, can lead to gross failure. Creep is the gradual accumulation of permanent (plastic) deformation over time, which may occur with polymeric materials but is not typical of metals or ceramics. Torsion refers to a torque being applied about the long axis of a bone or an implant. In general, the materials and dimensions of an implant are chosen to avoid plastic deformation or fatigue failure during typical clinical use.

Question 77

Figure 26 shows the radiograph of a 48-year-old woman who has right arm pain and hematuria. A bone scan reveals increased uptake in the left ribs and thoracic spine. A needle biopsy specimen shows that the lesion is highly keratin positive and composed primarily of clear cells. What is the best course of action?

Explanation

DISCUSSION: The lesion has the typical “blown out” lytic radiographic appearance that is most commonly found in thyroid or renal cell metastases. Given the history of hematuria and histology findings, the most likely diagnosis is metastatic renal cell carcinoma. This tumor is relatively resistant to chemotherapy. Radiation therapy is used as a postoperative adjuvant treatment with varying response rates. Surgery should be performed after preoperative embolization to decrease the risk of intraoperative bleeding, as no tourniquet can be used in this location. Patients with metastatic renal cell carcinomas may survive for years, resulting in a higher likelihood of local tumor progression with ineffective adjuvant therapy. Intramedullary fixation combined with curettage and cementation will provide the best chance of local control while maintaining the patient’s native shoulder and elbow joints. A total humeral resection is an extensive surgery with considerable morbidity and is not indicated for this patient because less extensive surgery is likely to be effective.
REFERENCES: Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathological fractures: Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-1054.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.
Katzner M, Schvingt E: Operative treatment of bone metastases secondary to renal carcinoma: Basic research and treatment of renal cell carcinoma metastasis. Prog Clin Biol Res EORTC 1990;348:151-168.

Question 78

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

Explanation

DISCUSSION: Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury.
REFERENCES: Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Gerber C, Sebesta A: Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report. J Shoulder Elbow Surg 2000;9:483-490.

Question 79

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

Explanation

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

Question 80

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

Explanation

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

Question 81

Initial management should consist of Review Topic

Explanation

The radiograph shows osteochondritis dissecans (OCD) of the capitellum, one manifestation of “pitcher’s elbow.” The lesion is nondisplaced, and healing is possible if the inciting throwing activities are curtailed. Long arm cast treatment may be reasonable for the noncompliant patient but should not exceed 6 weeks duration. Surgical treatment is indicated for loose bodies or cartilage flaps. Elbow OCD lesions are now being seen in younger children as more participate in organized sports, especially baseball and gymnastics.

Question 82

A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient's symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to

Explanation

EXPLANATION:
This patient has signs and symptoms of lateral epicondylitis. Treatments include various forms of physical therapy, iontophoresis, corticosteroid injection, nitroglycerin patch treatment, blood injections, prolotherapy, and surgical intervention. No single treatment is superior to other treatments for this common problem. Several studies have demonstrated a short-term decrease in symptoms following steroid injection (6 weeks) but an increased likelihood of persistent symptoms 1 year after treatment. Steroid injection at this site has not been associated with increased risk for tendon rupture or need for surgical intervention.

Question 83

What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement? Review Topic

Explanation

A systematic review of case studies looking at the results of surgical treatment for femoroacetabular impingement showed good results for most patients, with the exception of those with preoperative radiographs showing osteoarthritis or Outerbridge grade III or grade IV cartilage damage noted intraoperatively. Both Byrd and Jones and Philippon and associates have shown good surgical results for this condition among professional athletes. Likewise, Fabricant and associates demonstrated good surgical results among adolescent patients with an average age of

Question 84

15% to 2.5%. Acute Charcot arthropathy almost always appears with signs of inflammation. Profound unilateral swelling, an increase in local skin temperature (generally, an increase of 3° to 7° above the nonaffected foot's skin temperature), erythema, joint effusion, and bone resorption in an insensate foot are present. These characteristics, in the presence of intact skin and a loss of protective sensation, are often pathognomonic of acute Charcot arthropathy. Cellulitis is an infection of the skin. Examination would reveal erythema, edema, and pain. Osteomyelitis is an infection of the bone. Examination may reveal edema, drainage, and pain.

Explanation

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.
Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?
Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution
Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.
What is the post-amplification product of reverse transcription polymerase chain reaction (RT-PCR)?
RNA
DNA
Protein
Mitochondria
Immunoglobulins
Reverse transcription polymerase chain reaction (RT-PCR) is a variant of polymerase chain reaction (PCR) used in molecular biology to generate many copies of a DNA sequence from fragments of RNA. The RNA strand is first reverse transcribed into its DNA complement, followed by amplification of the resulting DNA using polymerase chain reaction. Polymerase chain reaction amplifies short segments of DNA by using the temperature stable DNA polymerase enzyme.
A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma?
Bone mineral density T-score < -2.5
Low vitamin D levels
Family history of osteoporosis
History of a prior fragility fracture
Ten year history of oral prednisone use
Each of the answer choices is a risk factor for subsequent fragility fracture, but patient history of a prior fragility fracture is the strongest predictor.
Bouxsein et al reviews the proper care, diagnosis, and prevention of fragility fractures. History of a fragility fracture is the greatest predictor of a future fracture from low energy trauma. Appropriate care includes not only treatment of the fracture itself, but also proper evaluation to identify the etiology of the fracture and appropriate intervention to rectify the underlying pathology. Evaluation includes bone densitometry, lab testing of Vitamin D and calcium.
A T-score compares your bone density to the optimal peak bone density for your gender. It is reported as number of standard deviations below the average. A T-score of -1 to -2.5 is considered osteopenia, and a risk for developing osteoporosis. A T- score of less than -2.5 is diagnostic of osteoporosis.
Long-term alendronate (Fosamax) use for osteoporosis has been associated
with which of the following?
Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures
Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with
uterine cancer or a detached retina.
Implants composed of polylactic acid are excreted by what system after they are absorbed?
Hepatic
Renal
Respiratory
Gastrointestinal
Polylactic acid suture and suture anchors are popular bioabsorbable orthopaedic implants. This material undergoes hydrolysis of the ester background in vivo. Resulting lactic acid enters the tricarboxylic acid (Krebs)
cycle and is excreted as carbon dioxide by the lungs. Polyglycolic acid and poly(p- dioxanone) may also be excreted by the kidneys.
A patient sustains a grade III medial collateral ligament injury. One year later, when compared to collagen in an uninjured ligament, an increase is likely in the
gross number of fibers.
proportion of type III fibers.
cross-linking.
mass and diameter of fibers.
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?
Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (ß-catenin) pathway
Parathyroid hormone (PTH) pathway
Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the ß-catenin. The unphosphorylated ß-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, ß- catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/ß- catenin pathway. The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation. BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.
During endochondral ossification of the growth plate, the process that most contributes to the longitudinal growth of long bones is
chondrocyte apoptosis.
chondrocyte hypertrophy.
chondrocyte proliferation.
growth plate matrix synthesis.
The growth plate is divided into 5 distinct zones: reserve, proliferative, maturation, hypertrophy, and vascular invasion. During growth-plate chondrocyte hypertrophy, intracellular volume and an increase in chondrocyte height are responsible for most growth of long bones. Other factors that contribute to bone growth are chondrocyte proliferation and matrix synthesis, but to a lesser degree than chondrocyte hypertrophy. Growth plate chondrocytes undergo programmed cell death (apoptosis) after hypertrophy
takes place.
Bacterial resistance to tetracycline is confirmed by ribosome protection, tetracycline modification, and
altered RNA polymerase.
altered membrane binding protein.
increased drug efflux.
DNA gyrase mutation.
Mutations of bacterial DNA gyrase can decrease the effectiveness of quinolones. Altered membrane-binding protein is observed with resistance to ?
-lactam antibiotics. Tetracyclines are antibiotics that inhibit bacterial growth by stopping protein synthesis. Three specific mechanisms of tetracycline
resistance have been identified: increased tetracycline efflux, ribosome protection, and tetracycline modification. Alteration of RNA polymerase is found in resistance to rifampin.
A 14-year-old boy has failed physical therapy management for Scheuermann kyphosis, and an extension thoracolumbosacral orthosis brace is recommended. The boy and his parents are told that the brace will force his thoracic spine into normal sagittal alignment and put the anterior vertebral bodies of the thoracic segment into tension, which will induce bone growth and normalization of wedge- shaped
vertebrae. What name is associated with this process?
Hooke's law
Kirchhoff's law
Wolff's law
Heuter-Volkmann principle
The Heuter-Volkmann principle shows that bone placed in longitudinal tension will tend to stimulate longitudinal growth, and that compressive longitudinal forces inhibit longitudinal growth, making this response the best choice. Hooke's law relates to stress being proportional to strain and is not directly related to bone growth. Kirchhoff's laws apply to electrical circuit design. Wolff's law states that bone remodels in response to mechanical stress, with the correlate that increased stress causes increased growth, and decreased stress leads to bone loss.
A tendon repair is thought to be weakest during which phase of tendon healing?
Inflammatory
Proliferation
Maturation
Remodeling
Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest
5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth
factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor- beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.
A 4-year-old boy has bilateral genu varum and is in the fifth percentile for height for his age. A younger sister has less severe genu varum. Radiographs reveal physeal cupping and widening on both the distal femur and proximal tibia. Laboratory studies show sodium 145 mEq/L (reference range, 136-142 mEq/L), potassium 4.0 mEq/L (reference range, 3.5-5.0 mEq/L), calcium 9.0 mg/dL (reference range, 8.2-10.2 mg/dL), phosphorous 2 mg/dL (reference range, 4-

Question 85

An otherwise healthy adolescent girl was treated for left slipped capital femoral epiphysis. The contralateral hip had not slipped, but was stabilized prophylactically with a single cannulated screw. The implants were removed after 1 year. The pelvic radiographs (Figures 215a and 215b) and the MRI scans of the hip that had not originally slipped (Figures 215c through 215e) were obtained 10 months after screw removal (22 months after the original fixation). Which findings are shown in these studies?

Explanation

Question 86

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

Explanation

DISCUSSION: The radiographs show a minimally displaced fracture of the tibial eminence, which is classified as a McKeever type II injury. In a number of studies, it has been found that most of these fractures will reduce with extension of the knee. This is often made easier with evacuation of the hemarthrosis. The position of knee immobilization is controversial, with some authors preferring full extension and others preferring 20 degrees of flexion. Flexion to 90 degrees will further displace the fragment. If the fragment does not reduce or if the patient has a McKeever type III or IV injury, reduction and internal fixation are required. This can be done with either an open or an arthroscopic procedure. Excision of the fragment is not indicated.
REFERENCES: Meyers MH, McKeever FM: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60
Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995;15:63-68.
Kuhn JE, Sailer MJ, Sterett WI, Hawkins RJ: Arthroscopic technique for the treatment of tibial spine fractures in the skeletally immature patient. J Ortho Tech 1995;3:7-12.

Question 87

A 46-year-old man has incomplete paraplegia after being involved in a motor vehicle accident. The CT scan shown in Figure 5 reveals marked canal compromise. What is the most appropriate management to improve neurologic status?

Explanation

DISCUSSION: According to a study by the Scoliosis Research Society, the use of anterior decompression is most predictable for improving neurologic status. This is particularly true of bowel and bladder functional loss. Laminectomy is contraindicated because it further destabilizes the spine. Posterior instrumentation and indirect reduction through distraction and ligamentotaxis only incompletely decompress the compromised canal and are successful only if performed within 48 hours of injury. While some improvement may occur with closed management, the amount of recovery is less than that achieved with surgical decompression. A posterior approach and instrumentation may be added to the anterior decompression based on the characteristics of associated injuries to the posterior element.
REFERENCES: Gertzbein SD: Scoliosis Research Society multicenter spine fracture study. Spine 1992;17:528-540.
Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-215.
Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.

Question 88

A 34-year-old man sustained a gunshot wound to the knee 18 months ago and was treated with bullet removal and a 10 day course of oral antibiotics. He now complains of 12 months duration of pain in the thigh and recent ulceration and drainage of the skin near the site of his gunshot wound. Physical exam is notable for a draining sinus tract, erythema and tenderness of the mid-thigh. He is afebrile. An MRI image of this patient is shown in Figure A. Which of the following is the most appropriate management?

Explanation

The clinical presentation and radiographs are consistent with chronic osteomyelitis. The MRI shows chronic changes of the distal femur with intraarticular (knee) extension. Chronic osteomyelitis is notable for a sequestrum, which is necrotic bone that has become avascular and no longer connected to the normal bone via the Haversian canal system. Involucrum refers to the new bone forming around the sequestrum. Often the involucrum will form a sinus tract allowing the sequestrum to drain into the soft tissues. Illustration A is a diagram of chronic osteomyelitis depicting the sequestrum (E), Involucrum (C), and sinus tract (D). In contrast to acute osteomyelitis, chronic osteomyelitis is often not eradicated with intravenous antibiotics alone. All necrotic bone (including the sequestrum) must be resected as it serves as a nidus for infection. Antibiotics should be guided off culture sampling of the infection.
In the referenced article by Parsons and Strauss, the management of chronic osteomyelitis is reviewed.

OrthoCash 2020

Question 89

When performing a revision total knee arthroplasty, trial components are inserted and the knee is stable in extension and loose in flexion. Which step should be taken to create a stable construct?

Explanation

DISCUSSION
The surgeon is facing a common scenario that occurs in revision knee surgery: a loose flexion gap with an appropriate extension gap. A flexion gap can be tightened by translating the femoral component more posteriorly and using an oversized femoral component. Insertion of a thicker tibial component changes both the flexion and extension gap. Augmentation of the distal femur tightens only the extension gap. A constrained insert would only be indicated if oversizing of the femoral component did not adequately tension the flexion gap.

Question 90

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms? Review Topic

Explanation

Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has been shown to be successful in the treatment of traumatic instability.

Question 91

What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?

Explanation

DISCUSSION: The presence of synchronous bone disease in young patients carries a dismal prognosis, one that is even worse than the presence of resectable pulmonary metastasis. Many osteosarcomas cross the physis; therefore, this has not been shown to be of prognostic importance. Similarly, the presence of the soft-tissue mass has less prognostic significance.
REFERENCE: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlation. Philadelphia, PA, Lea and Febiger, 1989, pp 344-350.

Question 92

A 29-year-old man who lifts weights states that he injured his left shoulder while performing a bench press 2 days ago. The following morning he noted ecchymosis and swelling in the left chest wall. Examination reveals ecchymosis and tenderness and deformity in the left anterior chest wall and axillary fold that is accentuated with resisted adduction of the arm. Passive range of motion beyond 90 degrees of forward flexion and 45 degrees of external rotation is extremely painful. Glenohumeral stability is difficult to assess because of severe guarding. Figure 29 shows an MRI scan. Management should consist of

Explanation

DISCUSSION: Rupture of the pectoralis major tendon most commonly occurs during bench pressing. Wolfe and associates have shown that the most inferiorly located fibers of the sternal head lengthen disproportionately during the final 30 degrees of humeral extension during the bench press. This creates a mechanical disadvantage in the final portion of the eccentric phase of the lift; with forceful flexion of the shoulder these maximally stretched fibers may rupture. In most patients, particularly in young athletes, the treatment of choice is anatomic repair of the ruptured tendon to its insertion in the proximal humerus either with suture anchors or transosseous sutures. Following surgery, most patients experience a near normal return of strength and significant improvement in the cosmetic appearance of the deformity. While more technically challenging, repair of chronic rupture is possible and is indicated in some patients.
REFERENCES: Wolfe SW, Wickiewicz TL, Cavanaugh JT: Ruptures of the pectoralis major muscle: An anatomic and clinical analysis. Am J Sports Med 1992;20:587-593.
Schepsis AA, Grafe MW, Jones HP, Lemos MJ: Rupture of the pectoralis major muscle: Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15.

Question 93

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Explanation

Numerous reports suggest an increased frequency of nutritional rickets in the US in children with dark skin pigmentation who are breast fed past 6 months of age without vitamin D supplementation. Nutritional rickets is rare in light-skinned children or those who are formula fed.

Question 94

The posterior cord of the brachial plexus terminates into what two main branches?

Explanation

DISCUSSION: The posterior cord of the brachial plexus terminates into the radial and axillary nerves. The lateral cord terminates in branches to the musculocutaneous and the lateral root of the median nerve. The medial cord terminates in branches to the ulnar and medial roots of the median nerve.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 228-236.

Question 95

-A 16-year-old girl was seen after a motor vehicle collision. Imaging studies including plain radiographs,MRI scans, and CT scans confirm bilateral jumped facets at C5-6 without disk herniation. She is alert,oriented, and neurologically intact. What is the most appropriate next step?

Explanation

Question 96

Closed chain kinetic exercises are differentiated from open chain exercises by which of the following? Review Topic

Explanation

Closed chain kinetic exercises confer a margin of safety and are protective of healing or repaired tissues by the compressive nature of the applied forces. Closed chain kinetic exercise is associated with decreased shear, translation, and distraction of the joints within the chain. Because of patterns of motion with closed chain kinetic exercises, individual muscles may not be maximally strengthened or all joint motion returned to normal. Closed chain kinetic exercises may be used earlier in the rehabilitation process.

Question 97

A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the

Explanation

DISCUSSION: The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum.
REFERENCES: Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.

Question 98

A 63-year-old woman has a femoral neck fracture. A biopsy specimen obtained from the fracture site at the time of her hemiarthroplasty reveals metastatic carcinoma. Seven days after surgery, she becomes confused and lethargic. Which of the following laboratory values is most likely implicated in the patient’s symptoms at this time?

Explanation

DISCUSSION: Although many hematologic and electrolyte abnormalities may be present in a patient with advanced metastatic cancer, an elevated serum calcium level is most commonly associated with confusion. Treatment with hydration, diuretics, and bisphosphonates is recommended.
REFERENCES: Clohishy D: Management of skeletal metastasis in clinical orthopaedics, in Craig E (ed): Operative Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 994-997.
Mundy GR: Hypercalcemia of malignancy revisited. J Clin Invest 1988;82:1-6.

Question 99

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

Explanation

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

Question 100

Which of the following is the strongest contraindication to unicompartmental knee arthroplasty (UKA)?

HLA-B27
Prostate-specific antigen
Rheumatoid factor
Antinuclear antibody
Serum protein electrophoresis

Correct Answer: HLA-B27

Explanation:

Question 6:

After full healing from this injury, which option most likely will help to optimize this patient's activities?

Options:

Extra-depth shoes
Rocker-bottom soles
Figure-of-8 soft-ankle brace
A patellar-tendon-bearing brace

Correct Answer: Rocker-bottom soles

Explanation:

DISCUSSION
Midfoot fracture dislocations typically occur after a fall from a height or a motor vehicle collision involving severe dorsiflexion loading of the foot from a brake pedal or the floorboards. The deformity that results may be subtle because the subluxation may be a valgus or varus rotation around the midfoot rather than pure dorsiflexion. Early recognition and reduction is indicated to minimize secondary complications such as nerve injury or vascular compromise. Closed reduction usually necessitates formal anesthesia in an operating room to permit adequate relaxation and reduction. In many cases, satisfactory reduction can be accomplished closed, but the surgeon must be prepared to perform an open reduction if needed. The most common reason for failed closed reduction is that the talar head is caught by the tibialis posterior tendon (under which the talar head has protruded). This acts as a Chinese finger trap, preventing relocation by the usual distraction followed by
a plantar flexion maneuver. In these cases, open reduction is performed through a dorsomedial incision through which the tibialis posterior is retracted medially, allowing reduction of the talonavicular joint. The joints usually require pinning to maintain stability during healing. The long-term prognosis for these injuries is guarded because many patients develop degenerative changes in the Chopart joint. If symptomatic arthritis develops, helpful external supports are designed to limit sagittal motion at the joint (for example, carbon fiber inserts or rocker-bottom soles).
RECOMMENDED READINGS
Swords MP, Schramski M, Switzer K, Nemec S. Chopart fractures and dislocations. Foot Ankle Clin. 2008 Dec;13(4):679-93, viii. Doi: 10.1016/j.fcl.2008.08.004. Review. PubMed PMID: 19013402.
View Abstract at PubMed
Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int. 2004 May;25(5):340-8. PubMed PMID: 15134617.
View Abstract at PubMed

Question 7:

Options:

Excise the spacer
Excise the spacer, debride all membranous tissue, perform exchange nailing
Excise the spacer, debride all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity, remove the nail

Correct Answer: Excise the spacer

Explanation:

Question 8:

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Options:

Increased loss of collagen tensile integrity in the superficial zone
Increased production of glycosaminoglycans
Decreased collagen in the middle zone
Loss of cartilage thickness that correlates with the total distance run during the course of adult life
Collagen loss in the medial compartment and collagen increase in the lateral compartment

Correct Answer: Increased production of glycosaminoglycans

Explanation:

Question 9:

Options:

Long thoracic nerve
Cranial nerve XI (spinal accessory nerve)
Suprascapular nerve
Axillary nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 10:

Options:

radiation therapy.
posterior laminectomy.
anterior corpectomy and reconstruction.
posterior laminectomy and fusion.
kyphoplasty.

Correct Answer: anterior corpectomy and reconstruction.

Explanation:

DISCUSSION: The MRI scans show a metastatic lesion in two contiguous vertebral bodies in the lower thoracic spine. Posterior laminectomy is not indicated because this does not adequately decompress the neural elements and will lead to progressive kyphosis. A posterior fusion may prevent progressive kyphosis but will not decompress the spinal cord. Renal cell carcinoma is not radiosensitive; therefore, radiation therapy would not be helpful in relieving neurologic compression. The lesion should be treated by an anterior corpectomy and reconstruction. This will allow for complete decompression as well as reconstruction of the anterior column. Kyphoplasty is not indicated in a lesion with disruption of the posterior cortex and neurologic impairment.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
White AP, Kwon BK, Lindskog DM, et al: Metastatic disease of the spine. J Am Acad Orthop Surg 2006;14:587-598.

Question 11:

In girls with idiopathic scoliosis, peak height velocity (PHV) typically occurs at what point?

Options:

Before Risser 1 and menarche
After Risser 1 and menarche
Between Risser 1 and menarche
After menarche but before Risser 1
At Risser 2

Correct Answer: Before Risser 1 and menarche

Explanation:

DISCUSSION: PHV generally occurs while girls are still Risser 0; menarche typically occurs before Risser 1, which has a wide variation in its timing. The curve magnitude at the PHV is the best prognostic indicator available. Most untreated patients with curves greater than 30 degrees at PHV require surgery, while patients with smaller curves at that stage typically do not
require surgery.
REFERENCES: Little DG, Song KM, Katz D, Herring JA: Relationship of peak height velocity to other maturity indicators in idiopathic scoliosis in girls. J Bone Joint Surg Am
2000;82:685-693.
Anderson M, Hwang SC, Green WT: Growth of the normal trunk in boys and girls during the second decade of life; related to age, maturity, and ossification of the iliac epiphyses. J Bone Joint Surg Am 1965;47:1554-1564.

Question 12:

Options:

Developmental dysplasia of the hip
Osteonecrosis
Perthes disease
Pseudogout
Femoral acetabular impingement

Correct Answer: Femoral acetabular impingement

Explanation:

DISCUSSION: Femoral acetabular impingement (FAI) is a pathologic entity leading to pain, reduced range of motion in flexion and internal rotation, and development of secondary arthritis of the hip. There are two types of FAI: cam impingement and pincher impingement. Cam impingement is seen when a nonspherical femoral head produces a cam effect when the prominent portion to the femoral head rotates into the joint. This mechanism produces shear forces that damage articular cartilage. Radiographs reveal early joint degeneration and flattening of the head neck junction (the so-called “pistol grip deformity”) as seen in this image. The pincher type of impingement involves abnormal contact between the femoral head neck junction and the acetabulum, in the presence of a spherical femoral head.
REFERENCES: Beall DP, Sweet CF, Martin HD, et al: Imaging findings of femoraoacetabular impingement syndrome. Skeletal Radiol 2005;34:691-701.
Mardones RM, Gonzalez C, Chen Q, et al: Surgical treatment of femoroacetabular impingement: Evaluation of the effect of the size of the resection. J Bone Joint Surg Am 2006;88:84-91.

Question 13:

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Options:

Weakness of the deltoid
Numbness in the C7 dermatomal distribution
Winging of the scapula
A positive lift-off test
Clinical findings similar to a large rotator cuff tear

Correct Answer: Clinical findings similar to a large rotator cuff tear

Explanation:

Question 14:

Options:

Neurofibroma of the suprascapular nerve
Ganglion cyst of the suprascapular notch
Ganglion cyst of the spinoglenoid notch
Lipoma of the suprascapular notch
Lipoma of the spinoglenoid notch

Correct Answer: Ganglion cyst of the spinoglenoid notch

Explanation:

Question 15:

A patient undergoes the procedure shown in Figure 19. An important part of this procedure is preservation of what wrist ligament?

Options:

Radioscaphocapitate
Scapholunate interosseous
Ulnotriquetral
Volar radioulnar
Deep proximal capitohamate

Correct Answer: Radioscaphocapitate

Explanation:

DISCUSSION: Proximal row carpectomy is a salvage wrist procedure that yields a surprisingly stable construct. This has been attributed to two factors: 1) the congruency of the head of the capitate in the lunate fossa (this articulation is less congruent than the native lunate/lunate fossa relationship, but surprisingly stable), and 2) preservation of the radioscaphocapitate ligament, the most radial of the palmar extrinsic ligaments, which prevents ulnar subluxation after proximal row carpectomy.
REFERENCE: Jebson PJ, Engber WD: Proximal row carpectomy. Tech Hand Up Extrem Surg 1999;3:32-36.

Question 16:

Options:

Loosening of the prosthesis
Modulus mismatch
Chronic infection
Osteoporosis
Metastatic tumor

Correct Answer: Loosening of the prosthesis

Explanation:

Question 17:

Acetaminophen is an antipyretic medication. It exerts its pharmacologic effects by inhibiting which of the following enzymes?

Options:

Cyclooxygenase-2 (COX-2)
Interleukin-1 beta (IL-1 β)
Tumor necrosis factor alpha (TNF-α)
Hydroxytryptamine (5-HT)
Metalloproteinases (MMPs)

Correct Answer: Interleukin-1 beta (IL-1 β)

Explanation:

Question 18:

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Options:

Use a translation program to print out instructions in the family’s native language and ask if they have questions
Have the patient translate the instructions if his or her English skills are adequate
Use a member of the hospital’s nonmedical staff to translate
Use a professional medical interpreter

Correct Answer: Use a professional medical interpreter

Explanation:

DISCUSSION
Ideally, professional medical interpreters should be used in situations involving language difficulties. Printed instructions are helpful, but, if there is a language barrier, these instructions cannot substitute for conversing and answering questions. Asking the child to translate (no matter how fluent he or she may be) is suboptimal. Nonmedical staff may not be fluent enough to adequately translate medical terms.
RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 19:

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Options:

Fetal position
Surgical approach
Mechanism of injury
Fracture classification
Trimester of pregnancy

Correct Answer: Mechanism of injury

Explanation:

Question 20:

What is the most serious complication that may occur with a ceramic-on-ceramic bearing in a total hip prosthesis?

Options:

Wear
Squeaking
Dislocation
Fracture
Subsidence

Correct Answer: Fracture

Explanation:

Question 21:

Which of the following findings is a contraindication to isolated percutaneous pinning of a distal radius fracture?

Options:

Dorsal comminution
Volar comminution
Radial comminution
Intra-articular fracture
Physeal fracture

Correct Answer: Volar comminution

Explanation:

DISCUSSION: Intrafocal pinning allows the Kirschner wires to be placed through a site of comminution and then drilled through intact cortex. Generally Kapandji intrafocal pinning is done for dorsal comminuted extra-articular dorsal bending fractures, but it also may be used to elevate and buttress radial comminution. Simple intra-articular fractures can also be treated with pinning alone. Intrafocal pinning works best as a dorsal or radial buttress to prevent shortening. When there is volar comminution, the fracture is prone to shortening and supplemental external fixation or plating is recommended.
REFERENCES: Trumble TE, Wagner W, Hanel DP, et al: Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am 1998;23:381-394.
Choi KY, Chan WS, Lam TP, et al: Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: A report of 157 cases. J Bone Joint Surg Br 1995;77:797-801.
Weil WM, Trumble TE: Treatment of distal radius fractures with intrafocal (Kapandji) pinning and supplemental skeletal stabilization. Hand Clin 2005;21:317-328.

Question 22:

Options:

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

Correct Answer: symptomatic nonsurgical treatment.

Explanation:

Question 23:

Options:

Costotransversectomy
Laminectomy
Transpedicular
Lateral extracavitary
Transthoracic

Correct Answer: Laminectomy

Explanation:

Question 24:

Options:

Trochanteric bursitis
Femoral component loosening
Iliopsoas tendonitis
Acetabular component loosening

Correct Answer: Iliopsoas tendonitis

Explanation:

Question 25:

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Options:

Medial sided tenderness
Medial sided swelling
Positive cotton test
Medial clear space widening with gravity stress radiographs
Positive squeeze test

Correct Answer: Medial sided tenderness

Explanation:

Question 26:

- A 12-year-old Little League pitcher has had pain in the dominant shoulder for the past week that prevents him from pitching. Examination reveals normal strength, full range of motion, normal stability, and mild tenderness about the proximal humerus. Radiographs with comparison views of the opposite shoulder show widening of the proximal humerus physis. Management should include

Options:

Diagnostic arthroscopy
Arthroscopy and subacromial decompression
Reduction and fixation of the proximal humeral epiphysis
Temporary cessation of throwing
Physical therapy for rotator cuff strengthening

Correct Answer: Temporary cessation of throwing

Explanation:

Question 27:

The initiating cellular event in development of posttraumatic osteoarthritis is attributed to which of the following?

Options:

Chondrocyte aging as the result of matrix degradation
Chondrocyte death from apoptosis
Cysteine protease-inhibited chondrocyte destruction
Interleukin-2-mediated chondrocyte hypertrophy

Correct Answer: Chondrocyte death from apoptosis

Explanation:

Question 28:

Options:

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

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

Explanation:

Question 29:

Figure 11 shows the radiograph of a 2-year-old child with marked genu varum and tibial bowing. Based on these findings, what is the best initial course of action?

Options:

Obtain serum phosphorous, calcium, and alkaline phosphatase levels.
Obtain a scanogram to assess for limb-length discrepancy.
Perform bilateral valgus osteotomies to correct the deformities.
Measure the child for a varus prevention orthosis.
Educate the family about physiologic genu varum and conduct a follow-up examination in
months.

Correct Answer: Obtain serum phosphorous, calcium, and alkaline phosphatase levels.

Explanation:

Question 30:

What nerve is most likely to be injured during the anterior exposure of C2-3?

Options:

Facial
Superior laryngeal
Vagus
Hypoglossal
Phrenic

Correct Answer: Hypoglossal

Explanation:

DISCUSSION: The hypoglossal nerve exits from the ansa cervicalis at approximately the C2-3 level and can be injured during retraction up to the C2 level. The superior laryngeal nerve lies at about C4-5. The facial nerve is much higher. The vagus nerve runs with the internal jugular and carotid much more laterally. The phrenic nerve exits posteriorly.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-54.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 31:

Options:

Dynamic ultrasound examination of the rotator cuff
Electrodiagnostic testing of the throwing shoulder
MR arthrogram of the throwing shoulder
Referral to a physical therapist to concentrate on range of motion
Laboratory studies to evaluate C-reactive protein and erythrocyte sedimentation rate

Correct Answer: MR arthrogram of the throwing shoulder

Explanation:

Question 32:

Options:

Cytokeratin positive
PAS negative
Reticulin positive
MIC-2 positive
Vimentin negative

Correct Answer: MIC-2 positive

Explanation:

DISCUSSION: The imaging studies show a permeative lesion of the left hemipelvis with a large soft-tissue mass. The photomicrograph demonstrates a small blue cell tumor with pseudorosettes. The most likely diagnosis is primitive neuroectodermal tumor (Ewing’s sarcoma family of tumors). MIC-2 is a highly sensitive and specific marker for this family of tumors. Cytokeratin is an epithelial marker. Vimentin is a mesenchymal marker. Thus, Ewing’s sarcomas are cytokeratin negative and vimentin positive. Before discovery of the MIC-2 antigen, PAS and reticulin stains were commonly used to help differentiate Ewing’s sarcoma from lymphoma. In contrast to lymphoma, Ewing’s sarcomas are typically PAS positive and reticulin negative.
REFERENCES: Halliday BE, Slagel DD, Elsheikh TE, et al: Diagnostic utility of MIC-2 immunocytochemical staining in the differential diagnosis of small blue cell tumors. Diagn Cytopathol 1998;19:410-416.
Llombart-Bosch A, Navarro S: Immunohistochemical detection of EWS and FLI-1 proteins is Ewing sarcoma and primitive neuroectodermal tumors: Comparative analysis with CD99
(MIC-2) expression. Appl Immunohistochem Mol Morphol 2001;9:255-260.

Question 33:

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Options:

Female athletes with valgus knee alignment and small femoral notch width
Female athletes with valgus knee alignment and large ACL width
Male athletes with valgus knee alignment and small ACL width
Male athletes with varus knee alignment and small femoral notch width

Correct Answer: Female athletes with valgus knee alignment and small femoral notch width

Explanation:

DISCUSSION
ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been proven to increase risk for ACL tears.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 34:

What is the most common behavioral effect of anabolic steroid use in athletes? Review Topic

Options:

Increased aggression
Psychosis
Drug dependence
Depression
Mania

Correct Answer: Increased aggression

Explanation:

Question 35:

Options:

SLAP tear
Subscapularis tear
Supraspinatous tear
Anterior labral tear
Posterior labral tear

Correct Answer: Posterior labral tear

Question 36:

Options:

No change in paresthesias and grip strength
Increase in grip strength and decrease in paresthesias
Decrease in grip strength and increase in paresthesias
Increase in grip strength and paresthesias

Correct Answer: Increase in grip strength and decrease in paresthesias

Explanation:

Question 37:

Options:

NSAIDs and/or cortisone injection
Arthroscopic rotator cuff repair
Shoulder hemiarthroplasty
Activity modification and/or physical therapy
Reverse total shoulder arthroplasty

Correct Answer: NSAIDs and/or cortisone injection

Explanation:

Question 38:

Options:

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

Correct Answer: Thoracolumbosacral orthosis (TLSO) molded in extension

Explanation:

Question 39:

What structure is located at the tip of the arrow in Figure 18? Review Topic

Options:

Left L3 nerve root
Right L3 nerve root
Right L4 segmental artery
Right L4 nerve root
Left lateral disk herniation

Correct Answer: Right L3 nerve root

Explanation:

The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.

Question 40:

Decreased risk of shoulder and elbow injury in a throwing athlete has been demonstrated with which of the following? Review Topic

Options:

Rotator cuff strengthening
Superior labral repair
Posterior capsular stretching
Periscapular muscle strengthening
Repair of partial-thickness rotator cuff tears

Correct Answer: Posterior capsular stretching

Explanation:

Question 41:

Options:

injection directly into the tendon with triamcinolone or methylprednisolone.
shock wave treatment to the posterior heel to break up calcific deposits.
brisement.
a simple lateral surgical approach to the posterior heel, with resection of the Haglund’s exostosis.
a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

Correct Answer: a central-splitting surgical approach through the tendon, excision of the Haglund’s exostosis and the insertional calcifications, bursectomy, flexor hallucis longus tendon transfer to the posterior tuberosity, and attachment of the tendon to the calcaneus.

Explanation:

Question 42:

Options:

Rotator cuff tear
Posttraumatic glenohumeral arthritis
Proximal humerus fracture nonunion
Shoulder infection
Post fracture stiffness

Correct Answer: Posttraumatic glenohumeral arthritis

Explanation:

Question 43:

Options:

Posttraumatic arthritis
Infection
Fixation failure
Malunion
Nonunion

Correct Answer: Posttraumatic arthritis

Explanation:

DISCUSSION: The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis. In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion. In another series, 26% had painful arthritis. Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs. Fusion is reserved for failure of nonsurgical management. Hardware failure may occur, but it is clinically unimportant.
REFERENCES: Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Arntz CT
, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am 1988;70:173-181.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 44:

Options:

Rheumatoid factor
HLA-B27
Synovial fluid analysis
MRI of the upper cervical spine
Urine screen for tetrahydrocannabinol (THC)

Correct Answer: MRI of the upper cervical spine

Explanation:

Question 45:

Options:

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

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

Explanation:

Question 46:

Options:

Staging studies to assess the extent of disease
Immediate stabilization of the fracture with an intramedullary nail
Curetting and bone culture
Segmental resection of the tibia and allograft reconstruction DISCUSSION… This patient has a pathologic fracture; in patients older than age 50, the most likely diagnosis is metastatic carcinoma or hematopoietic malignancy. A systemic work-up with staging imaging studies and laboratory tests as outlined by Rougraff and associates will identify the primary site of disease in approximately 90% of patients. A biopsy may not be necessary, and this protocol will also effectively exclude a primary sarcoma in the vast majority of patients. The other options all initiate treatment without first evaluating for extent of disease and diagnosis. If this turns out to be a sarcoma, stabilization or curetting the lesion might make subsequent limb salvage difficult or impossible. Segmental resection adds unnecessary morbidity to the surgical procedure in the more common circumstance that this is revealed to be metastatic carcinoma.

Correct Answer: Staging studies to assess the extent of disease

Explanation:

Question 47:

A 30-year-old patient has wrist pain. A radiograph and biopsy specimen are shown in Figures 34a and 34b. What is the most likely diagnosis?

Options:

Aneurysmal bone cyst
Giant cell tumor
Brown tumor
Pigmented villonodular synovitis
Telangiectatic osteosarcoma

Correct Answer: Aneurysmal bone cyst

Explanation:

Question 48:

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 49:

In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if Review Topic

Options:

a dural tear is repaired.
more than one level requires decompression.
less than one half of each facet is removed bilaterally.
the pars interarticularis is fractured.
the patient is a smoker.

Correct Answer: the pars interarticularis is fractured.

Explanation:

Question 50:

Options:

Gradual return to play
Physical therapy program
Custom orthosis
Non-weight-bearing cast
Weight-bearing AP radiograph

Correct Answer: Weight-bearing AP radiograph

Explanation:

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return
to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 51:

50%

Options:

greater than 50%
None, by 5 years the allograft cartilage will be completely acellular

Correct Answer: greater than 50%

Explanation:

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI
Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 52:

Options:

Subscapularis failure
Frozen shoulder
Recurrent instability
Loose body
Chondrolysis

Correct Answer: Chondrolysis

Explanation:

DISCUSSION: Postshoulder stabilization chondrolysis is a rare but devastating complication. It has been implicated with the use of the radiofrequency heat probe in some patients.
REFERENCES: Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Petty DH, Jazrawi LM, Estrada LS, et al: Glenohumeral chondrolysis after shoulder arthroscopy: Case reports and review of the literature. Am J Sports Med 2004;32:509-515.

Question 53:

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Options:

Accurate graft size
Donor cell viability
Reestablishment of the central meniscal blood supply
Suppression of the immune response
Cryopreservation of the donor graft

Correct Answer: Accurate graft size

Explanation:

Question 54:

Options:

prior patellecomy 2- tibial stem position.
limb malalignment
the posterior stabilized component 5- the notched femoral component

Correct Answer: limb malalignment

Explanation:

Barrack RL, Rorabeck C, Burt M. Sawhney J: Pain at the end of the stem after revision total knee arthroplasty. Clin Orthop 1999:367:216225.
back to this question next question

Question 55:

Options:

- Open reduction and internal fixation (ORIF)
- Closed reduction and percutaneous pinning
- Nonsurgical management with closed reduction and casting
- Primary arthrodesis of the first and second tarsometatarsal joints

Correct Answer: - Primary arthrodesis of the first and second tarsometatarsal joints

Explanation:

DISCUSSION
Ligamentous injuries to the tarsometatarsal and intermetatarsal joints are commonly a result of high-energy mechanisms. These injuries have resulted in worse outcomes following ORIF than Lisfranc injuries, which involve fractures. Multiple injury patterns may occur, with some injuries involving mostly the ligamentous structures. Ligamentous Lisfranc injuries treated with primary arthrodesis have been shown to result in improved American Orthopaedic Foot & Ankle Society scores and lower Visual Analog Scale pain scores at 2-year follow-up than injuries treated with ORIF. ORIF with either plate or screw fixation has resulted in higher rates of secondary surgeries and lower functional scores. Nonsurgical management is not recommended for displaced injuries. Cast placement is recommended for patients with midfoot sprains with displacement of less than 2 mm. Nonanatomic reductions have been associated with poor results. Closed reduction and percutaneous pinning is unlikely to achieve an anatomic reduction and stable fixation.
RECOMMENDED READINGS
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583.
View
Abstract at PubMed
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.
View
Abstract at PubMed
Kuo RS, Tejwani NC, Digiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000 Nov;82-A(11):1609-18. PubMed PMID: 11097452.
View Abstract at PubMed
Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002 Nov-Dec;30(6):871-8. PubMed PMID: 12435655.
View
Abstract at PubMed

Question 56:

Options:

casting.
closed reduction, casting, and no weight bearing for 6 weeks.
open reduction and internal fixation.
closed reduction and percutaneous Kirschner wire fixation.
closed reduction and percutaneous screw fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,
pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 57:

Options:

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

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

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

Question 58:

- A 40-year-old woman has had pain in the metatarsophal joint of the second toe for the past 6 months despite nonsurgical treatment. A dorsalplantar stress test reproduces the pain, and there is 10 mm of dorsal subluxation of the toe. Radiographs show a normal second metatarsophalangeal joint. Surgical treatment should consist of synovectomy and

Options:

Advancement of the plantar plate
Resection of the second metatarsal head
Dorsiflexion osteotomy of the second metatarsal neck
Transfer of the flexor digitorum longus tendon to the dorsum of the toe
Transfer of the extensor digitorum comminus tendon to the metatarsal neck

Correct Answer: Transfer of the flexor digitorum longus tendon to the dorsum of the toe

Explanation:

Question 59:

Options:

Platelet rich plasma injection
Eccentric exercises
Corticosteroid injection
Ultrasonic emulsification/aspiration
Surgical debridement and repair of the extensor carpi radialis brevis

Correct Answer: Platelet rich plasma injection

Explanation:

Question 60:

Options:

a rotator cuff exercise program and anti-inflammatory drugs.
repeat subacromial cortisone injections as necessary.
open subacromial decompression.
arthroscopic evacuation of calcium deposits.
open rotator cuff repair.

Correct Answer: arthroscopic evacuation of calcium deposits.

Explanation:

Question 61:

Options:

Knee aspiration with cell count/cultures, C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), CT
Knee aspiration with cell count/cultures, CRP, ESR
Fresh-frozen specimen at the time of revision knee arthroplasty only
Technetium-99m bone scan, knee aspiration with cell count/cultures

Correct Answer: Knee aspiration with cell count/cultures, CRP, ESR

Explanation:

Question 62:

A 40-year-old man with an acetabular chondrosarcoma has a small soft-tissue mass. Treatment should consist of

Options:

chemotherapy with ifosfamide and doxorubicin hydrochloride.
external beam radiation.
wide resection.
curettage and cementation of the pelvic lesion.
cemented total hip arthroplasty with acetabular reconstruction.

Correct Answer: wide resection.

Explanation:

Question 63:

Options:

lateral process fracture
anterior process fracture
tongue type
comminuted posterior facet
back to this question next question
joint depression type 18.03

Correct Answer: joint depression type 18.03

Explanation:

Question 64:

Options:

Analysis of variance (ANOVA)
Regression analysis
Student t test
Mann-Whitney U test

Correct Answer: Mann-Whitney U test

Explanation:

Question 65:

Options:

2% to 5%
15% to 20%
35% to 45%
60% to 70%
Greater than 90%

Correct Answer: 35% to 45%

Explanation:

DISCUSSION: The patient sustained an incomplete spinal cord injury known as central cord syndrome. Central cord syndrome characteristically has disproportionate involvement of the upper extremities with the lower extremities being relatively spared. It is most commonly seen after cervical injuries in elderly patients with spondylosis and spinal stenosis, often without fracture. Penrod and associates noted that 23 of 59 patients with central cord syndrome
(ASIA C and D) ultimately walked. The poorest prognosis, however, was in ASIA C patients older than age 50, in which only 40% walked.
REFERENCES: Penrod LE, Hegde SK, Ditunno JF Jr: Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehab 1990;71:963-968.
Northrup BE: Acute injuries to the spine and spinal cord: Evaluation and early treatment, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, p 735.

Question 66:

- Figure 16 shoes the AP radiograph of a 32-year-old man with a fracture cephalad to the fovea of the femoral head. A CT scan shows a single head fragment. After closed reduction of the hip, there is 5 mm of residual articular incongruity. Management should now include

Options:

Hybrid total hip arthroplasty
Noncemental hemiarthroplasty of the hip
Closed reduction and percutaneous pin fixation
Open reduction through an anterior approach to the hip
Excision of the head fragment

Correct Answer: Open reduction through an anterior approach to the hip

Explanation:

Question 67:

Options:

bone age of the left wrist.
MRI of the spine.
MRI of the brain.
renal and abdominal ultrasonography.
hip ultrasonography.

Correct Answer: renal and abdominal ultrasonography.

Explanation:

DISCUSSION: The patient may have Beckwith-Wiedemann syndrome (BWS), which consists of exophthalmos, macroglossia, gigantism, visceromegaly, abdominal wall defects, and neonatal hypoglycemia. Hemihypertrophy develops in approximately 15% of patients with BWS. Patients with hemihypertrophy that is the result of BWS have a 40% chance of developing malignancies such as Wilms’ tumor or hepatoblastoma; therefore, frequent ultrasound screening is recommended until about age 7 years. The absence of nevi and vascular markings helps to rule out other causes of hemihypertrophy, such as neurofibromatosis, Proteus syndrome, and Klippel-Trenaunay syndrome. Bone age estimations are not accurate at this young age but may become more useful later to help predict the timing of epiphysiodesis procedures.
REFERENCES: DeBaun MR, Tucker MA: Risk of cancer during the first four years of life in children from The Beckwith-Wiedemann Syndrome Registry. J Pediatr 1998;132:398-400.
Ballock RT, Wiesner GL, Myers MT, et al: Hemihypertrophy concepts and controversies.
J Bone Joint Surg Am 1997;79:1731-1738.
Carpenter CT, Lester EL: Skeletal age determination in young children: Analysis of three regions of the hand/wrist film. J Pediatr Orthop 1993;13:76-79.

Question 68:

Which of the following nutraceuticals has been associated with perioperative bleeding?

Options:

Glucosamine
Chondroitin sulfate
Ginseng
Nitric oxide
Ginkgo biloba

Correct Answer: Ginkgo biloba

Explanation:

DISCUSSION: Ginkgo biloba is a popular nutraceutical for patients who have early dementia, intermittent claudication secondary to peripheral vascular disease, vertigo, and tinnitus. It is reported to improve mental alertness and cognitive deficiency. It has antiplatelet properties as a result of one of its components, ginkgolide B, which displaces platelet-activating factor from its receptor binding sight. Rowin and Lewis reported on spontaneous bilateral subdural hematomas associated with chronic ginkgo biloba ingestion. Vale also reported on subarachnoid hemorrhage associated with ginkgo biloba. Bebbington and associates reported on persistent postoperative bleeding after total hip arthroplasty secondary to ginkgo biloba usage. Furthermore, the use of ginkgo biloba with aspirin or other antiplatelet agents or anticoagulants represents a relative contraindication. Physicians should be aware not only of prescribed medications but also alternative nutraceuticals that are used by the patient.
REFERENCES: Rowin J, Lewis SL: Spontaneous bilateral subdural hematomas associated with chronic ginkgo biloba ingestion. Neurology 1996;46:1775-1776.
Vale S: Subarachnoid hemorrhage associated with ginkgo biloba. Lancet 1998;352:36.
Bebbington A, Kulkarni R, Roberts P: Ginkgo biloba: Persistent bleeding after total hip arthroplasty caused by herbal self-medication. J Arthroplasty 2005;20:125-126.

Question 69:

Options:

cessation of physical therapy and acceptance of the limited range of motion.
additional physical therapy for 3 to 4 months.
arthroscopic capsular release.
open release with Z-plasty lengthening of the subscapularis tendon.
closed manipulation under anesthesia.

Correct Answer: arthroscopic capsular release.

Explanation:

Question 70:

Options:

insert a standard humeral prosthesis with cerclage wires at the fracture site and autologous cancellous bone graft.
insert a standard humeral component and apply a humeral orthosis postoperatively.
cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of replacement surgery until the fracture has healed.
discontinue the procedure and return for completion of total shoulder replacement when the fracture has healed.

Correct Answer: cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.

Explanation:

Question 71:

Options:

Diagnostic arthroscopy
MRI-arthrography
Stress radiographs
CT
Weighted radiographs of the arm

Correct Answer: MRI-arthrography

Explanation:

DISCUSSION: MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct.
REFERENCES: Applegate GR, Hewitt M, Snyder SJ, et al: Chronic labral tears: Value of magnetic resonance arthrography in evaluating the glenoid labrum and labral-bicipital complex. Arthroscopy 2004;20:959-963.
Bencardino JT, Beltran J, Rosenberg ZS, et al: Superior labrum anterior-posterior lesions: Diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-271.
Nam EK, Snyder SJ: The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med 2003;31:798-810.

Question 72:

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Options:

Nonmodular implant
Instability
Well-designed, well-fixed modular implant
Complete radiolucency of the acetabular component
Migration of the acetabular component

Correct Answer: Well-designed, well-fixed modular implant

Explanation:

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 73:

When balancing gaps in the coronal plane, what structure preferentially impacts the flexion space more than the extension space?

Options:

Iliotibial band
Popliteus tendon
Lateral collateral ligament
Lateral head of the gastrocnemius

Correct Answer: Popliteus tendon

Explanation:

Question 74:

Which component is most common to both simple and complex elbow dislocations?

Options:

radial head fracture
radial neck fracture
loss of terminal extension
coronoid tip fracture
coronoid base fracture

Correct Answer: radial head fracture

Explanation:

Question 75:

What type of muscle contraction occurs while the muscle is lengthening?

Options:

Isometric
Isotonic
Concentric
Isokinetic
Eccentric

Correct Answer: Eccentric

Explanation:

DISCUSSION: A muscle that lengthens as it is activated is an eccentric contraction. Isometric contraction involves no change in length. Concentric contraction occurs while the muscle is shortening. In isotonic contraction, the force remains constant through the contraction range. Isokinetic muscle contraction occurs at a constant rate of angular change of the involved joint.
REFERENCES: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000,
pp 12-13.
Lieber RL: Form and function of skeletal muscle, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 76:

Options:

Plastic
Elastic
Fatigue
Creep
Torsion

Correct Answer: Elastic

Explanation:

Question 77:

Options:

Interleukin-2-based chemotherapy
Embolization followed by curettage, intramedullary fixation, and cementation
Embolization followed by curettage and cementation
External beam radiation
Total humeral resection and prosthetic reconstruction

Correct Answer: Embolization followed by curettage, intramedullary fixation, and cementation

Explanation:

Question 78:

Options:

Inferior glenohumeral ligament
Middle glenohumeral ligament
Superior labrum
Subscapularis tendon
Supraspinatus tendon

Correct Answer: Subscapularis tendon

Explanation:

Question 79:

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

Options:

Chondrosarcoma
Osteoblastoma
Chondroblastoma
Giant cell tumor of bone
Subchondral cyst

Correct Answer: Chondrosarcoma

Explanation:

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

Question 80:

Options:

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

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

Explanation:

Question 81:

Initial management should consist of Review Topic

Options:

cessation of throwing activities.
a long arm cast for 3 months.
a corticosteroid injection into the elbow joint.
excision of the fragment.
arthroscopic drilling of the lesion.

Correct Answer: cessation of throwing activities.

Explanation:

Question 82:

Options:

have no difference in elbow pain.
no longer have elbow pain.
need surgery.
experience tendon rupture.

Correct Answer: have no difference in elbow pain.

Explanation:

Question 83:

What factor highly correlates with poor outcomes after surgery for femoroacetabular impingement? Review Topic

Options:

Age younger than 20
Degenerative arthritis
Prominence of the femoral head in cam impingement
The patient is a professional athlete

Correct Answer: Degenerative arthritis

Explanation:

Question 84:

Options:

Of the following variables, which has the strongest influence on external fixator stiffness?
Pin diameter
Pin spread
Bone quality
Stacking a second fixator bar
Distance from bone to fixator bar

Correct Answer: Of the following variables, which has the strongest influence on external fixator stiffness?

Explanation:

Whereas all of the factors will have an impact on frame rigidity and stability, the single biggest factor is the pin diameter because it has an exponential effect.
Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?
Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution
Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.
What is the post-amplification product of reverse transcription polymerase chain reaction (RT-PCR)?
RNA
DNA
Protein
Mitochondria
Immunoglobulins
Reverse transcription polymerase chain reaction (RT-PCR) is a variant of polymerase chain reaction (PCR) used in molecular biology to generate many copies of a DNA sequence from fragments of RNA. The RNA strand is first reverse transcribed into its DNA complement, followed by amplification of the resulting DNA using polymerase chain reaction. Polymerase chain reaction amplifies short segments of DNA by using the temperature stable DNA polymerase enzyme.
A 63-year-old woman falls from standing and lands on her right hand. She complains of deformity and wrist pain. Radiographs are provided in Figure A. Following closed reduction, the patient inquires whether she has osteoporosis and if she is likely to have another fracture. In counselling the patient, which of the following is the strongest predictor for a future fracture from low energy trauma?
Bone mineral density T-score < -2.5
Low vitamin D levels
Family history of osteoporosis
History of a prior fragility fracture
Ten year history of oral prednisone use
Each of the answer choices is a risk factor for subsequent fragility fracture, but patient history of a prior fragility fracture is the strongest predictor.
Bouxsein et al reviews the proper care, diagnosis, and prevention of fragility fractures. History of a fragility fracture is the greatest predictor of a future fracture from low energy trauma. Appropriate care includes not only treatment of the fracture itself, but also proper evaluation to identify the etiology of the fracture and appropriate intervention to rectify the underlying pathology. Evaluation includes bone densitometry, lab testing of Vitamin D and calcium.
A T-score compares your bone density to the optimal peak bone density for your gender. It is reported as number of standard deviations below the average. A T-score of -1 to -2.5 is considered osteopenia, and a risk for developing osteoporosis. A T- score of less than -2.5 is diagnostic of osteoporosis.
Long-term alendronate (Fosamax) use for osteoporosis has been associated
with which of the following?
Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures
Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with
uterine cancer or a detached retina.
Implants composed of polylactic acid are excreted by what system after they are absorbed?
Hepatic
Renal
Respiratory
Gastrointestinal
Polylactic acid suture and suture anchors are popular bioabsorbable orthopaedic implants. This material undergoes hydrolysis of the ester background in vivo. Resulting lactic acid enters the tricarboxylic acid (Krebs)
cycle and is excreted as carbon dioxide by the lungs. Polyglycolic acid and poly(p- dioxanone) may also be excreted by the kidneys.
A patient sustains a grade III medial collateral ligament injury. One year later, when compared to collagen in an uninjured ligament, an increase is likely in the
gross number of fibers.
proportion of type III fibers.
cross-linking.
mass and diameter of fibers.
Studies on animal models have shown that there is a change in collagen fiber type and distribution early in the healing process. There is a higher portion of type III fibers than in
normal ligament initially, but this ratio returns to normal about 1 year after the injury occurs. Healing ligaments show an increased number of collagen fibers, but the number of mature collagen cross-links is
45% of predicted value after 1 year. There is also a decrease in the mass and diameter of the collagen fibers.
Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?
Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (ß-catenin) pathway
Parathyroid hormone (PTH) pathway
Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the ß-catenin. The unphosphorylated ß-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, ß- catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/ß- catenin pathway. The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation. BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.
During endochondral ossification of the growth plate, the process that most contributes to the longitudinal growth of long bones is
chondrocyte apoptosis.
chondrocyte hypertrophy.
chondrocyte proliferation.
growth plate matrix synthesis.
The growth plate is divided into 5 distinct zones: reserve, proliferative, maturation, hypertrophy, and vascular invasion. During growth-plate chondrocyte hypertrophy, intracellular volume and an increase in chondrocyte height are responsible for most growth of long bones. Other factors that contribute to bone growth are chondrocyte proliferation and matrix synthesis, but to a lesser degree than chondrocyte hypertrophy. Growth plate chondrocytes undergo programmed cell death (apoptosis) after hypertrophy
takes place.
Bacterial resistance to tetracycline is confirmed by ribosome protection, tetracycline modification, and
altered RNA polymerase.
altered membrane binding protein.
increased drug efflux.
DNA gyrase mutation.
Mutations of bacterial DNA gyrase can decrease the effectiveness of quinolones. Altered membrane-binding protein is observed with resistance to ?
-lactam antibiotics. Tetracyclines are antibiotics that inhibit bacterial growth by stopping protein synthesis. Three specific mechanisms of tetracycline
resistance have been identified: increased tetracycline efflux, ribosome protection, and tetracycline modification. Alteration of RNA polymerase is found in resistance to rifampin.
A 14-year-old boy has failed physical therapy management for Scheuermann kyphosis, and an extension thoracolumbosacral orthosis brace is recommended. The boy and his parents are told that the brace will force his thoracic spine into normal sagittal alignment and put the anterior vertebral bodies of the thoracic segment into tension, which will induce bone growth and normalization of wedge- shaped
vertebrae. What name is associated with this process?
Hooke's law
Kirchhoff's law
Wolff's law
Heuter-Volkmann principle
The Heuter-Volkmann principle shows that bone placed in longitudinal tension will tend to stimulate longitudinal growth, and that compressive longitudinal forces inhibit longitudinal growth, making this response the best choice. Hooke's law relates to stress being proportional to strain and is not directly related to bone growth. Kirchhoff's laws apply to electrical circuit design. Wolff's law states that bone remodels in response to mechanical stress, with the correlate that increased stress causes increased growth, and decreased stress leads to bone loss.
A tendon repair is thought to be weakest during which phase of tendon healing?
Inflammatory
Proliferation
Maturation
Remodeling
Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest
5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth
factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor- beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.
A 4-year-old boy has bilateral genu varum and is in the fifth percentile for height for his age. A younger sister has less severe genu varum. Radiographs reveal physeal cupping and widening on both the distal femur and proximal tibia. Laboratory studies show sodium 145 mEq/L (reference range, 136-142 mEq/L), potassium 4.0 mEq/L (reference range, 3.5-5.0 mEq/L), calcium 9.0 mg/dL (reference range, 8.2-10.2 mg/dL), phosphorous 2 mg/dL (reference range, 4-

Question 85:

Options:

Both hips are normal and no further assessments will be needed.
A neoplasm has developed in the femoral head on the unslipped side.
There is now increased risk for a slip in the hip and a new screw should be inserted.
Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.
The screw track in the bone has not filled spontaneously as expected and grafting should beconsidered.

Correct Answer: Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.

Question 86:

Options:

open reduction and internal fixation.
arthroscopic reduction and internal fixation.
closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.
closed reduction and casting in 90 degrees of flexion.
excision of the fragment.

Correct Answer: closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.

Explanation:

Question 87:

Options:

Postural reduction and application of a hyperextension cast
Posterior laminectomy alone
Laminectomy and posterior stabilization
Bed rest for 6 weeks
Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Correct Answer: Anterior L2 corpectomy and iliac crest strut grafting, with or without posterior instrumentation and fusion from L1 to L3

Explanation:

Question 88:

Options:

Two week course of oral cephalosporin
Core needle bone culture followed by intravenous antibiotics
Surgical debridement, culture, and intravenous antibiotics
Core needle biopsy, chest CT scan, and bone scan
Neoadjuvant chemotherapy and wide resection followed by adjuvant chemotherapy

Correct Answer: Surgical debridement, culture, and intravenous antibiotics

Explanation:

Question 89:

When performing a revision total knee arthroplasty, trial components are inserted and the knee is stable in extension and loose in flexion. Which step should be taken to create a stable construct?

Options:

Insert a constrained tibial insert
Insert a thicker tibial component
Insert a larger femoral component
Augment the distal portion of the femoral component

Correct Answer: Insert a larger femoral component

Explanation:

Question 90:

Options:

Anterior glenoid rim fracture tear
Anterior inferior labral tear
Posterior labral tear
Total capsular laxity
Osteochondral defect of the humeral head

Correct Answer: Posterior labral tear

Explanation:

Question 91:

What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?

Options:

A solitary peripheral lung metastasis
Tumor crossing the physis
Extracompartmental extension
Skeletal metastasis
Tumor necrosis of 99% after chemotherapy

Correct Answer: Skeletal metastasis

Explanation:

Question 92:

Options:

proximal biceps tenodesis.
application of a sling for 3 weeks, followed by physical therapy.
anterior capsulolabral reconstruction.
repair of the subscapularis tendon.
repair of the pectoralis major tendon.

Correct Answer: repair of the pectoralis major tendon.

Explanation:

Question 93:

Nutritional rickets in the US occurs more frequently in infants older than 6 months of age who do not receive vitamin D supplementation and are Review Topic

Options:

Caucasian and formula fed.
Caucasian and breast fed.
African American and formula fed.
African American and breast fed.
Asian and formula fed.

Correct Answer: African American and breast fed.

Explanation:

Question 94:

The posterior cord of the brachial plexus terminates into what two main branches?

Options:

Lateral and medial pectorals
Lateral pectoral and suprascapular
Radial and axillary nerves
Musculocutaneous and the lateral root of the median nerve
Ulnar and medial roots of the median nerve

Correct Answer: Radial and axillary nerves

Explanation:

Question 95:

Options:

Awake closed reduction
Application of a halo orthosis
Placement of a cervical collar
Open reduction under anesthesia
Closed reduction under anesthesia

Correct Answer: Awake closed reduction

Question 96:

Closed chain kinetic exercises are differentiated from open chain exercises by which of the following? Review Topic

Options:

Increased joint shear
Maximally rehabilitate individual muscles
Achieve normal motion in all the joints of the kinetic chain
Maximize joint distraction
The compressive nature of applied loads

Correct Answer: The compressive nature of applied loads

Explanation:

Question 97:

Options:

extensor digitorum brevis.
plantar fascia.
peroneus brevis.
peroneus longus.
syndesmosis.

Correct Answer: peroneus longus.

Explanation:

Question 98:

Options:

Hemoglobin level of 9.0 g/dL (normal value 11-15 g/dL)
Sodium level of 132 mEq/L (normal value 135-145 mEq/L)
Potassium level of 5.0 mEq/L (normal value 4.0-5.2 mEq/L)
Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)
Serum uric acid level of 10 mg/dL (normal value 2.7-7.3 mg/dL)

Correct Answer: Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)

Explanation:

Question 99:

Options:

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

Correct Answer: open reduction and internal fixation

Explanation:

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

Question 100:

Which of the following is the strongest contraindication to unicompartmental knee arthroplasty (UKA)?

Options:

Patient age of younger than 60 years
Patient age of older than 80 years
Anterior cruciate ligament (ACL) deficiency
Varus deformity of 5 degrees
Outerbridge grade II chondromalacia of the patella

Correct Answer: Anterior cruciate ligament (ACL) deficiency

Explanation:

DISCUSSION: UKA prostheses cannot substitute for an absent ACL, and if arthroplasty is indicated, these patients should receive a total knee arthroplasty rather than a UKA. Age is not an absolute contraindication, and the procedure has been advocated for young patients as well as older patients if they meet the appropriate indications for an arthroplasty. Varus deformities of the mechanical axis of up to 10 degrees generally are not a contraindication to unicompartmental arthroplasty, as long as the knee can be properly balanced at the time of surgery. Modest chondromalacia of the patellofemoral joint, especially if asymptomatic, is not a contraindication to UKA.
REFERENCES: Lotke PA (ed): Knee Arthroplasty: Master Techniques in Orthopaedic Surgery. New York, NY, Raven Press, 1995, pp 275-293.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, NY, Churchill Livingstone, 1993, pp 805-814.
Tabor OB Jr, Tabor OB: Unicompartmental arthroplasty: A long-term follow-up study.
J Arthroplasty 1998;13:373-379.

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

Orthopedic Board Review MCQs: Shoulder, Arthroplasty & Foot | Part 243

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 243

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index