Orthopedic Board Review MCQs: Trauma, Arthroplasty & Foot Surgery | Part 245

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

A 19-year-old female long-distance runner has an incomplete tension-side femoral neck stress fracture. Management should consist of

A 68-year-old woman had advanced right knee arthritis and total knee replacement was planned. She learned she had primary biliary cirrhosis at age 41 and now has advancing liver failure. Preoperative coagulation tests show a baseline International Normalized Ratio (INR) of 1.36. Appropriate methods to prevent thromboembolic disease as recommended by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty , include

A 35-year-old man is seen in the emergency department with a bullet wound to the foot that occurred 2 hours ago. Examination reveals a 0.5-cm entrance wound on the dorsum of the foot and a 1.5-cm exit wound on the plantar aspect. Exploration of the plantar wound in the emergency department reveals bone and metal fragments. Radiographs reveal a comminuted, unstable fracture of the base of the first metatarsal and cuneiform. Management should consist of tetanus toxoid, and

A 62-year-old woman reports diffuse aches and pains of the hip and pelvis. She denies any significant trauma but does have a history of chronic anemia. Figure 17a shows a radiograph of the pelvis, and Figures 17b and 17c show T 2 -weighted MRI scans. What is the most likely diagnosis?

Figure below shows the radiograph obtained from a 68-year-old man who fell 3 weeks after undergoing a successful left primary total hip arthroplasty. He is experiencing a substantial increase in pain and an inability to bear weight. What is an appropriate treatment plan?

An 84-year-old female community ambulator with a history of hypertension undergoes a right hip hemiarthroplasty for a femoral neck fracture. When performed in the post-operative period, the timed up and go (TUG) test may be used to predict which patient outcome?

A 55-year-old man who underwent total shoulder arthroplasty 10 years ago recently reports an increase in shoulder pain. Laboratory studies consisting of a white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are all negative, as is joint aspiration. Radiographs are shown in Figures 95a and 95b. If all intraoperative frozen sections are negative, what is the appropriate treatment during revision surgery to provide pain relief and improved function? Review Topic

Where is the most common site for tuberculosis (TB) spondylitis in children? Review Topic

During a revision total knee arthroplasty (TKA), there is difficulty gaining exposure and a tibial tubercle osteotomy (TTO) is performed. The final components are stable and include a stemmed tibial component that bypasses the osteotomy site. The tibial tubercle is reattached to the osteotomy site with multiple cerclage wires. Following closure of the arthrotomy, the knee is flexed to 90 degrees, and there is no observed displacement of the TTO. What is the best next step in postsurgical rehabilitation?

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

A 3-year-old girl has had wrist pain, a fever, and has refused to move her right wrist for the past 10 days. She has an oral temperature of 102 degrees F (38.7 degree C). Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h, a WBC count of 11,000/mm 3 , and a left shift. AP and lateral radiographs are shown in Figures 57a and 57b. What is the most likely diagnosis?

Compared to eumenorrheic athletes, amenorrheic athletes have more frequent occurrences of

Which is the best initial study for the diagnostic evaluation of diskogenic low back pain? Review Topic

A 71-year-old woman has a failed revision hip arthroplasty and is undergoing a re-revision hip arthroplasty. Her last hip surgery was 4 years ago with revision of the acetabular component. Radiographs show a well-fixed extensively porous-coated femoral component and a failed acetabular component with proximal and medial migration through the floor of the acetabulum. Preoperative laboratory studies reveal an erythrocyte sedimentation rate (ESR) of 70 mm/h (normal 0-29 mm/h), a C-reactive protein (CRP) of 23.3 (normal 0.2-8.0), and a negative hip aspiration. At the time of surgery, tissues look inflamed and a frozen section shows 20 WBC per high power field; however, a Gram stain is negative. What is the most appropriate action at this point?

A 3-year-old boy sustains a complete paralysis following a high thoracic spinal cord injury consistent with a SCIWORA-type injury (spinal cord injury without radiographic abnormality). Subsequent progressive spinal deformity will develop in what percent of patients with this injury?

Figure 53 shows the pedigree of a family with an unusual type of muscular dystrophy. This pedigree is most consistent with what type of inheritance pattern?

An 19-year-old male presents to the emergency room following an motor vehicle accident as an unrestrained driver. Examination reveals unilateral jugular vein engorgement. Chest and special view radiographs are seen in Figures A and B respectively. Following CT scan of the chest, the next step in management is Review Topic

A 12-year-old boy who pitches on two “select” baseball teams has had pain in his dominant right shoulder for the past 6 weeks. The pain is present only with throwing and is associated with decreased throwing velocity and control. He has no radiation of pain or paraesthesias of the upper extremity. An AP radiograph and MRI scan are shown in Figures 19a and 19b, respectively. Management should consist of Review Topic

Up to what time frame are the risks minimized in anterior revision disk replacement surgery?

• A 32-year-old man has swelling of the knee as a result of falling with the knee flexed and his foot in plantar flexion. A Lachman’s test reveals an apparent increase in anterior translation. Passive external tibial rotation at 30 degrees and 90 degrees is equal to the contralateral side, and the quadriceps active test is positive on the affected side. The neurovascular examination is normal. Treatment should consist of

A complication unique to computer navigation of total knee arthroplasty (TKA) is

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

What method of spinal fixation requires the largest force to disrupt the bone-implant interface?

An otherwise healthy 45-year-old woman reports the onset of severe right leg pain. Figure 20a shows an axial MRI scan of the L4-5 level, and Figure 20b shows a sagittal view with the arrow at the L4-5 level. What nerve root is the most likely source of her pain?

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

A 65-year-old man has a painful and often audible crepitus after undergoing a total knee arthroplasty 8 months ago. His symptoms are reproduced with active extension of about 30°. Examination reveals no effusion or localized tenderness, a stable knee, and a range of motion of 5° to 120°. Radiographs are shown in Figures 37a and 37b. Management should consist of

What is the most frequent complication of percutaneous repair of an acute Achilles tendon rupture?

A 25-year-old tennis player has shoulder pain and weakness to external rotation. MRI scans are shown in Figures 16a and 16b. What is the most likely cause of his weakness?

A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include

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

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

A 47-year-old man is seen in consultation in the ICU after being admitted and treated emergently for a dissecting aortic aneurysm. Current examination reveals generalized weakness of the lower extremities with a significant decrease in pain and temperature sensation from approximately the waist down. Proprioception is maintained. What is the most likely diagnosis at this time? Review Topic

Figures 61a and 61b show the CT and MRI scans of a 40-year-old man who has hip pain. He undergoes total hip arthroplasty and curettage and cementation of the lesion as shown in Figure 61c. Histopathologic photomicrographs of the curettage specimen are shown in Figures 61d and 61e. What is the best course of treatment?

Anterior penetration of an iliosacral screw through the sacral ala would most likely lead to weakness of which of the following movements?

What is the most likely explanation for the change between the initial intraoperative radiograph (Figure 11a) and the radiograph taken 4 weeks after surgery (Figure 11b) in an 87-year-old man who underwent primary hip replacement for osteoarthritis?

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

..Figures 112a and 112b are the anteroposterior and lateral radiographs of a 65-year-old man who has a significant history of tobacco abuse and a 6-week history of right thigh pain. Axial and sagittal MRI scans are seen in Figures 112c and 112d. His MR angiogram is shown in Figure 112e. A biopsy of a lesion is shown in Figure 112f. What is the most likely diagnosis?

A 13-year-old girl with Down syndrome has bilateral chronic patellar dislocations. She denies knee pain. She is able to straighten her knees and walks with a symmetric but awkward gait. She does not flex her knees in midstance. Examination reveals that the patellae cannot be brought into a reduced position. Management should consist of

• Which of the following injuries is most commonly associated with a fracture of the scapular body?

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

What preoperative factor correlates best with the outcome of rotator cuff repair?

Which of the following positions of immobilization has been shown to best approximate the anterior labrum against the glenoid rim following anterior dislocation of the shoulder?

What is the most common malignant tumor of the foot?

A 53-year-old man with a history of severe left hip pain has a significant limp that is the result of a 5-cm limb-length discrepancy. An AP radiograph is shown in Figure 48. The underlying etiology is most likely related to a history of

In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?

Which of the following best describes the legal definition of standard of care?

• The pharmacologic action of botulinum-A toxin can be best described as

• Which of the following medicolegal relationships between an attending surgeon and a resident assistant applies when a patient files a malpractice suit relating to surgical complications following a total knee arthroplasty?

Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of

A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis? Review Topic

A 51-year-old woman has had progressively increasing right knee pain for the past 6 months. She has a history of metastatic renal cell carcinoma to the lung and the skeletal system. Radiographs are seen in Figures 18a and 18b. The next step in management of the right distal femur lesion should consist of

An otherwise healthy 75-year-old man has a painful mass in the popliteal fossa of his right knee. A lateral radiograph of the knee, a CT scan of the distal femur, and a histopathologic specimen are shown in Figures 13a through 13c. Management should consist of

Immediately after undergoing lumbar instrumentation, a patient reports severe right leg pain and has 4+/5 weakness. Figure 24 shows an axial CT scan of L5. Exploratory surgery will most likely reveal

A 78-year-old man has a history of worsening bilateral calf pain with activity. MRI scans are shown in Figures 31a through 31d. His symptoms are not improved with forward flexion of the lumbar spine. His lower extremity pain is relieved when he sits or ceases activity. Which of the following tests would be most helpful in establishing a diagnosis? Review Topic

A 64-year-old man who underwent an L4-5 decompression approximately 1 year ago reported relief of his claudicatory leg pain initially, but he now has increasing low back pain and recurrent neurogenic claudication despite nonsurgical management. Radiographs show new asymmetric collapse and spondylolisthesis at the decompressed segment, and MRI scans show lateral recess stenosis. The next most appropriate step in management should consist of

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

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

Commotio cordis is best treated with

Which of the following zones of articular cartilage has the highest concentration of proteoglycans?

A 22-year-old college football player reports shortness of breath and dyspnea after a tackle. Examination reveals tachypnea, tachycardia, the trachea is shifted to the right, and there are decreased breath sounds on the left lung fields. The first line of treatment on the field should be

When planning revision of a total hip arthroplasty where an acetabular reconstruction will be required, what prerequisite is important to ensure long-term success of a cementless component?

A 28-year-old man has had a 2-year history of progressive lateral ankle pain. History reveals that he underwent a triple arthrodesis at age 13 for a tarsal coalition. The pain has been refractory to braces, custom inserts, and nonsteroidal anti-inflammatory drugs. Weight-bearing radiographs of the ankle and foot are shown in Figures 3a through 3d. Surgical management should include which of the following?

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

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time? Review Topic

The first branch of the lateral plantar nerve innervates the

A B C Figures 30a through 30c are the radiograph and MR images of a 54-year-old woman who has severe leg pain with walking. Her treatment has included 12 weeks of physical therapy, anti-inflammatory medications, and narcotic pain relievers, and she is interested in surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) is recommended. When compared with open TLIF, MIS TLIF is associated with

A 19-year-old man has had pain and swelling in his left forearm for the past 8 months. Laboratory studies show a mildly elevated WBC count and erythrocyte sedimentation rate. Radiographs are shown in Figures 58a and 58b, a CT scan is shown in Figure 58c, and T 1 - and T 2 -weighted MRI scans are shown in Figures 58d and 58e, respectively. A biopsy specimen is shown in Figure 58f. Immunohistochemistry demonstrates that the lesion is negative for leukocyte common antigen (CD34). What is the most common cytogenetic translocation associated with this lesion?

A 20-year-old basketball player sustains a knee injury during a game and is seen in the orthopaedic clinic 3 days after injury. Examination reveals a positive Lachman, pivot shift, joint line tenderness, and moderate effusion. Which of the following tissue injuries is most likely causing the jointline tenderness?

What pathology is most likely to result in failure of an arthroscopic Bankart repair?

A 35-year-old man has a brachial plexus injury affecting the lateral cord. He partially improves with observation and now has complete return of median nerve function and pectoral muscle function. What nerve transfer is most likely to restore the motor function he is lacking?

At what age does the lateral epicondyle normally ossify in males?

A 27-year-old man sustained a gunshot wound to the lumbar spine and undergoes an exploratory laparotomy. An injury to the cecum is identified and treated. Management should now include

A 6-year-old boy had a 4-day history of worsening atraumatic right thigh and knee pain. He was seen in the emergency department, where he had a temperature of 39.1°C. Laboratory studies reveal a white blood cell count of 15000 /µL (reference range, 4500-11000 /µL). He had a small knee effusion with range of motion 0 to 90 degrees and a swollen, painful, hot distal thigh. The knee effusion was aspirated, revealing a white blood cell (WBC) count of 2000 with negative gram stain (reference range < 2000 WBC/mL). The boy was admitted to the pediatric medical service and intravenous (IV) antibiotics were initiated. The next day, MR imaging was obtained and orthopaedics was consulted. Based on Figures 8a and 8b, what is the most appropriate description of his condition?

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

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

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

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

A 50-year-old pipefitter falls from a ladder at work and dislocates his non-dominant shoulder. His MRI scan shows supraspinatus and infraspinatus tears with retraction to the glenoid. He cannot actively raise his arm away from his side. He denies prior shoulder symptoms before his fall. Three weeks of physical therapy have failed to improve his function. Which factor has been demonstrated to result in a poor clinical outcome following surgical intervention?

A 54-year-old woman reports worsening pain in her buttock, especially when sitting for long periods of time. She has occasional pain and paresthesias radiating down her posterior leg. She has no significant medical history. MRI scans are shown in Figures 15a and 15b and a biopsy specimen is shown in Figure 15c. What is the most likely diagnosis?

A 35-year-old construction worker has developed isolated lateral compartment arthritis. He has lost 50 pounds, now has a body mass index of 30, and still has pain that limits his activities of daily living and work despite receiving a 4-month course of nonsteroidal anti-inflammatory medications and 2 intra-articular cortisone injections. His range of motion is 5 to 110 degrees, and his mechanical axis is 18 degrees of valgus. What is the most appropriate surgical treatment for this patient?

Figure 1 is the right hand of a 65-year-old man with a history of hypertension and rheumatoid arthritis. He is taking immunosuppressive disease-modifying antirheumatic drugs (DMARDs) and is seen in the emergency department with rapid progression of erythema from his right thumb to his right arm during the last 12 hours. He is confused, lethargic, and has these vital signs: blood pressure 92/40, respiratory rate 45, temperature 39.7°C, pulse 135, and oxygen saturation 90% on 4 liters of oxygen by face mask. An examination of his right upper extremity reveals black bulla extending from the metacarpophalangeal down to the tip and no capillary refill at the pulp. Immediate treatment should consist of

A 50-year-old woman who underwent a joint replacement of the hallux metatarsophalangeal joint 6 months ago now has pain and swelling about the great toe. Radiographs are shown in Figures 39a and 39b. What is the next most appropriate step in management?

A 31-year-old woman has increasing pain and tightness in her right knee, with occasional stiffness and recurrent hemorrhagic effusions. MRI scans are shown in Figures 2a and 2b. What is the most likely diagnosis?

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

Which of the following medications has been shown to improve skeletal muscle regeneration and decrease fibrosis following muscle injury in an animal model? Review Topic

What is the most consistent finding regarding glenohumeral kinematics in patients with symptomatic tears of the rotator cuff?

A coach of three football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on one team are different from those on the other teams?

What is the most likely contributory factor to this patient's problem?

A 35-year-old woman with type 1 diabetes mellitus has been treated for the past 2 years at a wound care center for persistent bilateral fifth metatarsal head ulcers. Management has consisted of shoe wear modifications, treatment with multiple enzymatic ointments, and a fifth metatarsal head resection on the left side. Physical examination reveals intact pulses, minimal ankle dorsiflexion, neutral hindfoot, and a persistent ulcer under the fifth metatarsal heads. What treatment will best help heal the ulcers?

The most appropriate surgical approach includes which of the following? Review Topic

What is the most common causative bacteria in septic arthritis in children? Review Topic

The essential lesion in recurrent or posterior instability following simple dislocation of the elbow typically involves which of the following structures?

Which of the following is the most sensitive parameter to detect the increased inflammatory response seen with both postoperative infection and the use of instrumentation in spinal surgery?

A 17-year-old high school track athlete has had progressive midfoot pain for the past 3 weeks that prevents him from running. Examination reveals pain over the tarsal navicular. Radiographs are normal, but a CT scan reveals a nondisplaced sagittally oriented fracture line. Management should consist of

A 23-year-old man sustained an injury to his left foot when a forklift rolled over it at work. Examination reveals marked swelling of the midfoot and forefoot, with tenderness to palpation over the medial hindfoot and dorsomedial forefoot. The distal dorsalis pedis pulse is audible on Doppler examination, and his sensation is intact to touch. Radiographs are shown in Figures 33a and 33b. Management should consist of

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?