OITE & AAOS Orthopedic Board Review MCQs: Part 247

About This Board Review Set

This is Part 247 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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Two distinct learning modes are available:

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

Topics Covered in Part 247

This module focuses heavily on: Ankle, Arthroplasty, Dislocation, Foot, Fracture, Hip, Trauma.

Sample Questions from This Set

Sample Question 1: What mechanism of injury is most likely to cause a fracture of the anteromedial facet of the coronoid?...

Sample Question 2: A 19-year-old girl has had pain and swelling in the right ankle for the past 4 months. She denies any history of trauma. Examination reveals a small soft-tissue mass over the anterior aspect of the ankle and slight pain with range of motion...

Sample Question 3: A 63-year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coatedtitanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 ye...

Sample Question 4: Which of the following treatments of polyethylene results in the highest amount of oxidative degradation?...

Sample Question 5: Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropat...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

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

Explanation

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

Question 2

A 19-year-old girl has had pain and swelling in the right ankle for the past 4 months. She denies any history of trauma. Examination reveals a small soft-tissue mass over the anterior aspect of the ankle and slight pain with range of motion of the ankle joint. The examination is otherwise unremarkable. A radiograph and MRI scan are shown in Figures 45a and 45b, and biopsy specimens are shown in Figures 45c and 45d. What is the most likely diagnosis?

Explanation

DISCUSSION: Giant cell tumors typically occur in a juxta-articular location involving the epiphysis and metaphysis of long bones, usually eccentric in the bone. The radiographs show a destructive process within the distal tibia and an associated soft-tissue mass. The histology shows multinucleated giant cells in a bland matrix with a few scattered mitoses. Osteosarcoma can have a similar destructive appearance but a very different histologic pattern with osteoid production. Ewing’s sarcoma also can have a diffuse destructive process in the bone. The histologic pattern of Ewing’s sarcoma is diffuse round blue cells. Aneurysmal bone cysts typically are seen as a fluid-filled lesion on imaging studies and have only a scant amount of giant cells histologically. Metastatic adenocarcinoma does not demonstrate the pattern shown in the patient’s histology specimen.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 198-199.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 200-202.

Question 3

A 63-year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coated titanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 years but has now had two dislocations and reports pain and weakness around the left hip. She denies any fevers, chills, or constitutional symptoms. On examination, the patient walks well without any signs of an antalgic or Trendelenburg gait. Her abductor mechanism demonstrates good strength. Her erythrocyte sedimentation rate and C-reactive protein level are normal. On radiographs, all components appear well fixed and in good alignment. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Trunnionosis is a recently recognized complication following total hip arthroplasty and can occur when a cobalt alloy femoral head is used on a titanium alloy or cobalt alloy femoral stem. Patients often present with pain or swelling around the hip but at times can present with instability. Certain femoral stem designs have been associated with increased reports of trunnionosis. In a patient with a cobalt alloy femoral head who presents with instability, swelling, and weakness around the hip, the potential for trunnionosis and
an adverse local tissue reaction should be considered.

Question 4

Which of the following treatments of polyethylene results in the highest amount of oxidative degradation?

Explanation

DISCUSSION: Oxidative degradation of polyethylene occurs as a function of time in an air environment. In an environment such as argon, nitrogen, or a vacuum, the process is reduced. Ethylene oxide is an alternative for sterilization in which the cross-link degradation is minimized because of the absence of oxidative interactions. Gamma sterilization or use of ethylene oxide gas is the industry standard; however, oxygen concentrations are now reduced to a minimal level to retard the oxidation phenomenon.
REFERENCES: Sanford WM, Saum KA: Accelerated oxidative aging testing of UHMWPE. Trans Orthop Res Soc 1995;20:119.
Sun DC, Schmidig G. Stark C, et al: On the origins of a subsurface oxidation maximum and its relationship to the performance of UHMWPE implants. Trans Soc Biomater 1995;18:362.
Callaghan JJ, Dennis DA, Paprosky WA, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 35-41.
McKellup HA: Bearing surfaces in total hip replacement: State of the art and future developments. Instr Course Lect 2001;50:165-179.

Question 5

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

Explanation

DISCUSSION: Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration. In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective. Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained.
REFERENCES: Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996;19:465-475.
Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81:535-538.

Question 6

An axillary nerve lesion may cause weakness in the deltoid and the

Explanation

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 7

A 21-year-old collegiate track athlete increased her training 4 months ago in anticipation of starting the season. Two months into her training program, she reported pain followed by a 1-month history of diffuse pain in the first metatarsophalangeal joint that was aggravated by weight bearing. A removable walker boot partially relieved the pain, and she was able to complete the season. Her pain has now returned; however, she denies any history of injury. Examination reveals tenderness over the medial sesamoid but no deformities. A radiograph and bone scan are shown in Figures 22a and 22b. What is the best treatment option at this time?

Explanation

DISCUSSION: The radiograph reveals either a fractured or bipartite sesamoid. The bone scan shows asymmetrically increased uptake over the medial sesamoid. Given the history and physical examination, a stress fracture is the most likely diagnosis. Medial sesamoidectomy reliably improves pain, and athletes return to sports on an average of 7 weeks after excision. Immobilization typically requires more than 4 to 8 weeks and is not always successful; however, it would be appropriate management for a patient who is not an elite athlete.
REFERENCES: Sanders R: Fractures of the midfoot and forefoot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1601-1603.
Saxena A, Krisdakumtorn T: Return to activity after sesamoidectomy in athletically active individuals. Foot Ankle Int 2003;24:415-419.

Question 8

A patient underwent an anterior cervical diskectomy and interbody fusion for a C5-6 herniated nucleus pulposus and left C6 radiculopathy 8 months ago. He now reports new onset of severe neck pain and left C6 radicular pain, with wrist extension weakness. The radiograph and CT scan shown in Figures 26a and 26b reveal pseudarthrosis at C5-6. The next step in management should consist of

Explanation

DISCUSSION: Brodsky and associates reviewed 34 cases of cervical pseudarthrosis after anterior fusion. Seventeen were treated with revision anterior fusion and 17 with posterior foraminotomy and fusion. Good results were seen in 75% of patients who underwent revision anterior surgery, but better results (94%) were seen with posterior surgery, including foraminotomy and stabilization. Tribus and associates reported treatment of 16 patients with pseudarthrosis using revision anterior debridement of the fibrous tissue and fusion with autograft and plates. There was improvement of the neck in 75% of the patients, nonunion in 19%, continued weakness in 28%, and dysphagia in 5%. Farey and associates reported on 19 patients treated with posterior foraminotomy, stabilization, and fusion with a fusion rate of 100%, resolution of arm pain in 94%, resolution of weakness in 100%, and resolution of neck pain in 75%. It would appear that posterior foraminotomy is more effective for relieving arm pain and neurologic deficits associated with pseudarthrosis. Posterior fusion has the most reliable rate of arthrodesis in this setting. Dysphagia is reported in some patients undergoing more extensive anterior dissections required for applying plates. A neck brace is unlikely to aid in healing of pseudarthrosis in a patient who underwent surgery 8 months ago. A neck brace would be most effective within the first 3 months if a delayed union is identified.
REFERENCES: Brodsky AE, Khalil MA, Sassard WR, Neuman BP: Repair of symptomatic pseudarthrosis of anterior cervical fusion: Posterior versus anterior repair. Spine

1992;17:1137-1143.
Tribus CB, Corteen DP, Zdeblick TA: The efficacy of anterior cervical plating in the management of symptomatic pseudarthrosis of the cervical spine. Spine 1999;24:860-864.
Farey ID, McAfee PC, Davis RF, Long DM: Pseudarthrosis of the cervical spine after anterior arthrodesis: Treatment by posterior nerve root decompression, stabilization, and arthrodesis.

J Bone Joint Surgery Am 1990;72:1171-1177.

Question 9

The Injury Severity Score (ISS), using point scores from five different body systems, is a method that aids in predicting the chances of mortality in a patient with multiple injuries by

Explanation

The Abbreviated Injury Scale (AIS) is made up of scores from 5 body systems (head/neck, face, chest, abdomen, extremity/pelvis) graded from 1 minor to 5 critical. The ISS is the sum of the squares of the highest AIS grade in each of the three most severely injured areas. The AIS pertains to individual injuries. The ISS is used for multiple injuries. Using the ISS dramatically increased the correlation between severity of injury and mortality.

Question 10

Figures 11a and 11b show the clinical photograph and radiograph of a newborn. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The newborn has posteromedial bowing of the tibia and calcaneal valgus deformity of the foot. Both are thought to be caused by abnormal intrauterine positioning. The foot deformity typically responds to stretching. The tibial bowing straightens with growth. The long-term problem is limb-length discrepancy.
REFERENCES: Heyman CH, Herndon CH, Heiple KG: Congenital posterior angulation of the tibia with talipes calcaneus. J Bone Joint Surg Am 1959;41:476-488.
Hofmann A, Wenger DR: Posteromedial bowing of the tibia: Progression of discrepancy in leg lengths. J Bone Joint Surg Am 1981;63:384-388.

Question 11

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Explanation

DISCUSSION: Increased levels of calcium are known to cause anorexia, nausea, vomiting, dehydration, muscle weakness, polyuria, and polydipsia. Treatment may include hydration, saline diuresis, and bisphosphonates.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 12

A 45-year-old man who smokes reports the rapid onset of color changes and coolness in the fingers. Examination shows an abnormal Allen test. Plain radiographs of the hand and wrist are normal. Which of the following studies will best aid in diagnosis?

Explanation

DISCUSSION: The patient has symptoms typical of Raynaud’s phenomenon secondary to underlying vascular disease. The next most appropriate step in the management of this patient should be to perform contrast angiography on the involved upper extremity to look for proximal or distal arterial lesions or insufficiencies. MRI and contrast CT are not as specific as angiography for the identification of vascular lesions of the upper extremity. Although patients with primary Raynaud’s vasospastic disease can have normal angiographic findings, they typically are younger than age 40 years, are female, and have normal results on an Allen test.
REFERENCES: Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 2288-2290.
Manske PR (ed): Hand Surgery Update. Rosemont, IL, American Society for Surgery of the Hand, 1994, pp 197-205.

Question 13

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

Explanation

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

Question 14

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Explanation

DISCUSSION: There are multiple causes for failure of total knee arthroplasty, and more than one may exist at the same time. Sharkey and associates reviewed a series of revision total knee arthroplasties, and found that polyethylene failure was the most common cause of failure followed closely by component loosening. The most common cause of early failure (< 2 years post op) was infection. Instability and malalignment are both complications of surgical technique, and if these categories are combined, they would be the most common cause of all total knee failures.
REFERENCE: Sharkey PF, Hozack WJ, Rothman RH, et al: Insall Award paper: Why are total knee arthroplasties failing today? Clin Orthop Relat Res 2002;404:7-13.

Question 15

Figure 35 shows the radiograph of a 35-year-old weightlifter who has had pain with overhead lifts for the past 7 months. Cortisone injections in the acromioclavicular joint provided only temporary relief. A bone scan reveals increased activity of the acromioclavicular joint. Treatment should now consist of

Explanation

DISCUSSION: Osteolysis of the distal clavicle is common in weightlifters; therefore, distal clavicle excision is the treatment of choice. A subacromial decompression alone would not alleviate the acromioclavicular joint symptoms. Interval closure, biceps degeneration, and superior labrum anterior and posterior repair would limit superior migration but would not explain the abnormal bone scan. Thermal capsular shrinkage does not have a role here.
REFERENCES: Flatow EL, Cordasco FA, McCluskey GM, Bigliani LU: Arthroscopic resection of the distal clavicle via a superior portal: A critical quantitative radiographic assessment of bone removal. Arthroscopy 1990;6:153-154.
Lyons FR, Rockwood CA: Osteolysis of the clavicle, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 541-546.

Question 16

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Explanation

DISCUSSION: Nonsurgical management such as a functional brace, hanging arm cast, or sugar tong splint is the treatment of choice for a fracture of the humeral shaft that is the result of throwing. The fracture surface typically is wide and the degree of displacement is not large; therefore, surgery is not indicated in most patients.
REFERENCES: Ogawa K, Yoshida A: Throwing fracture of the humeral shaft: An analysis of 90 patients. Am J Sports Med 1998;26:242-246.
Kaplan H, Kiral A, Kuskucu M, et al: Report of eight cases of humeral fracture following the throwing of hand grenades. Arch Orthop Trauma Surg 1998;117:50-52.

Question 17

A 77-year-old man with diabetes mellitus has had a nonhealing Wagner grade I ulcer under the medial sesamoid for the past 3 months. He smokes tobacco regularly. He has undergone several debridements and total contact casting. Examination reveals no palpable pulses. He has no erythema or purulence, and he is afebrile. Radiographs reveal no abnormalities. What is the best initial diagnostic test to help determine why the ulcer has failed to heal?

Explanation

DISCUSSION: The best initial test for this patient is to assess the vascular supply to the foot. An elderly smoker with diabetes mellitus has a high risk of peripheral vascular disease. Decreased weight bearing has not been successful. Although a bone scan might be helpful, it would take secondary consideration to the patient’s vascular supply, especially in the absence of any acute infection. Monofilament testing would help diagnosis neuropathy, which is a root cause behind the ulcer forming, but does not prevent it from healing. The Thompson’s test is used to diagnosis an Achilles tendon rupture.
REFERENCE: Brodsky JW: Evaluation of the diabetic foot. Instr Course Lect 1999;48:289-303.

Question 18

A 40-year-old female recreational basketball player notes pain deep within her shoulder that occurs with activity. Pain began insidiously 6 months previously. She has completed a physical therapy program, and an intra-articular corticosteroid injection provided excellent temporary relief. Physical examination shows symmetric range of motion of her shoulder. She has a positive O'Brien’s active compression test. There is no pain with cross-arm adduction or tenderness to palpation over the acromioclavicular joint. Resisted abduction is nonpainful and strong. MRI shows increased signal in the substance of the superior labrum, low-grade bursal surface fraying of the supraspinatus, and mild degenerative changes within the acromioclavicular joint. What is the best treatment option?

Explanation

A 50-year-old man sustained an external rotation traction injury to his right arm. He felt a pop in the anterior aspect of his shoulder associated with immediate pain and swelling. The MRI scan shows a tear of the subscapularis tendon, as shown in Figures 1 and 2. The arrow points to what anatomic structure?

Question 19

A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of

Explanation

DISCUSSION: The coracoid process is an essential component of the superior shoulder suspensory complex and must be maintained. Open reduction and internal fixation is recommended if the fragment is large and displaced more than 1 cm.
REFERENCES: Froimson AI: Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978;60:710-711.
Gil JF, Haydar A: Isolated injury of the coracoid process: Case report. J Trauma

1991;31:1696-1697.

Question 20

Implants composed of polylactic acid are excreted by what system after they are absorbed?

Explanation

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.

Question 21

A 58-year-old African-American female who sustained an injury to her upper arm six months ago presents with persistent arm pain. She was initially treated with splinting, with conversion to fracture bracing. She is neurovascularly intact. An injury radiograph and a current radiograph are shown in Figures A and B respectively. What nutritional or metabolic disturbance is the most likely associated with this patient's diagnosis? Review Topic

Explanation

This patient has sustained a humeral diaphyseal fracture that has gone on to an atrophic nonunion. Vitamin D deficiency is the most likely associated metabolic disturbance.
The incidence of nonunion with non-operative management of humeral shaft injuries ranges from 2-10%. Risk factors include vitamin D deficiency (most common), open fractures, segmental injuries, smoking and obesity. The optimal treatment is compression plating with bone grafting, which has been shown to be superior to intramedullary nailing with bone grafting or compression plating alone.
Ring et al. reviewed factors that contributed to humeral diaphyseal nonunion after fracture bracing. Fractures in the proximal to middle one-third of the shaft or fractures with a spiral/oblique pattern were more likely to go on to nonunion.
Brinker et al. reviewed 37 low-energy fractures that went onto nonunion. These patients were evaluated by clinical endocrinologists for evaluation of metabolic abnormalities. Thirty-one of the 37 patients (84%) had a metabolic issue, with 68% (25 of 37 patients) having Vitamin D deficiency.
Figure A demonstrates a humeral shaft fracture. Figure B demonstrates an atrophic nonunion of the humeral shaft fracture.
Incorrect Answers:

Question 22

A 67-year-old woman has persistent anterior thigh and knee pain after undergoing total knee arthroplasty 1 year ago. Examination and radiographs reveal no problems in the knee, mild hip flexor weakness (grade 4+), and decreased sensation over the anterior thigh including and proximal to the incision. MRI of the lumbar spine will most likely reveal which of the following findings?

Explanation

DISCUSSION: Degenerative spondylolisthesis at L3-4 is the most likely diagnosis. This spondylolisthesis would result in foraminal stenosis affecting the third lumbar root and leading to anterior thigh and knee pain and hip flexor weakness. L4-5 spondylolisthesis would impinge on the L4 root in the foramen. Degenerative disk disease without hypertrophy is unlikely to have root impingement. Posterolateral herniations typically affect the inferior root and are less common in this age group.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 250.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 23

A 78-year-old woman underwent total hip arthroplasty 15 years ago. She reports a recent history of increasing thigh pain prior to a fall and is now unable to ambulate. Radiographs are shown in Figures 87a and 87b. What is the best treatment for this condition?

Explanation

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Question 24

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Explanation

The complication rate with halo vest treatment in children is reported to be as high as 68% in contrast to a 36% complication rate in adults. These complications include not only pin tract infections, but also skull penetration. Multiple pins allow for the early removal of pins without fixation consequences should pin site infections begin to develop. Moreover, there is significant variability in the insertional torque applied by a variety halo pin torque wrenches, including those from the same manufacturer. Consequently, the use of a large number of pins (8 to 12) placed a very low insertional torque (1 to 5 in-lb) in children is recommended. A CT scan of the head should also be considered to assess for the thickest areas of the skull suitable for pin application.

Question 25

A 34-year-old woman reports constant midlateral arm pain after sustaining minimal trauma to the shoulder. Radiographs and a biopsy specimen are shown in Figures 29a and 29b. What is the most likely diagnosis?

Explanation

DISCUSSION: Eighty percent of giant cell tumors occur in patients older than age 20 years, with the peak incidence in the third decade of life. Most of these tumors are eccentrically located and epiphyseal in location. They are lytic in nature as in this patient. Although named for the hallmarked multinucleated giant cells seen in the lesion, the basic cell type is the spindle-shaped stromal cell. Chondroblastoma is highly cellular and contains large multinucleated giant cells with intercellular chondroid material, some of which is calcified. Chondromyxoid fibroma has chondroid tissue separated by strands of more cellular tissue with occasional multinucleated giant cells. Desmoplastic fibroma is characterized by poorly cellular fibrous tissue, and lymphoma is highly cellular with characteristic round cells.
REFERENCES: Campanacci M, Baldini N, Boriani S, et al: Giant cell tumor of bone. J Bone Joint Surg Am 1987;69:106-114.
Goldenberg RR, Campbell CJ, Bonfiglio M: Giant cell tumor of bone: An analysis of two hundred and eighteen cases. J Bone Joint Surg Am 1970;52:619-664.

Question 26

Figure 11a shows the AP pelvis radiograph of a 25-year-old man who sustained a spinal cord injury 10 years ago. A bone scan and a CT scan are shown in Figures 11b and 11c. To prevent recurrence after resection, management should consist of

Explanation

DISCUSSION: The studies reveal significant heterotopic ossification that appears to be mature. Following resection, the most reliable way to prevent recurrence is with low-dose external-beam radiation therapy. Bisphosphonate therapy can be considered; however, when terminated, heterotopic bone may reform. Heterotopic ossification is unrelated to the patient’s endocrine status and is not associated with any metabolic abnormalities.
REFERENCES: Moore K, Goss K, Anglen J: Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fracture. J Bone Joint Surg Br 1998;80:259.
Stover S, Niemann K, Tullos J: Experience with surgical resection of heterotopic bone in spinal cord injury patients. Clin Orthop 1991;263:71-77.

Question 27

A patient with degenerative osteoarthritis of the sternoclavicular (SC) joint reports constant pain, discomfort, and marked prominence and instability of the SC joint following medial clavicle resection. Which of the following procedures is most likely to produce these signs and symptoms?

Explanation

DISCUSSION: Medial clavicle excision alone can be associated with postoperative instability of the clavicle. The clavicle should be stabilized to the first rib by reconstructing the costoclavicular ligament if it is torn or if the resection is lateral to its clavicular insertion. Therefore, care must be taken to resect only that part of the clavicle that is medial to the costoclavicular ligament. Adequate protection for vital structures that lie posterior to the medial end of the clavicle must be provided.
REFERENCES: Bremner RA: Nonarticular noninfected subacute arthritis of the sternoclavicular joint. J Bone Joint Surg Br 1959;41:749-753.
Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 583-586.

Question 28

Which of the following changes in the parameters of the gait cycle occurs in the transition from normal walking to running?

Explanation

The same basic mechanisms that have been described for the biomechanics of the foot and ankle are not significantly altered during running. The major differences observed during running are that the gait cycle is altered considerably; the amount of force generated, as measured by force plated data, is markedly increased; the range of motion of the joints of the lower extremities is increased; and the phasic activity of the muscles of the lower extremities is altered. During walking one foot is always in contact with the ground; as the speed of gait increases a float phase incorporated into the gait cycle, during which time both feet are off the ground. There also is no longer a period of double limb support. As the speed of gait continues to increase, the time the foot spends on the ground, both in real time and in percentage of cycle, decreases considerably. Question 71 -
Examination of a 5-year-old child who has fibular hemimelia reveals the foot has two rays and is stiff in equinus and valgus. The level of the foot is just proximal to the midshaft of the contralateral tibia, and the knee has full active flexion and extension, but slight valgus. Treatment should include
Amputation through the midshaft of the tibia
Correction of the foot deformity and lengthening with a ring fixator
Knee disarticulation
Ankle disarticulation
Ankle disarticulation and contralateral epiphyseodesis of the proximal tibia Answer: 4
Congenital absence of the fibula, also called fibula hemimelia, has several manifestations. These range from complete absence of the fibula with missing lateral rays of the foot (i.e. terminal longitudinal deficiency) to absence of only a portion of the fibula without foot involvement (i.e. intercalary longitudinal; deficiency). Congenital fibular deficiency usually occurs sporadically without a known cause. The child with complete absence of the fibula presents clinically with an anterolateral bow of the tibia, an equinovalgus deformity of the foot, and a tarsal coalition. The talotibial joint is usually malformed, with the fused talocalcaneus having a flat upper surface that articulates with the tibia in a valgus and equinus position. The foot may be missing one or two lateral rays. There is always significant shortening of the epsilateral femur. Treatment: There is a reasonable consensus that complete fibular hemimelia is best treated by performing an ankle disarticulation in early childhood and fitting a Syme-type prosthesis. Children with lesser (<5cm) at birth may be a candidate for lengthening procedures, but the exact indications and results of these procedures have not been well defined. Children with large discrepancies (>5cm) at birth and those with major foot deformities are better managed with amputation.

Question 29

Which of the following therapies has a direct anabolic effect on bone?

Explanation

Bisphosphonates are antiresorptive agents that act by targeting osteoclatic bone resorption. Calcitonin also inhibits osteoclastic bone resorption. Excessive cortisol decreases intestinal calcium absorption, increases calcium loss from the kidney, inhibits bone matrix formation, and causes secondary hyperparathyroidism. TNF-a inhibits osteoblastic activity and enhances osteoclastic bone resorption. Intermittent administration of PTH isoforms is anabolic, whereas persistent elevated levels of PTH promotes bone resorption.

Question 30

A 45-year-old man has persistent hindfoot pain that is aggravated by weight-bearing activities. History reveals that he sustained a calcaneus fracture 2 years ago, and he underwent a subtalar fusion 1 year ago. Examination reveals tenderness in the sinus tarsi and across the transverse tarsal joint. A plain radiograph and a CT scan are shown in Figures 24a and 24b. A technetium Tc 99m bone scan reveals uptake at the subtalar joint and at the transverse tarsal joints. Management should now consist of

Explanation

DISCUSSION: The patient has a nonunion at the subtalar joint because of poor preparation of the arthrodesis site with incomplete removal of the articular cartilage. Clinically, he has arthritis at the transverse tarsal joint. Casting with a bone stimulator is not expected to result in a union of the subtalar arthrodesis. To address both the subtalar nonunion and the transverse tarsal joint arthritis, revision of the subtalar arthrodesis and conversion to a triple arthrodesis is the preferred option.
REFERENCES: Graves SC, Mann RA, Graves KO: Triple arthrodesis in older adults: Results after long-term follow-up. J Bone Joint Surg Am 1993;75:355-362.
Haddad SL, Myerson MS, Pell RF IV, Schon LC: Clinical and radiographic outcome of revision surgery for failed triple arthrodesis. Foot Ankle Int 1997;18:489-499.
Sangeorzan BJ, Smith D, Veith R, Hansen ST Jr: Triple arthrodesis using internal fixation in treatment of adult foot disorders. Clin Orthop 1993;294:299-307.
Sangeorzan BJ: Salvage procedures for calcaneus fractures. Instr Course Lect 1997;46:339-346.
Wapner KL: Triple arthrodesis in adults. J Am Acad Orthop Surg 1998;6:188-196.

Question 31

Which nerve is most commonly injured after total knee arthroplasty?

Explanation

DISCUSSION
The tibial or peroneal nerves usually are not injured during total knee arthroplasty. Incidence of peroneal nerve damage is highest in knees with a valgus deformity and an associated flexion contracture attributable to nerve stretch. This nerve injury occurs in as many as 9% of patients undergoing knee arthroplasty. Tibial nerve injury is a rare occurrence and usually an iatrogenic transection injury. The infrapatellar branch of the saphenous nerve and its nerve plexus is commonly injured after the medial parapatellar approach, and altered sensation attributable to injury is reported in up to 70% of cases. Injury typically manifests as numbness inferior to the patella. The sartorial branch of the saphenous nerve provides sensation distal to the knee and is uncommonly injured with a medial parapatellar approach. These concepts are illustrated in video 57, “Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition.”
RECOMMENDED READINGS
Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.View Abstract at PubMed
Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.View Abstract at PubMed
Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.View Abstract at PubMed

Question 32

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

Explanation

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 33

A 55-year-old man falls from a ladder and dislocates his nondominant shoulder. He undergoes an uncomplicated closed reduction under sedation in the emergency department. Postreduction radiographs reveal a small Hill-Sachs lesion and no other bony abnormalities. Six weeks after the dislocation, the patient has persistent pain at rest and forward elevation and external rotation weakness, but the remaining motor function in the extremity and sensation are intact. What is the best next step?

Explanation

For a patient >40 years of age who has persistent pain and weakness isolated to the rotator cuff following an acute anterior shoulder dislocation, an MRI is indicated to evaluate rotator cuff integrity. EMG is not indicated in this case because this patient has no evidence of distal motor functional abnormality and their sensation is intact, thereby making a brachial plexus injury unlikely. Corticosteroid injections and physical therapy
modalities do not adequately address the concern over his potential for having sustained a rotator cuff tear.

Question 34

-T1-weighted, fat-saturated MRI scans are shown in Figures 37a and 37b. What is the next step intreatment?

Explanation

DISCUSSION FOR QUESTIONS 37 AND 38
Examination findings of posterior glenohumeral tenderness, decreased internal rotation, and reproduction of symptoms with a posterior stress test indicate a posterior shoulder injury or instability. The jerk test,with the patient seated, positions the arm in forward flexion and internal rotation with elbow flexion. One hand of the examiner is placed on the patient’s distal clavicle and scapular spine and the other hand grasps the elbow. The arm is jerked posteriorly while the shoulder girdle is jerked anteriorly, which creates pain as the posteriorly subluxated humeral head relocates into the glenoid fossa. During the Kim test, the patient is seated with the arm in 90 degrees of abduction. While the arm is elevated 45 degrees diagonally (forward flexion and adduction), the examiner applies an axial load to the elbow and a downward and posterior force to the upper arm. A positive result causes a sudden onset of posterior shoulder pain. A positive jerk test combined with a positive Kim test has a 97% sensitivity for posterior instability. After extensive PT, the patient continues to have examination findings consistent with posterior shoulder injury or instability, so an MRI scan or MRI arthrography would be helpful to assess for any pathology.A subacromial injection is not indicated by this examination, which shows a strong rotator cuff and no demonstrated bursal-sided symptoms. A CT scan can be helpful in scenarios involving bony pathology,but an MRI is indicated at this stage in the evaluation of soft tissue. Although continuing PT may help to abate symptoms, the patient was continuing to have symptoms with PT. The MRI arthrogram shows a complex posterior labrum tear at the inferior to mid glenoid with separation of labrum from the glenoid. Because the examination findings are consistent with the MRI findings and nonsurgical treatment has failed to resolve symptoms, the next step is to recommend surgical treatment with labrum debridement and/or repair. No examination or MRI findings indicate a need for injection, rotator cuff repair, ORIF, or chondroplasty unless incidental intrasurgical findings are found.

Question 35

A 22-year-old volleyball player reports the insidious onset of superior and posterior shoulder pain. Radiographs are normal. An MRI scan is shown in Figure 25. What is the most specific physical examination finding?

Explanation

DISCUSSION: Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.
REFERENCES: Romeo AA, Rotenberg DD, Bach BR Jr: Suprascapular neuropathy. J Am Acad Orthop Surg 1999;7:358-367.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.

Question 36

A patient sustained a joint depression-type fracture of the calcaneus that healed despite lack of treatment. The loss of dorsiflexion the patient is now experiencing is most likely the result of

Explanation

Closed treatment is geared toward padding the heel externally. The horizontal talus may abut the tibia anteriorly. This is caused by a joint depression type fracture. The primary fracture line begins in the sinus tarsi and propagates obliquely across the posterior facet to the medial wall. The posterior facet is no longer under the talus and the talus settles into a position parallel to the ground. When the talus is parallel to the floor, it is often fully dorsiflexed, even with the foot in neutral position. The changes in the subtalar joint also affects the transverse tarsal joint. Because of the relative positions of the calcaneus at the cuboid (neutral) and the talus at the navicular (dorsiflexed) are different, this has the net effect of locking the transverse tarsal joint.

Question 37

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Explanation

DISCUSSION: The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper’s injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach.
REFERENCES: Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, p 668.

Question 38

A 46-year-old man fell 20 feet and sustained the injury shown in Figure 3. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters. The most appropriate initial management should consist of

Explanation

DISCUSSION: Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is

not indicated.
REFERENCES: Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.

Question 39

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Explanation

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899. View Abstract at PubMed Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053. View Abstract at PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 40

Accurate evaluation of the upper portion of the subscapularis muscle is best accomplished with active internal rotation

Explanation

DISCUSSION: Internal rotators of the shoulder include the subscapularis, pectoralis major, teres major, and latissimus dorsi muscles. The subscapularis has two portions, with the upper portion receiving its innervation from the upper subscapular nerve (C5) and the lower portion from the lower subscapular nerve (C5-6). The two tests commonly performed to isolate the internal rotation to the subscapularis muscle are the lift-off test and the belly press test. Electromyographic findings have shown the lift-off test to be more accurate for the lower portion of the subscapularis and the belly press test to be more sensitive for the upper portion.
REFERENCES: Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ: Electromyographic activity and applied load during shoulder rehabilitation exercises using elastic resistance. Am J Sports Med 1998;26:210-220.
Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.

Question 41

Following its exit from the sciatic notch, the sciatic nerve passes between what two muscles?

Explanation

DISCUSSION: Though anatomic variations exist, both divisions of the sciatic nerve most commonly pass between the piriformis and superior gemellus. This anatomic consideration is relevant during the posterior approach to the hip, where careful retraction of the rotators avoids sciatic nerve injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 335-348.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Williams,

1978, Figure 4-34.
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Question 42

Figure 51 shows the standing AP radiograph of a 56-year old woman who has multiple toe deformities and pain beneath the metatarsal heads. Shoe modification has failed to provide relief. In addition to correction of the proximal interphalangeal joint deformities, surgical treatment should consist of

Explanation

Surgical correction of severe rheumatoid forefoot deformities with resection arthroplasties of the lesser metatarsal phalangeal joints and arthrodesis of the first metatarsal phalangeal joint resulted in a significant long-term improvement with respect to shoe wear, pain and the ability to stand and walk in 95% of the patients. There was minimal recurrence of the deformity. Previous procedures attempt to correct the lesser MTP joint deformities and a resection-type arthroplasty procedure to the 1st MTP joint. Recurrent symptomatic deformities were found in the latter.
A modification was then used that maintained the proximal phalangeal bases and used K-wires to fixate the MTP arthroplasty and IP joints which resulted in improved cosmetic result and simplified post-op management. Equal results were seen w/ no increase in recurrence or complications.

Question 43

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

Explanation

DISCUSSION: The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively. Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.
REFERENCE: Glassman SD, Anagnost SC, Parker A, et al: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608-2615.

Question 44

A B Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

Explanation

DISCUSSION
This injury pattern represents a flexion distraction injury, or a Chance fracture. The imaging hallmark of this injury is the axial split of the pedicle seen on the sagittal CT scan. This injury necessitates surgical intervention to prevent progressive deformity and pain. A rotation mechanism results in a dislocation with a rotational deformity at the level of injury. An extension force causes failure of the anterior column in tension with compression of the posterior column. An axial load force would result in a burst fracture.
RECOMMENDED READINGS
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.
Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, DiPaola M, Ranier P, Austin L, Ropiak R, Ciminello M, Okafor C, Eichenbaum M, Rapuri V, Smith E, Orozco F, Ugolini P, Fletcher M, Minnich J, Goldberg G, Wilsey J, Lee JY, Lim MR, Burns A, Marino R, DiPaola C, Zeiller L, Zeiler SC, Harrop J, Anderson DG, Albert TJ, Hilibrand AS. Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S62-9; discussion S104. PubMed PMID:16685239.View Abstract at PubMed

Question 45

What structure provides the major blood supply to the humeral head?

Explanation

DISCUSSION: The ascending branch of the anterior circumflex humeral artery provides

the major blood supply to the humeral head. The posterior circumflex humeral artery

supplies a much smaller portion of the proximal humerus. The nutrient humeral artery is the main blood supply for the humeral shaft. The thoracoacromial artery is primarily a muscular branch. The rotator cuff insertions contribute some blood supply to the tuberosities but not a major contribution.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Cushner MA, Friedman RJ: Osteonecrosis of the humeral head. J Am Acad Orthop Surg 1997;5:339-346.

Question 46

A 35-year-old man presents one week after an acute right shoulder posterior dislocation after being electrocuted. He is evaluated in the emergency department and undergoes closed reduction. The patient reports global right shoulder pain and limited active and passive range of motion. He has mild anterior and lateral bruising. He is distally neurovascularly intact. Current radiographs and an MRI scan are shown in Figures 1 through 3. What is the best next step?

Explanation

A 68-year-old man presents with chronic progressive right shoulder pain and loss of motion. He has active shoulder elevation of 120° and 5-/5 shoulder forward flexion strength limited by pain. He has exhausted nonsurgical management over the past year and is now interested in surgical intervention. Figure 1 is the preoperative axial CT scan of his shoulder. During surgical reconstruction, the surgeon should anticipate the location of maximal glenoid erosion to be

Question 47

A 52-year-old woman slipped on ice in her driveway. Radiographs are shown in Figures 19a and 19b. The patient was treated in a short leg cast with weight bearing as tolerated for 6 weeks. Due to persistent tenderness at the fracture site, a CAM walker was used for an additional 8 weeks. Nine months after the injury, the patient still walks with a limp and reports pain with deep palpation at the fracture site. What is the next most appropriate step in management? Review Topic

Explanation

Persistent pain at the fracture site in the absence of infection is most likely due to a nonunion, best detected by CT. Walsh and DiGiovanni reported on a series of closed rotational fibular fractures in which nonunions were detected by CT in the absence of standard ankle radiographic findings. Repeat immobilization would not be appropriate at this late date. Pain management/sympathetic blocks would be considered if the patient displayed pain with light touch and disproportionate pain consistent with a complex mediated pain syndrome. Acupuncture would be expected to be of limited benefit.

Question 48

From which artery does the princeps pollicis artery branch?

Explanation

DISCUSSION
The princeps pollicis artery can be located on the palmar aspect of the adductor pollicis and emerges into the subcutaneous tissue at the thumb metacarpophalangeal flexion crease. It branches from the radial artery just distal to the location of the deep palmar arch.
RECOMMENDED READINGS
Coleman SS, Anson B: Arterial patterns in the hand based on a study of 650 specimens. Surg Gynec Obstet 1961;4:409-424.
Ames EL, Bissonnette M, Acland R, Lister G, Firrell J. Arterial anatomy of the thumb. 78 J Hand Surg Br. 1993 Aug;18(4):427-36. PubMed PMID: 8409651. View Abstract at PubMed

Question 49

A 30-year-old man has had a slowly enlarging mass on the plantar medial aspect of the foot for the past 6 months. The mass is now 1 cm in diameter, adherent to the plantar fascia, and painful with weightbearing. The overlying skin is mobile. Management at this time should consist of

Explanation

The only reason to treat plantar fibromatosis is to relieve the associated symptoms that often result from local extension and invasion. An indolent lesion can invade the neurovascular structures, necessitating operative intervention. Non-operative treatment begins with the construction of a well molded, padded shoe and an orthosis.

Question 50

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

Explanation

DISCUSSION: On T1-weighted images, the posterior cruciate ligament is a low-signal (black) structure that courses from the posterior aspect of the tibia to the medial femoral condyle. The posterior cruciate ligament can appear as arcuate, U-shaped, or kinked. The other structures have similar signal but different anatomic locations.
REFERENCES: Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA: Magnetic resonance imaging of the posterior cruciate ligament: Clinical use to improve diagnostic accuracy. Am J Sports Med 1992;20:732-737.
Sonin AH, Fitzgerald SW, Friedman H, Hoff FL, Hendrix RW, Rogers LF: Posterior cruciate ligament injury: MR imaging diagnosis and patterns of injury. Radiology 1994;190:455-458.

Question 51

A 36-year-old man sustains blunt chest trauma, an open right femur fracture, and a closed left tibia fracture following a high-speed MVC. Upon presentation to the emergency room, blood pressure is 80/40, HR 135, and urine output is .4 cc/kg/hr. Fluids and blood products are administered, and the patient is transferred to the ICU for further care. Which of the following indicates adequate resuscitation has been achieved?

Explanation

DISCUSSION: Of the following variables, only a normal gastric mucosal pH (>7.3) is associated with restoration of tissue oxygenation.
Shock is an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. This leads to anaerobic metabolism with the development of lactic acidosis and oxygen debt. Shock is either classified as compensated or uncompensated. Compensated shock exists when there is evidence of ongoing inadequate tissue perfusion despite the normalization of blood pressure, heart rate, and urine output. Uncompensated shock occurs when there is inadequate tissue perfusion and abnormal blood pressure, heart rate, and urine output. Thus, a patient may have normal vital signs but still be in a state of compensated shock that requires additional resuscitation.
Porter et al. review the optimal end points of resuscitation in trauma patients. They conclude that using traditional end points such as blood pressure, urine output and heart rate, may leave up to 85% of patients in "compensated" shock. They urge the use of lactate, base deficit, and gastric intramucosal pH as appropriate end points of resuscitation.
Roberts et al. discuss various aspects of damage control orthopaedics in the multiply injured trauma patient. Although they do not discuss the end points for resuscitation, they note that they presence of shock is a clinical parameter associated with adverse outcomes in the trauma patient.
Incorrect answers:

Question 52

Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?

Explanation

DISCUSSION: Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.

Question 53

Decreased activity of which of the following proteins may be predictive of an aggressive soft-tissue sarcoma?

Explanation

DISCUSSION: It has been proposed that an imbalance in the proteolytic cascade involving matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) may play a role in the development or progression of malignancy. TIMP activity has been shown to be weak or nonexistent and MMP activity to be high in patients with soft-tissue sarcoma. The level of vascular endothelial growth factor is shown to be a negative prognostic indicator because the expression of this factor is associated with angiogenesis and aggressive growth of many tumors including Ewing’ s sarcoma and chondrosarcoma. Stromelysin is a type of MMP. The biology of cytokines in malignancy is complex. A low level of interleukin-1 is not known to be associated with high-grade tumors.
REFERENCE: Benassi MS, Magagnoli G, Ponticelli F, et al: Tissue and serum loss of metalloproteinase inhibitors in high grade soft tissue sarcomas. Histol Histopathol 2003;18:1035-1040.

Question 54

A 16-year-old high school football player sustains an injury to the left hip. The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?

Explanation

DISCUSSION: The avulsed fragment represents the origin of the rectus femoris from the anterior inferior iliac spine and the brim of the acetabulum. Avulsion of the anterior inferior iliac spine is much less common than avulsion of the anterior superior iliac spine with its origin of the sartorius. The origin of the gluteus minimus is from the outer cortex of the iliac wing and has not been reported as a source of bony avulsion. The hip capsule is composed of the ischiofemoral and pubofemoral ligaments, in addition to the iliofemoral ligament. The pelvic attachment of the ischiofemoral ligament is from the ischial part of the acetabulum posteriorly, while the pubofemoral ligament attaches to the pubic portion inferiorly. Technically, ligaments do not have origins and insertions as muscle tendon groups do, but have attachment sites.
REFERENCES: Metzmaker JN, Pappas AM: Avulsion fractures of the pelvis. Am J Sports Med 1985;13:349-358.
Mader TJ: Avulsion of the rectus femoris tendon: An unusual type of pelvic fracture. Pediatr Emerg Care 1990;6:198-199.

Question 55

A young male patient underwent intramedullary nail fixation for a diaphyseal femur fracture. A post-operative CT scanogram is performed to assess rotational alignment between the surgical and non-surgical femur. Which of the following measurement(s) are considered acceptable differences in regards to femoral rotational malreduction after intramedullary nail fixation as compared to the uninjured femur?

Explanation

All of the above Corrent answer: 4
The maximum acceptable difference in rotational malreduction between the surgical and contralateral legs for femoral version is 15°. Therefore, answers 1 and 2 are correct.
Normal femoral neck anteversion is approximately 11-13°, with a normal range between 5-20°. The variation within the same patients can also be up to 15° difference between limbs. Current literature has shown that this 15° difference is well tolerated by patients, including when this has occured as a result of rotational malreduction following intramedullary nail fixation for a diaphyseal femur fracture.
Ayalon et al. aimed to compare the difference in femoral version (DFV) after intramedullary nailing performed by a trauma-trained and non-trauma trained surgeon. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. Post-operative version or percentage of DFV >15° did not significantly differ between these two groups.
Omar et al. studied the utility of pre-operative 'virtual reduction' of bilateral femoral fractures that were initially stabilized with external fixation. After external fixation, the mean rotational difference between both legs was 15.0°
± 10.2°. Following virtual reduction, the mean rotational difference between both legs was 2.1° ± 1.2°, after intramedullary nailing, compared to 6.1° ±

Question 56

A 74-year-old man has had worsening left shoulder pain for the past 3 years. Extensive nonsurgical management has provided only minimal relief. Examination reveals limitations in motion due to pain but good rotator cuff strength. Radiographs are shown in Figures 53a and 53b. What surgical procedure is most appropriate?

Explanation

DISCUSSION: The patient has end-stage shoulder arthritis with posterior glenoid erosion and large humeral osteophyte formation. Since the rotator cuff is likely intact, the reverse total shoulder arthroplasty is unnecessary. All the remaining procedures may provide symptomatic relief in appropriate patients; however, for most patients, total shoulder arthroplasty has been associated with the most predictive pain relief and functional improvements.
REFERENCES: Bryant D, Litchfield R, Sandow M, et al: A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder: A systemic review and meta-analysis. J Bone Joint Surg Am 2005;87:1947-1956.
Edwards TB, Kadakia NR, Boulahia A, et al: A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: Results of a multicenter study. J Shoulder Elbow Surg 2003;12:207-213.
Gartsman GM, Roddey TS, Hammerman SM: Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 2000;82:26-34.

Question 57

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Explanation

DISCUSSION: Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2 vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks, p=0.001). However, 15% had hardware and wound complications. At one year, the operative group was more likely to be satisfied with the shoulder in general (p=0.002) and the appearance of the shoulder in particular (p=0.001) in comparison to the nonoperative group.
Prior studies have shown that greater than 2cm of shortening treated non-operatively results in increased fatigueability and poor outcome, but not necessarily nonunion. The Lazarides article concluded that “Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result.”
Studies have shown no difference in outcome when treated with a Figure-of-8 harness compared to a simple sling

Question 58

What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum?

Explanation

DISCUSSION: All of the reorientation innominate osteotomies require a concentric reduction of the hip. The Staheli shelf procedure may be performed even with the hip subluxated, but it is a salvage procedure that covers a portion of the femoral head with capsular fibrocartilage rather than hyaline cartilage.
REFERENCES: Staheli LT, Chew DE: Slotted acetabular augmentation in childhood adolescence. J Pediatr Orthop 1992;12:569-580.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 618-650.

Question 59

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 60

A 30-year-old man presents with a distal third tibia fracture that has healed in 25 degrees of varus alignment. The patient is at greatest risk of developing which of the following conditions as a result of this malunion?

Explanation

CORRECT
DISCUSSION: A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

Question 61

A 29-year-old male sustained a mid-shaft femur fracture in a motor cycle accident. Even if asymptomatic, what additional radiographs must be obtained either preoperatively or intraoperatively before performing intramedullary nailing of the femoral shaft fracture?

Explanation

DISCUSSION: Ipsilateral femoral neck fractures are seen in 1-9% of femoral shaft fractures and the femoral neck must be properly imaged either preoperatively or intraoperatively in any patient with a femoral shaft fracture. Dedicated hip films, possibly including an internal rotation AP, should be obtained before entering the OR. Daffner et al reported that in 11 of 20 cases of combined femoral shaft and neck fractures, the initial preoperative radiographs did not demonstrate the femoral neck fracture. Intraoperative fluoroscopy should also be used to evaluate for a femoral neck fracture both before (to evaluate for unrecognized fx) and after (to evaluate for iatrogenic fx) IM nailing. Tornetta et al also describe using preoperative CT scans to evaluate for a femoral neck fracture and found that they were able to reduce the number of missed ipsilateral femoral neck fractures.

Question 62

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

Explanation

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

Question 63

A 36-year-old woman was injured in a train derailment. She has a significant open depressed skull fracture with active bleeding, a hemopneumothorax, and blood in the left upper quadrant and colic gutter by Focused Assessment with Sonography for Trauma (FAST) examination. Additionally, she has the pelvic injury seen on the CT scans in Figures 18a and 18b. The mortality rate for this patient approaches

Explanation

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.

J Trauma 1982;22:691-693.

Question 64

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Explanation

DISCUSSION: A closed mid-diaphyseal humerus fracture with a radial nerve palsy on presentation is not a contraindication to functional brace management.
Commonly accepted parameters for closed treatment include less than 30 degrees of varus angulation, 20 degrees of anterior/posterior angulation, and 3 cm of shortening. Operative indications are: associated vascular injuries, bilateral humeral shaft fractures, polytrauma patient (including paraplegia), segmental fractures, injury to the brachial plexus, pathological fractures, floating elbow, and floating shoulder.
The article by Rutgers and Ring found that proximal one-third oblique humeral shaft fractures had an unacceptably high 29% rate of nonunion treated with a functional brace.
The article by Sarmiento et al found a 97% rate of union, a radial nerve palsy incidence of 11%, and no contraindication to the use of functional braces in humeral shaft fractures associated with radial nerve palsy.
The review article by Defranco and Lawton states that 70% of these radial nerve injuries recover spontaneously. They note that it "seems reasonable, however, to consider surgical intervention (radial nerve exploration) between 4 and 6 months based on the patient’s clinical course."

Question 65

Video 1 shows a 20-year-old right-hand dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

Explanation

A 53-year-old woman is experiencing thumb weakness. She has a remote history of a wrist fracture treated with a cast. She cannot lift her thumb off of a table when her hand is lying flat, palm-down. What is the most appropriate course of treatment?
A. Abductor pollicis longus reconstruction with palmaris autograft
B. Extensor pollicis brevis repair
C. Extensor pollicis longus (EPL) repair
D. Extensor indicis proprius (EIP) to extensor pollicis longus tendon transfer
The EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.
15- Figure 1 is the clinical photograph of a very functional 17-year-old boy with cerebral palsy and quadriplegia. He has no active supination but has full passive supination. His ability to determine position and sensibility without visual input are good. Radiographs show no osseous malalignment. Which treatment can best improve this patient's function?
A. Physical therapy for supination strengthening
1- Figures 1 through 3 are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?

A. Observation only
B. Fluoroscopic-guided intralesional steroid injection followed by serial radiographs
C. Immediate curettage without bone grafting
D. Splint immobilization with curettage and possible grafting after the fracture has healed
This patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized.

Question 66

Figures 23a and 23b show the AP and lateral radiographs of the elbow of a 30-year-old professional pitcher. The pathology shown in these studies is most consistent with which of the following conditions?

Explanation

DISCUSSION: The radiographs show the osteophytic build-up of the posteromedial corner of the elbow that occurs with valgus extension overload in the pitching elbow. This is the result of excessive valgus forces during the acceleration and deceleration phases of throwing. These forces, coupled with medial elbow stresses, cause a wedging of the olecranon into the medial wall of the olecranon fossa. Valgus instability of the elbow may further stimulate osteophyte formation. Repetitive impact of a spur within the olecranon fossa may cause fragmentation and eventual formation of loose bodies.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Field LD, Savoie FJ: Common elbow injuries in sport. Sports Med 1988;26:193-205.
Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88.

Question 67

A 30-year-old patient has acetabular dysplasia and moderate secondary osteoarthrosis. Which of the following studies will best help predict the success of periacetabular osteotomy?

Explanation

DISCUSSION: Improvement in the appearance of the hip joint on functional radiographic evaluation (abduction/adduction views) has been shown to be predictive of outcome following joint preserving surgery. CT and MRI findings have not been shown to be predictive of outcome.
REFERENCE: Murphy S, Deshmukh R: Periacetabular osteotomy: Preoperative radiographic predictors of outcome. Clin Orthop 2002;405:168-174.

Question 68

A 25-year-old semiprofessional football player sustains a hyperextension injury to the left foot. He is unable to bear weight. Examination reveals tenderness along the midfoot with swelling and plantar ecchymosis. Radiographs are negative. What is the next step in evaluation of this patient?

Explanation

DISCUSSION: The patient has a suspected Lisfranc sprain based on the plantar ecchymosis. The first step in diagnosis is a dynamic radiographic study. This should include a physician-assisted midfoot stress examination or standing weight-bearing radiographs to evaluate for displacement. There is no evidence of compartment syndrome, and a bone scan, CT, and MRI are expensive tests that are not warranted.
REFERENCES: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.
Hunt SA, Ropiak C, Tejwani NC: Lisfranc joint injuries: Diagnosis and treatment. Am J Orthop 2006;35:376-385.

Question 69

A 14-year-old boy has an anteromedial distal thigh mass. A radiograph and MRI scan are shown in Figures 39a and 39b. An open biopsy of the mass should include

Explanation

DISCUSSION: Biopsy of the soft-tissue component is often diagnostic. Alternatively, in centers with pathologists familiar with bone tumors, needle biopsy is usually successful. The principles of biopsy of bone tumors include avoiding contamination of uninvolved structures and compartments, taking the most direct path to the tumors, making an excisable biopsy tract, and obtaining diagnostic tissue. Transverse biopsy incisions should be avoided because they hinder the definitive surgical procedure.
REFERENCES: Peabody TD, Simon MA: Making the diagnosis: Keys to a successful biopsy in children with bone and soft-tissue tumors. Orthop Clin North Am 1996;27:453-459.
Mankin HJ, Mankin CJ, Simon MA: The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am 1996;78:656-663.
Skrzynski MC, Biermann JS, Montag A, Simon MA: Diagnostic accuracy and charge-savings of outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors. J Bone Joint Surg Am 1996;78:644-649.

Question 70

A 16-year-old right-hand dominant male pitcher has had increasing pain in his dominant shoulder for the past 6 months without treatment. A coronal T2-weighted MRI scan is shown in Figure 80. What is the most appropriate treatment plan? Review Topic

Explanation

The coronal MRI scan shows an undersurface partial-thickness rotator cuff tear. Initial treatment for this injury should include complete cessation of throwing (or other overhead activities dependent on the athlete). Despite the duration of symptoms, he has had no treatment to date; therefore, nonsurgical management should include activity cessation, a rotator cuff and periscapular strengthening program, and then a slow and supervised return to throwing with particular attention to proper pitching mechanics. Decreasing the pitch count or continued play with observation risks progression of the problem. Surgical intervention is not indicated for initial treatment.

Question 71

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 72

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

Explanation

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

Question 73

A 20-year-old woman has lateral foot and ankle pain after sustaining an inversion injury of the ankle while playing soccer 3 months ago. Activity modifications and physical therapy have failed to provide relief. She describes burning pain that extends from the anterior aspect of the ankle to the foot and lateral two toes. The pain is often worse at night. Plain radiographs, a bone scan, and an MRI scan are normal. Stress examination reveals no instability. What is the most likely diagnosis?

Explanation

DISCUSSION: Persistent pain following an ankle sprain can present a diagnostic dilemma. All of the injuries listed should be considered in the differential diagnosis. The superficial peroneal nerve courses in the lateral compartment and exits the crural fascia 12 to 15 cm above the level of the ankle. Muscle herniation through the fascial defect has been reported to be associated with entrapment of this nerve. The fascial hiatus also may serve as a potential tether in cases of inversion injuries causing injury to the superficial peroneal nerve.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.
Baumhauer JF: Superficial peroneal nerve entrapment. Foot Ankle Clin 1998;3:439-446.

Question 74

A 42-year-old woman who has had an 18-month history of severe low back pain is referred to your office for surgical evaluation. She reports that the pain initially began with right lower extremity pain and management consisted of oral analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. She has seen a chiropractor as well as a pain management specialist and she is status-post epidural steroid injections. She has also completed exhaustive physical therapy, as she is a certified athletic trainer and runs a health fitness program at a community hospital. Currently, she denies lower extremity pain and her pain is isolated to her low back and is subjectively graded as 8/10, with 10 being the worst pain she has ever experienced. The pain is interfering with her activities of daily living and she is seeking definitive treatment. Figures 32a through 32c show current MRI scans. Based on the current available medical literature, what is the most appropriate treatment?

Explanation

DISCUSSION: The MRI scans reveal advanced degenerative disk disease at L5-S1. Nonsurgical management has failed to provide relief and the patient is quite debilitated as a result of her back pain. Fritzell and associates demonstrated that in a well-informed and selected group of patients with severe low back pain, lumbar fusion can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatments. In a recent updated Cochrane Review of surgery for degenerative lumbar spondylosis, it was noted that while Fritzell and associates appeared to provide strong evidence in favor of fusion, a more recent trial by Brox and associates demonstrated no difference between those patients undergoing lumbar fusion compared to those receiving cognitive intervention and exercise. The Cochrane Review suggests that this may reflect a difference between the control groups. Fritzell and associates compared lumbar fusion to standard 1990s “usual care,” whereas Brox and associates compared lumbar fusion to a “modern rehabilitation program.” Bear in mind that this patient is a certified athletic trainer and runs a hospital health fitness department; therefore, at least for purposes of this question, it can be assumed that she has participated in a “modern rehabilitation program.” The Cochrane Review goes on to state that preliminary results of three small trials of intradiskal electrotherapy suggest that it is ineffective and that preliminary data from three trials of disk arthroplasty do not permit firm conclusions.
REFERENCES: Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: Updated Cochrane Review. Spine 2005;30:2312-2320.
Fritzell P, Hagg O, Wessberg P, et al: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521-2532.
Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.

Question 75

What is the correct order of the elastic modulus of the following materials from greatest to least?

Explanation

DISCUSSION: In Young’s modulus of elasticity, E is a measure of the stiffness of a material and its ability to resist deformation. In the elastic region of the stress-stain curve, E = stress/strain. The moduli of elasticity for these materials are alumina ceramic = 380 Gigapascals (GPa), cobalt-chromium = 210 GPa, stainless steel = 190 GPa, titanium = 116 GPa, and PMMA = 1.1 to 4.1 GPa.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 182-215.
Brinker MR: Basic science section 8: Biomechanics and biomaterials, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 120-123.

Question 76

Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

Explanation

DISCUSSION: Evidence has shown that PNF is the treatment of choice to increase joint range of motion and flexibility. PNF has the advantage of pushing the patient to stretch a little further when the muscle tendon unit is relaxed by a partner. While isokinetic and eccentric exercises can improve flexibility, and therefore increase range of motion, their main purpose is to increase strength and endurance. Ballistic stretching involves a large load applied rapidly; however, evidence has shown that static stretching, where a low load is applied for a long duration, offers a more significant benefit.
REFERENCES: Sady SP, Wortman M, Blanke D: Flexibility training: Ballistic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 1982;63:261-263.
Tanigawa MC: Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Phys Ther 1972;52:725-735.
Wallin D, Ekblom B, Grahn R, Nordenberg T: Improvement of muscle flexibility: A comparison between two techniques. Am J Sports Med 1985;13:263-268.

Question 77

A 14-year-old patient who has homocystinuria and is Risser 3 is referred for surgical treatment of scoliosis. In addition to the usual risks associated with posterior spinal fusion, the family should be advised that the patient ‘s underlying condition significantly increases the perioperative risk of

Explanation

Tendency towards venous and arterial thrombosis along with mental retardation, dislocation of the lens and skeletal changes resembling Marfan’s are all clinical features of homocystinuria. Homocysteine is toxic and causes endothelial cell damage. Increased platelet stickiness is also associated with the disease.
1 and 2 are concerns during spinal fusion but are not specific to this disease. 4 may occur with homocystinuria but is not related to spinal fusion. 5 occurs with PSF in the younger population because of the growth potential remaining.

Question 78

A 25-year-old man is involved in a motor vehicle accident and brought to the emergency department at 4 am on Sunday morning. He has a closed distal third femoral shaft fracture. His leg is initially pulseless but after applying inline traction, a distal pulse can be palpated and the limb appears to be viable. The pulse in the injured limb “feels” different than the pulse in the uninjured limb. What is the next step in assessing the vascular status of this limb?

Explanation

DISCUSSION: The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations.
REFERENCES: Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index. Am J Emerg Med 2005;23:689-695.
Abou-Sayed H, Berger DL: Blunt lower-extremity trauma and politeal artery injuries: Revisiting the case for selective arteriography. Arch Surg 2002;137:585-589.
Mills WJ, Barei DP, McNair P: The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. J Trauma 2004;56:1261-1265.

Question 79

Which of the following structures are found in the anterior tarsal tunnel?

Explanation

DISCUSSION: The contents of the anterior tarsal tunnel are the extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, and the deep peroneal nerve. The term “anterior tarsal tunnel syndrome” is used to specifically describe the compression of the deep peroneal nerve under the inferior extensor retinaculum. With nerve compression, patients report a burning sensation across the dorsum of the foot with paresthesias in the first web space. There also may be wasting and weakness of the extensor digitorum brevis.
REFERENCES: Kuritz HM: Anterior entrapment syndromes. J Foot Surg 1976;15:143-148.
Sarrafian S: The Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 113-158.

Question 80

In the majority of patients with chronic anterior cruciate ligament (ACL)-deficient knees, analysis of the gait pattern during level walking will most likely reveal which of the following changes?

Explanation

DISCUSSION: Patients with chronic ACL-deficient knees typically have lower than normal net quadriceps activity during the middle portion of the stance phase; the net moment about the knee reverses from one that demands quadriceps activity to one that demands increased hamstring activity. This type of gait is termed “quadriceps avoidance.” This avoidance is believed to be a functional adaptation to reduce anterior tibial translation, and it is most prevalent as the knee moves from 45° of flexion toward full extension, the arc of motion through which the ACL is most responsible for stability.
REFERENCES: Hurwitz DE, Andriacchi TP, Bush-Joseph CA, Bach BR Jr: Functional adaptations in patients with ACL-deficient knees. Exerc Sport Sci Rev 1997;25:1-20.
Andriacchi TP, Birac D: Functional testing in the anterior cruciate ligament-deficient knee. Clin Orthop 1993;288:40-47.
Solomonow M, Baratta R, Zhou BH, et al: The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med 1987;15:207-213.

Question 81

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Explanation

Of the materials listed titanium (100GPa) has an elastic modulus closest to cortical bone (approximately 18GPa) as well as cancellous bone (approximately 2GPa).
Titanium is a material that is light, highly ductile, strong and corrosion resistant. However, titanium has poor wear resistance and is notch sensitive. It is commonly used as an orthopaedic implant materials because it has torsional and axial stiffness (moduli) that most closely mimics bone. Young’s modulus is constant and different for each material and represents the material's ability to maintain shape under external loading.
Rho et al found that the average Young's modulus for trabecular bone measured ultrasonically and mechanically was 14.8 GPa (S.D. 1.4) and 10.4 (S.D. 3.5), respectively. The average Young's modulus of microspecimens of cortical bone measured ultrasonically and mechanically was 20.7 GPa (S.D. 1.9) and 18.6 GPa (S.D. 3.5), respectively.
Illustration A depicts a stress vs. strain curve. The slope of the line in the elastic zone represents the Young Modulus of Elasticity.
Incorrect Answers:

Question 82

A 27-year-old man has recurrent anterior shoulder instability following an arthroscopic Bankart repair 4 years ago. Current CT scans are shown in Figures 19a and 19b. Deficiency of what mechanism is most likely to contribute to the current joint instability? Review Topic

Explanation

Loss of the anterior glenoid rim can commonly occur as a result of acute fracture or progressive wear following multiple dislocations. This decreases the effective depth of the glenoid. The ability of the rotator cuff to stabilize the joint through production of a joint reactive force is markedly decreased. Synovial fluid adhesion-cohesion and negative intra-articular pressure are maintained in the closed capsular space. The Hill-Sachs lesion in this case is not large enough to be a significant factor in failed Bankart repair. Poor scapulothoracic rhythm can increase the risk of instability but is not typically the primary factor.

Question 83

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

Explanation

DISCUSSION: Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).
REFERENCE: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 84

Figures 1 through 3 are the radiographs of a 27-year-old man who has had wrist pain since falling 1 day ago. Which treatment offers the best prognosis for prevention of carpal collapse and progressive arthritis?

Explanation

EXPLANATION:
Although this patient’s history includes a recent fall, the radiographs show evidence of a scaphoid nonunion with carpal collapse but no arthritis. Obtaining union of the scaphoid is important to prevent progressive carpal collapse and arthritic changes. ORIF with bone graft is most appropriate to obtain union and correct the collapse deformity. Screw fixation with volar wedge graft often is performed to realign a scaphoid humpback deformity, although cancellous bone graft also is a reasonable option. Vascularized bone graft is considered for a nonunion of long duration, avascular necrosis of the proximal pole, and failed prior surgery. Cast immobilization will not lead to union of the scaphoid. Percutaneous screw fixation is not indicated for the treatment of a displaced nonunion. A proximal
row carpectomy is a salvage procedure and is not indicated for this patient because there are no arthritic changes.

Question 85

A 15-year-old boy with epilepsy who is treated with phenytoin sustains a vertebral compression fracture during a breakthrough seizure. Radiographs of the spine reveal generalized osteopenia. What is the most likely cause of the osteopenia?

Explanation

DISCUSSION: As a side effect of treatment, phenytoin induces osteomalacia, or rickets, in growing children, through interference with metabolism of vitamin D. Oral supplementation of vitamin D can minimize this effect in patients who are undergoing prolonged treatment with phenytoin.
REFERENCE: Chung S, Ahn C: Effects of anti-epileptic drug therapy on bone mineral density in ambulatory epileptic children. Brain Dev 1994;16:382-385.

Question 86

Which of the following diagnostic studies best distinguishes Ewing’s sarcoma from small cell osteosarcoma?

Explanation

DISCUSSION: Cytogenetics best demonstrates the 11;22 translocation characteristic of Ewing’s sarcoma. The translocation also can be detected with polymerase chain reaction and fluorescent in situ hybridization. The Ewing antibody is used for immunostaining to check for cell membrane (surface) staining of a marker unrelated to the translocation; this could also help distinguish Ewing’s sarcoma from small cell osteosarcoma. A bone scan will show increased uptake with both types of tumors. Although most Ewing’s sarcoma tumors are diploid, some are polyploid as are most osteosarcomas. Flow cytometry is used to sort cells, sometimes based on antibody binding. LDH can be elevated in both Ewing’s sarcoma and osteosarcoma and is a poor prognostic indicator when elevated. Lymph node metastases are uncommon in both of these tumors.
REFERENCES: Perotti D, Corletto V, Giardini R, Parafioriti A, Fossati-Bellani F, Luksch R: Retrospective analysis of ploidy in primary osseous and extraosseous Ewing family tumors in children. Tumori 1998;84:493-498.
Riley RD, Burchill SA, Abrams KR, Heney D, Sutton AJ, Jones DR, et al: A systematic review of molecular and biological markers in tumours of the Ewing’s sarcoma family. Eur J Cancer 2003;39:19-30.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 11-20.

Question 87

Primary chondrosarcoma of bone most commonly occurs in which of the following locations?

Explanation

DISCUSSION: The most common location of chondrosarcoma is the pelvis (30%), followed by the proximal femur (20%) and shoulder girdle (15%). Chondrosarcoma rarely affects the spine or hand.
REFERENCES: Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome. J Bone Joint Surg Am 1999;81:326-338.
Simon M, Springfield D, et al: Chondrosarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 276.

Question 88

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

Explanation

Question 89

A 52-year-old woman slips in her bathroom and strikes her right hand on a cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in Figures 5a through 5c. What is the most appropriate treatment?

Explanation

DISCUSSION: Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 90

Following a radial nerve neurapraxia at or above the elbow, return of muscle function can be expected to start at the brachioradialis and return along which of the following progressions?

Explanation

DISCUSSION: Following a radial nerve neurapraxia above the elbow, muscle recovery can be expected in a predictable pattern. Although variations will occur, the return of function or reinnervation usually occurs in the following order: brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum comminus, extensor digiti minimi, extensor indicis proprious, extensor pollicis longus, abductor pollicis longus, and extensor pollicis brevis.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ,

Ciba-Geigy, 1991, vol 8, p 53.
Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA,

Harper and Row, 1982, vol 3, pp 428-429.

Question 91

Which of the following is not a reported mode of failure for a constrained acetabular component?

Explanation

DISCUSSION: There is no evidence of increased polyethylene wear in constrained acetabular components. The rates of wear appear to be the same using standard or constrained liners.
REFERENCES: Lachiewicz PF, Kelley SS: Constrained components in total hip arthroplasty. J Am Acad Orthop Surg 2002;10:233-238.
Anderson MJ, Murray WR, Skinner HB: Constrained acetabular components. J Arthroplasty 1994;9:17-23.
Fisher DA, Kiley K: Constrained acetabular cup disassembly. J Arthroplasty 1994;9:325-329.

Question 92

What is the goal of surgical treatment in this scenario?

Explanation

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 93

A teenage female is referred to you for evaluation of curvature in her back that was discovered on routine school screening. She is diagnosed with adolescent idiopathic scoliosis. In which of the following scenarios is a bracing program the most appropriate treatment? Review Topic

Explanation

Bracing is most appropriate for skeletally immature patients with a curve > 20/25 degrees. Thus the patient with a left upper thoracic curve of 15 degrees and right main thoracic curve of 30 degrees in Risser stage 1 of growth meets criteria.
The treatment of adolescent idiopathic scoliosis (AIS) depends on the magnitude and location of curve as well skeletal maturity of the patient. For curves less than 20 degrees, observation is appropriate until skeletal maturity, with closer intervals during
times of peak growth. Curves between 20-25 and 45 degrees in patients who are Risser stage 0,1 or 2 are best treated with bracing to stop progression. Curves with an apex at T7 or below are typically treated with a Boston brace. Curves over 50 degrees generally warrant a discussion about surgery to prevent progression past maturity.
In a landmark study, Weinstein et al. evaluated both a randomized and preference based cohort of bracing versus observation. The trial was stopped early due to efficacy of bracing. The rate of treatment success was 72% after bracing and 48% after observation. Treatment success was strongly correlated to time of brace wear.
Schlenzka et al. reviewed indications, treatment, and complications associated with brace treatment of AIS. They state that further evidence is necessary to evaluate the efficacy of bracing in AIS.
Figure 1, 2, and 3 are radiographs depicting Risser stage 0, 1, and 4 respectively. Illustration B shows radiographs of all Risser stages. Illustration C is the Lenke classification system for idiopathic scoliosis.
Incorrect Answers:

Question 94

A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm 3 (normal 3,500 to 10,500/ mm 3 ) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

Explanation

DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 95

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Explanation

DISCUSSION: Most lesions of eosinophilic granuloma are simply observed, but larger aggressive lesions may require curettage and bone grafting. Frequently, biopsy is required to rule out a malignant diagnosis. The differential diagnosis of eosinophilic granuloma is osteomyelitis, Ewing’s sarcoma of bone, or osteogenic sarcoma. The biopsy alone can be followed by spontaneous resolution. In some patients, low-dose radiation therapy is used. Chemotherapy or amputation is not indicated for these benign lesions.
REFERENCE: Simon M, Springfield D, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 200.

Question 96

A 69-year-old woman is seen in the emergency department with a bilateral C5-6 facet dislocation and complete quadriplegia after falling down a flight of stairs. After initial evaluation and treatment by the trauma service, she is moved to the intensive care unit. Examination reveals a blood pressure of 90/50 mm/Hg, a pulse rate of 50/min, a respiration rate of 12/min, and urine output of 1 mL/kg/h. Her hemodynamic status should be addressed by

Explanation

DISCUSSION: The patient’s heart rate is not responding to hypotension with tachycardia, as would be expected in the event of hypovolemic shock. Additionally, the adequate urine

output suggests proper fluid resuscitation. Instead, she is bradycardic, possibly indicating neurogenic shock and loss of sympathetic tone to the heart. A Swan-Ganz catheter should be used to help differentiate these problems and guide appropriate fluid resuscitation and use of vasopressor agents.
REFERENCES: Hadley MN: Management of acute spinal cord injuries in an intensive care unit or other monitored setting. Neurosurgery 2002;50:S51-S57.
Vaccaro AR, An HS, Betz RR, et al: The management of acute spinal trauma: Prehospital and in-hospital emergency care. Instr Course Lect 1997;46:113-125.

Question 97

During the implantation of a cementless acetabular component in total hip arthroplasty, placement of a screw in the anterior superior quadrant puts which of the following structures at risk for damage?

Explanation

DISCUSSION: A knowledge of the safe quadrants for screw placement for acetabular component implantation is essential when performing total hip arthroplasty. The external iliac vessels are on the inner wall of the pelvis, corresponding to the anterior superior quadrant of the acetabulum.
REFERENCES: Keating EM, Ritter MA, Faris PM: Structures at risk from medially placed acetabular screws. J Bone Joint Surg Am 1990;72:509-511.
Wasielewski RC, Cooperstein L, Kruger MP, Rubash HE: Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am

1990;72:501-508.

Question 98

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include

Explanation

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 99

Acral metastases are most commonly seen in what type of carcinoma?

Explanation

DISCUSSION: Metastatic lesions to bone are usually located in the axial and proximal appendicular skeleton. Metastases below the elbow and knee are rare, but when they do occur they are most commonly from lung carcinoma.
REFERENCES: Hayden RJ, Sullivan LG, Jebson PJ: The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004;20:335-343.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 313.

Question 100

Video 1 depicts a 20-year-old right-hand-dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

Explanation

EXPLANATION:
Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Full Question & Answer Text (for Search Engines)

Question 1:

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

Options:

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

Correct Answer: Extension and axial load

Explanation:

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

Question 2:

Options:

Osteogenic sarcoma
Ewing’s sarcoma
Giant cell tumor of bone
Aneurysmal bone cyst
Metastatic adenocarcinoma

Correct Answer: Giant cell tumor of bone

Explanation:

Question 3:

Options:

Physical therapy to improve hip stability
Use of an abduction brace to limit the patient’s range of motion
Conversion to a constrained acetabular liner
Cobalt and chromium serum metal ion level testing

Correct Answer: Cobalt and chromium serum metal ion level testing

Explanation:

Question 4:

Which of the following treatments of polyethylene results in the highest amount of oxidative degradation?

Options:

Ethylene oxide sterilization
Gamma irradiation in air
Gamma irradiation in an inert environment
Gamma irradiation followed by cross-linking
Gas plasma sterilization

Correct Answer: Gamma irradiation in air

Explanation:

Question 5:

Options:

an extra-depth shoe with an accommodative orthosis.
surgical debridement and metatarsal head resection.
posterior tibial tendon transfer through the interosseous membrane.
Achilles tendon lengthening and total contact casting.
hyperbaric oxygen therapy.

Correct Answer: Achilles tendon lengthening and total contact casting.

Explanation:

Question 6:

An axillary nerve lesion may cause weakness in the deltoid and the

Options:

teres major.
teres minor.
teres major and teres minor.
latissimus dorsi.
latissimus dorsi and teres major.

Correct Answer: teres minor.

Explanation:

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 7:

Options:

Cast immobilization and no weight bearing for 4 to 8 weeks
Immobilization in a walking cast for 4 to 8 weeks
Hard-soled shoe for 4 to 8 weeks
Sesamoid bone grafting
Medial sesamoidectomy

Correct Answer: Medial sesamoidectomy

Explanation:

Question 8:

Options:

application of a neck brace for 6 to 12 weeks.
revision anterior diskectomy and interbody fusion with autograft at C5-6.
revision anterior diskectomy with interbody autograft and anterior plate fixation at C5-6.
posterior fusion at C5-6.
posterior foraminotomy at left C6 and posterior fusion at C5-6 with stabilization and autograft.

Correct Answer: posterior foraminotomy at left C6 and posterior fusion at C5-6 with stabilization and autograft.

Explanation:

DISCUSSION: Brodsky and associates reviewed 34 cases of cervical pseudarthrosis after anterior fusion. Seventeen were treated with revision anterior fusion and 17 with posterior foraminotomy and fusion. Good results were seen in 75% of patients who underwent revision anterior surgery, but better results (94%) were seen with posterior surgery, including foraminotomy and stabilization. Tribus and associates reported treatment of 16 patients with pseudarthrosis using revision anterior debridement of the fibrous tissue and fusion with autograft and plates. There was improvement of the neck in 75% of the patients, nonunion in 19%, continued weakness in 28%, and dysphagia in 5%. Farey and associates reported on 19 patients treated with posterior foraminotomy, stabilization, and fusion with a fusion rate of 100%, resolution of arm pain in 94%, resolution of weakness in 100%, and resolution of neck pain in 75%. It would appear that posterior foraminotomy is more effective for relieving arm pain and neurologic deficits associated with pseudarthrosis. Posterior fusion has the most reliable rate of arthrodesis in this setting. Dysphagia is reported in some patients undergoing more extensive anterior dissections required for applying plates. A neck brace is unlikely to aid in healing of pseudarthrosis in a patient who underwent surgery 8 months ago. A neck brace would be most effective within the first 3 months if a delayed union is identified.
REFERENCES: Brodsky AE, Khalil MA, Sassard WR, Neuman BP: Repair of symptomatic pseudarthrosis of anterior cervical fusion: Posterior versus anterior repair. Spine
1992;17:1137-1143.
Tribus CB, Corteen DP, Zdeblick TA: The efficacy of anterior cervical plating in the management of symptomatic pseudarthrosis of the cervical spine. Spine 1999;24:860-864.
Farey ID, McAfee PC, Davis RF, Long DM: Pseudarthrosis of the cervical spine after anterior arthrodesis: Treatment by posterior nerve root decompression, stabilization, and arthrodesis.
J Bone Joint Surgery Am 1990;72:1171-1177.

Question 9:

- The Injury Severity Score (ISS), using point scores from five different body systems, is a method that aids in predicting the chances of mortality in a patient with multiple injuries by

Options:

adding the scores, in all five body systems
adding the squares of the scores in the three most severely injured systems
doubling the cumulative score for head and chest injuries
combining the scores from the most and least injured systems
correcting the score in the most severely injured system for age

Correct Answer: adding the squares of the scores in the three most severely injured systems

Explanation:

Question 10:

Figures 11a and 11b show the clinical photograph and radiograph of a newborn. Based on these findings, what is the best course of action?

Options:

Genetic testing
Stretching exercises performed by the parents
A series of corrective plaster casts
A long leg orthosis to control the foot and leg
Surgical lengthening of the anterior tibial tendon and a short leg cast

Correct Answer: Stretching exercises performed by the parents

Explanation:

Question 11:

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Options:

Atrial fibrillation
Seizures
Urinary retention
Muscle weakness
Hyperreflexia

Correct Answer: Muscle weakness

Explanation:

Question 12:

Options:

Contrast CT of the hand and wrist
MRI of the hand and wrist
Contrast angiography of the involved upper extremity
Digital subtraction angiography
Single-shot fluoroscopic angiography

Correct Answer: Contrast angiography of the involved upper extremity

Explanation:

Question 13:

Options:

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

Correct Answer: 50 degrees of plantar flexion

Explanation:

Question 14:

What is the most common cause for late revision (> 2 years post op) total knee arthroplasty?

Options:

Infection
Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Polyethylene wear

Explanation:

Question 15:

Options:

rotator cuff interval closure.
distal clavicle excision.
superior labrum anterior and posterior repair.
biceps tenodesis.
thermal capsulorrhaphy.

Correct Answer: distal clavicle excision.

Explanation:

Question 16:

An otherwise healthy 13-year-old boy sustains the fracture shown in Figure 40 while throwing a fastball. Management should consist of

Options:

an arm sling.
functional bracing supporting the humerus and arm.
closed reduction and a shoulder spica cast.
open reduction and internal fixation with retrograde rods.
open reduction and internal fixation with a rigid plate and screws.

Correct Answer: functional bracing supporting the humerus and arm.

Explanation:

Question 17:

Options:

07 Semmes-Weinstein monofilament
Bone scan
Thompson’s test
CT
Noninvasive vascular studies

Correct Answer: Noninvasive vascular studies

Explanation:

Question 18:

Options:

Biceps tenodesis
Superior labrum anterior to posterior (SLAP) repair
Rotator cuff repair
Distal clavicle excision The patient has a clinical history and physical examination consistent with degenerative superior labral pathology, which is supported by the MRI scan. She has failed appropriate nonoperative treatment, and surgical intervention would be indicated. In a middle-aged patient with a degenerative superior labral tear, biceps tenodesis has been shown to have better outcomes and return to sport than SLAP repair. In a young patient with a traumatic superior labral tear, repair would be indicated. The other MRI findings noted are incidental and asymptomatic in this patient. As a result, rotator cuff repair or distal clavicle excision is not indicated.

Correct Answer: Biceps tenodesis

Explanation:

Question 19:

Options:

rest and a sling for 3 to 6 weeks.
physical therapy with modalities for pain relief.
pain medication and activity as tolerated.
open reduction and internal fixation.
coracoid excision.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 20:

Implants composed of polylactic acid are excreted by what system after they are absorbed?

Options:

Hepatic
Renal
Respiratory
Gastrointestinal

Correct Answer: Respiratory

Explanation:

Question 21:

Options:

Vitamin A deficiency
Low serum testosterone
Low serum thyroxine
Vitamin D deficiency
Hypocalcemia

Correct Answer: Vitamin A deficiency

Explanation:

Question 22:

Options:

Posterolateral herniated nucleus pulposus at L3-4
Posterolateral herniated nucleus pulposus at L4-5
Degenerative disk disease at L3-4 and L4-5 with no significant facet hypertrophy
Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis
Degenerative spondylolisthesis at L4-5 with central stenosis

Correct Answer: Degenerative spondylolisthesis at L3-4 with central and foramenal stenosis

Explanation:

Question 23:

Options:

Surgical traction for 6 weeks followed by application of a cast brace
Application of a femoral cable plate
Femoral revision with a cemented long stem prosthesis
Application of cerclage wired double allograft femoral struts
Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Correct Answer: Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Explanation:

Question 24:

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Options:

4 to 6 pins with an insertional torque of 1 to 5 in-lb
4 to 6 pins with an insertional torque of 4 to 6 in-lb
4 to 6 pins with an insertional torque of 6 to 8 in-lb
8 to 12 pins with an insertional torque of 1 to 5 in-lb
8 to 12 pins with an insertional torque of 4 to 6 in-lb

Correct Answer: 8 to 12 pins with an insertional torque of 1 to 5 in-lb

Explanation:

Question 25:

Options:

Chondroblastoma
Lymphoma
Giant cell tumor
Chondromyxoid fibroma
Desmoplastic fibroma

Correct Answer: Giant cell tumor

Explanation:

Question 26:

Options:

radiation therapy.
bisphosphonate therapy.
antitubercular therapy.
parathyroidectomy.
a diet low in phosphate.

Correct Answer: radiation therapy.

Explanation:

Question 27:

Options:

Excision medial to the costoclavicular ligament
Excision lateral to the costoclavicular ligament
Excision of the coracoclavicular ligaments and lateral clavicle
Excision of the coracohumeral ligaments
Leaving the costoclavicular ligament intact

Correct Answer: Excision lateral to the costoclavicular ligament

Explanation:

Question 28:

Which of the following changes in the parameters of the gait cycle occurs in the transition from normal walking to running?

Options:

Increased time in stance and swing phase
Addition of a double leg float phase
Decreased vertical ground reaction forces
Decreased arc of motion in the hip, knee, and ankle
Decreased joint reaction forces in the hip, knee, and ankle

Correct Answer: Addition of a double leg float phase

Explanation:

The same basic mechanisms that have been described for the biomechanics of the foot and ankle are not significantly altered during running. The major differences observed during running are that the gait cycle is altered considerably; the amount of force generated, as measured by force plated data, is markedly increased; the range of motion of the joints of the lower extremities is increased; and the phasic activity of the muscles of the lower extremities is altered. During walking one foot is always in contact with the ground; as the speed of gait increases a float phase incorporated into the gait cycle, during which time both feet are off the ground. There also is no longer a period of double limb support. As the speed of gait continues to increase, the time the foot spends on the ground, both in real time and in percentage of cycle, decreases considerably.
Question 71 -
Examination of a 5-year-old child who has fibular hemimelia reveals the foot has two rays and is stiff in equinus and valgus. The level of the foot is just proximal to the midshaft of the contralateral tibia, and the knee has full active flexion and extension, but slight valgus. Treatment should include
Amputation through the midshaft of the tibia
Correction of the foot deformity and lengthening with a ring fixator
Knee disarticulation
Ankle disarticulation
Ankle disarticulation and contralateral epiphyseodesis of the proximal tibia Answer: 4
Congenital absence of the fibula, also called fibula hemimelia, has several manifestations. These range from complete absence of the fibula with missing lateral rays of the foot (i.e. terminal longitudinal deficiency) to absence of only a portion of the fibula without foot involvement (i.e. intercalary longitudinal; deficiency). Congenital fibular deficiency usually occurs sporadically without a known cause. The child with complete absence of the fibula presents clinically with an anterolateral bow of the tibia, an equinovalgus deformity of the foot, and a tarsal coalition. The talotibial joint is usually malformed, with the fused talocalcaneus having a flat upper surface that articulates with the tibia in a valgus and equinus position. The foot may be missing one or two lateral rays. There is always significant shortening of the epsilateral femur. Treatment: There is a reasonable consensus that complete fibular hemimelia is best treated by performing an ankle disarticulation in early childhood and fitting a Syme-type prosthesis. Children with lesser (<5cm) at birth may be a candidate for lengthening procedures, but the exact indications and results of these procedures have not been well defined. Children with large discrepancies (>5cm) at birth and those with major foot deformities are better managed with amputation.

Question 29:

Which of the following therapies has a direct anabolic effect on bone?

Options:

Bisphosphonates
Tumor necrosis factor-a (TNF-a) inhibitors
Calcitonin
Intermittent PTH
Corticosteroids

Correct Answer: Intermittent PTH

Explanation:

Question 30:

Options:

casting with an external bone stimulator.
ankle arthrodesis.
revision subtalar arthrodesis.
conversion to triple arthrodesis without revision of the subtalar arthrodesis.
conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Correct Answer: conversion to triple arthrodesis with revision of the subtalar arthrodesis.

Explanation:

Question 31:

Which nerve is most commonly injured after total knee arthroplasty?

Options:

Tibial nerve
Superficial peroneal nerve
Infrapatellar branch of the saphenous
nerve 52
Sartorial branch of the saphenous nerve

Correct Answer: Infrapatellar branch of the saphenous

Explanation:

DISCUSSION
The tibial or peroneal nerves usually are not injured during total knee arthroplasty. Incidence of peroneal nerve damage is highest in knees with a valgus deformity and an associated flexion contracture attributable to nerve stretch. This nerve injury occurs in as many as 9% of patients undergoing knee arthroplasty. Tibial nerve injury is a rare occurrence and usually an iatrogenic transection injury. The infrapatellar branch of the saphenous nerve and its nerve plexus is commonly injured after the medial parapatellar approach, and altered sensation attributable to injury is reported in up to 70% of cases. Injury typically manifests as numbness inferior to the patella. The sartorial branch of the saphenous nerve provides sensation distal to the knee and is uncommonly injured with a medial parapatellar approach. These concepts are illustrated in video 57, “Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition.”
RECOMMENDED READINGS
Clarke HD, Bush-Joseph CA, Wolf BR. Selective Exposures in Orthopaedic Surgery: The Knee, 2nd Edition [DVD]. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2012.
Hunter LY, Louis DS, Ricciardi JR, O'Connor GA. The saphenous nerve: its course and importance in medial arthrotomy. Am J Sports Med. 1979 Jul-Aug;7(4):227-30. PubMed PMID: 474860.
View Abstract at PubMed
Mistry D, O'Meeghan C. Fate of the infrapatellar branch of the saphenous nerve post total knee arthroplasty. ANZ J Surg. 2005 Sep;75(9):822-4. PubMed PMID: 16174002.
View Abstract at PubMed
Schinsky MF, Macaulay W, Parks ML, Kiernan H, Nercessian OA. Nerve injury after primary total knee arthroplasty. J Arthroplasty. 2001 Dec;16(8):1048-54. PubMed PMID: 11740762.
View Abstract at PubMed

Question 32:

Options:

2 cm distal to the articular surface of the radial head
1 cm distal to the articular surface of the radial head
Within a 90-degree arc or safe zone
Within a 120-degree arc or safe zone
Within a 180-degree arc or safe zone

Correct Answer: Within a 90-degree arc or safe zone

Explanation:

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 33:

Options:

Physical therapy with electrical stimulation and iontophoresis
Corticosteroid injection
MRI of the shoulder
Electromyography (EMG) of the arm

Correct Answer: MRI of the shoulder

Explanation:

Question 34:

-T1-weighted, fat-saturated MRI scans are shown in Figures 37a and 37b. What is the next step intreatment?

Options:

Open reduction internal fixation (ORIF)
Rotator cuff repair
Labrum repair
Chondroplasty

Correct Answer: Labrum repair

Explanation:

DISCUSSION FOR QUESTIONS 37 AND 38
Examination findings of posterior glenohumeral tenderness, decreased internal rotation, and reproduction of symptoms with a posterior stress test indicate a posterior shoulder injury or instability. The jerk test,with the patient seated, positions the arm in forward flexion and internal rotation with elbow flexion. One hand of the examiner is placed on the patient’s distal clavicle and scapular spine and the other hand grasps the elbow. The arm is jerked posteriorly while the shoulder girdle is jerked anteriorly, which creates pain as the posteriorly subluxated humeral head relocates into the glenoid fossa. During the Kim test, the patient is seated with the arm in 90 degrees of abduction. While the arm is elevated 45 degrees diagonally (forward flexion and adduction), the examiner applies an axial load to the elbow and a downward and posterior force to the upper arm. A positive result causes a sudden onset of posterior shoulder pain. A positive jerk test combined with a positive Kim test has a 97% sensitivity for posterior instability. After extensive PT, the patient continues to have examination findings consistent with posterior shoulder injury or instability, so an MRI scan or MRI arthrography would be helpful to assess for any pathology.A subacromial injection is not indicated by this examination, which shows a strong rotator cuff and no demonstrated bursal-sided symptoms. A CT scan can be helpful in scenarios involving bony pathology,but an MRI is indicated at this stage in the evaluation of soft tissue. Although continuing PT may help to abate symptoms, the patient was continuing to have symptoms with PT. The MRI arthrogram shows a complex posterior labrum tear at the inferior to mid glenoid with separation of labrum from the glenoid. Because the examination findings are consistent with the MRI findings and nonsurgical treatment has failed to resolve symptoms, the next step is to recommend surgical treatment with labrum debridement and/or repair. No examination or MRI findings indicate a need for injection, rotator cuff repair, ORIF, or chondroplasty unless incidental intrasurgical findings are found.

Question 35:

Options:

Positive impingement sign
Positive apprehension
Positive active compression
Weakness of external rotation
Weakness of abduction

Correct Answer: Weakness of external rotation

Explanation:

Question 36:

- A patient sustained a joint depression-type fracture of the calcaneus that healed despite lack of treatment. The loss of dorsiflexion the patient is now experiencing is most likely the result of

Options:

widening and shortening of the heel.
weakness of the gastrocnemius-soleus complex.
anterior impingement from a horizontal talus.
unrecognized compartment syndrome of the foot.
degenerative arthritis of the tibiotalar joint.

Correct Answer: anterior impingement from a horizontal talus.

Explanation:

Question 37:

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Options:

early motion and muscle strengthening.
immobilization in a thumb spica cast with the thumb abducted.
open reduction and internal fixation through a volar approach.
open reduction and internal fixation through a dorsal approach.
closed reduction and percutaneous pin fixation.

Correct Answer: open reduction and internal fixation through a dorsal approach.

Explanation:

Question 38:

Options:

a long leg cast.
a short leg cast.
immediate open reduction and internal fixation.
a temporizing spanning external fixator.
primary ankle fusion.

Correct Answer: a temporizing spanning external fixator.

Explanation:

DISCUSSION: Although this is a fracture of the medial and lateral malleoli, the degree of displacement and comminution of the medial dome indicate that this injury is similar to a pilon fracture. Initial management should consistent of stabilization to allow for soft-tissue healing. The use of temporizing spanning external fixation should be the initial step, followed by limited or more extensive open reduction and internal fixation when the soft-tissue status will allow. Initial placement in either a short or long leg cast does not provide the needed stability and does not allow for care and monitoring of soft tissues. In addition, maintaining reduction of the talus may be very difficult. Immediate open reduction and internal fixation through an injured soft-tissue envelope adds the risk of difficulties with incision healing and a higher risk of deep infection. In the acute setting, a primary ankle fusion through this soft-tissue envelope is
not indicated.
REFERENCES: Marsh JL, Bonar S, Nepola JV, et al: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.
Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.

Question 39:

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Options:

Better clinical outcomes
Less blood loss
Less pseudarthrosis risk
Lower revision surgery rate

Correct Answer: Less blood loss

Explanation:

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899.
View Abstract at PubMed
Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053.
View Abstract at
PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 40:

Accurate evaluation of the upper portion of the subscapularis muscle is best accomplished with active internal rotation

Options:

in adduction and the arm in external rotation.
in adduction and the arm in neutral rotation.
with the dorsum of the hand on the buttocks.
with the dorsum of the hand on the midlumbar level.
with the palm of the hand pressing against the belly.

Correct Answer: with the palm of the hand pressing against the belly.

Explanation:

Question 41:

Following its exit from the sciatic notch, the sciatic nerve passes between what two muscles?

Options:

Piriformis and superior gemellus
Superior gemellus and obturator internus
Inferior gemellus and quadratus femoris
Gluteus medius and minimus
Quadratus femoris and gluteus maximus

Correct Answer: Piriformis and superior gemellus

Explanation:

DISCUSSION: Though anatomic variations exist, both divisions of the sciatic nerve most commonly pass between the piriformis and superior gemellus. This anatomic consideration is relevant during the posterior approach to the hip, where careful retraction of the rotators avoids sciatic nerve injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 335-348.
Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams & Williams,
1978, Figure 4-34.
FOR ALL MCQS CLICK THE LINK ORTHO
MCQ BANK

Question 42:

Options:

resection of the metatarsal heads of the first through fifth toes.
Silastic MP joint arthroplasties of the first through fifth toes.
fusion of the hallux MP joint and resection arthroplasty of the 2 nd through fifth metatarsal heads.
fusion of hallux MP joint and distal osteotomy of the 2 nd through 5 th MT.
plantar condylectomy of the 2 nd through 5 th MT heads & resection of proximal phx of the hallux.

Correct Answer: fusion of the hallux MP joint and resection arthroplasty of the 2 nd through fifth metatarsal heads.

Explanation:

Question 43:

When compared to smokers who do not quit, an improvement in the rate of lumbar fusion is seen in patients who cease smoking for at least how many months postoperatively?

Options:

1 month
2 months
4 months
6 months
12 months

Correct Answer: 6 months

Explanation:

DISCUSSION: The effects of cigarette smoking and smoking cessation on spinal fusion have been studied extensively. Although permanent smoking cessation is ideal, significant improvements in fusion rates are seen in patients who avoid smoking for greater than 6 months postoperatively.
REFERENCE: Glassman SD, Anagnost SC, Parker A, et al: The effect of cigarette smoking and smoking cessation on spinal fusion. Spine 2000;25:2608-2615.

Question 44:

A B Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

Options:

Axial load
Rotation
Extension
Distraction

Correct Answer: Distraction

Explanation:

Question 45:

What structure provides the major blood supply to the humeral head?

Options:

Posterior circumflex humeral artery
Anterior circumflex humeral artery, ascending branch
Nutrient humeral artery
Thoracoacromial artery, deltoid branch
Small arteries of the rotator cuff insertions

Correct Answer: Anterior circumflex humeral artery, ascending branch

Explanation:

DISCUSSION: The ascending branch of the anterior circumflex humeral artery provides
the major blood supply to the humeral head. The posterior circumflex humeral artery
supplies a much smaller portion of the proximal humerus. The nutrient humeral artery is the main blood supply for the humeral shaft. The thoracoacromial artery is primarily a muscular branch. The rotator cuff insertions contribute some blood supply to the tuberosities but not a major contribution.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Cushner MA, Friedman RJ: Osteonecrosis of the humeral head. J Am Acad Orthop Surg 1997;5:339-346.

Question 46:

Options:

Open reduction internal fixation (ORIF)
Sling immobilization in external rotation
Bristow-Latarjet
Shoulder hemiarthroplasty The patient has sustained a displaced lesser tuberosity fracture with medial displacement following a posterior shoulder dislocation. Nonoperative management would risk long-term loss of normal subscapularis function, as well as anterior shoulder instability. An ORIF of lesser tuberosity is recommended. The current radiographs do not demonstrate any obvious compromise of glenoid bone stock that would necessitate a coracoid transfer. The humeral head is not compromised; therefore, a hemiarthroplasty is not indicated. Correct answer : A 57 76- A 51-year-old man sustains the injury shown in the MRI scan in Figures 1 and 2 following a fall. After a thorough discussion regarding risks and benefits, he elects to proceed with surgery. What is the most appropriate surgical treatment for his fracture?
Open reduction internal fixation with locking plate
Intramedullary (IM) nail
Hemiarthroplasty
Closed reduction and percutaneous pinning The patient has sustained a complex proximal humerus fracture with head split component and multiple articular fragments. When the articular surface is significantly compromised, arthroplasty procedures are favored. The only procedure listed that addresses the damaged humeral head is hemiarthroplasty, making it the correct response. Although a possible option, ORIF would be difficult due to the fragmented humeral head, and there would be a high risk for fracture collapse or avascular necrosis. IM nailing will not provide enough control of the fracture pieces, nor will it replace the damaged articular surface. Closed reduction is not an option given the complex nature of the fracture.

Correct Answer: Bristow-Latarjet

Explanation:

Question 47:

Options:

CT scan
Repeat period of immobilization
Referral to pain management for sympathetic blocks
Continued observation and physical therapy
Acupuncture

Correct Answer: CT scan

Explanation:

Question 48:

From which artery does the princeps pollicis artery branch?

Options:

Dorsal radial carpal artery
Dorsal ulnar carpal artery
Ulnar artery
Radial artery

Correct Answer: Radial artery

Explanation:

DISCUSSION
The princeps pollicis artery can be located on the palmar aspect of the adductor pollicis and emerges into the subcutaneous tissue at the thumb metacarpophalangeal flexion crease. It branches from the radial artery just distal to the location of the deep palmar arch.
RECOMMENDED READINGS
Coleman SS, Anson B: Arterial patterns in the hand based on a study of 650 specimens. Surg Gynec Obstet 1961;4:409-424.
Ames EL, Bissonnette M, Acland R, Lister G, Firrell J. Arterial anatomy of the thumb.
78
J Hand Surg Br. 1993 Aug;18(4):427-36. PubMed PMID: 8409651.
View Abstract at
PubMed

Question 49:

Options:

low-dose radiation
steroid injection
a load-relieving insert and shoe modification
complete excision of the mass and the entire plantar fascia
wide excision of the mass with a 2 cm margin of normal fascia

Correct Answer: a load-relieving insert and shoe modification

Explanation:

Question 50:

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

Options:

Popliteal tendon
Ligament of Humphrey
Anterior cruciate ligament
Posterior cruciate ligament
Lateral gastrocnemius tendon

Correct Answer: Posterior cruciate ligament

Explanation:

Question 51:

Options:

Systolic blood pressure > 120
Heart rate between 60-100
Urine output equals 0.4 cc/kg/hr
Gastric intramucosal pH of 7.4
Normal mentation

Correct Answer: Systolic blood pressure > 120

Explanation:

Question 52:

Options:

Decreased joint penetration of distal screws
Increased rigidity
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation

Correct Answer: Decreased joint penetration of distal screws

Explanation:

Question 53:

Decreased activity of which of the following proteins may be predictive of an aggressive soft-tissue sarcoma?

Options:

Matrix metalloproteinases (MMP)
Interleukin-1
Vascular endothelial growth factor
Tissue inhibitor of metalloproteinases (TIMP)
Stromelysin

Correct Answer: Tissue inhibitor of metalloproteinases (TIMP)

Explanation:

Question 54:

A 16-year-old high school football player sustains an injury to the left hip. The avulsed fragment identified by the arrow in Figure 34 represents the origin of which of the following structures?

Options:

Ischiofemoral ligament
Pubofemoral ligament
Rectus femoris
Sartorius
Gluteus minimus

Correct Answer: Rectus femoris

Explanation:

Question 55:

Options:

9 degrees internal rotation
14 degrees external rotation
18 degrees internal rotation

Correct Answer: 9 degrees internal rotation

Explanation:

All of the above
Corrent answer: 4
The maximum acceptable difference in rotational malreduction between the surgical and contralateral legs for femoral version is 15°. Therefore, answers 1 and 2 are correct.
Normal femoral neck anteversion is approximately 11-13°, with a normal range between 5-20°. The variation within the same patients can also be up to 15° difference between limbs. Current literature has shown that this 15° difference is well tolerated by patients, including when this has occured as a result of rotational malreduction following intramedullary nail fixation for a diaphyseal femur fracture.
Ayalon et al. aimed to compare the difference in femoral version (DFV) after intramedullary nailing performed by a trauma-trained and non-trauma trained surgeon. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. Post-operative version or percentage of DFV >15° did not significantly differ between these two groups.
Omar et al. studied the utility of pre-operative 'virtual reduction' of bilateral femoral fractures that were initially stabilized with external fixation. After external fixation, the mean rotational difference between both legs was 15.0°
± 10.2°. Following virtual reduction, the mean rotational difference between both legs was 2.1° ± 1.2°, after intramedullary nailing, compared to 6.1° ±

Question 56:

Options:

Arthroscopic removal of osteophytes and soft-tissue release
Soft-tissue interpositional arthroplasty
Reverse total shoulder arthroplasty
Hemiarthroplasty
Total shoulder arthroplasty

Correct Answer: Total shoulder arthroplasty

Explanation:

DISCUSSION: The patient has end-stage shoulder arthritis with posterior glenoid erosion and large humeral osteophyte formation. Since the rotator cuff is likely intact, the reverse total shoulder arthroplasty is unnecessary. All the remaining procedures may provide symptomatic relief in appropriate patients; however, for most patients, total shoulder arthroplasty has been associated with the most predictive pain relief and functional improvements.
REFERENCES: Bryant D, Litchfield R, Sandow M, et al: A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder: A systemic review and meta-analysis. J Bone Joint Surg Am 2005;87:1947-1956.
Edwards TB, Kadakia NR, Boulahia A, et al: A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: Results of a multicenter study. J Shoulder Elbow Surg 2003;12:207-213.
Gartsman GM, Roddey TS, Hammerman SM: Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 2000;82:26-34.

Question 57:

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Options:

Sling immobilization
Displacement and comminution
Age less than 40 years old
Immediate motion exercises
Male

Correct Answer: Sling immobilization

Explanation:

Question 58:

What acetabular procedure for developmental dysplasia of the hip does not require a concentric reduction of the femoral head in the acetabulum?

Options:

Salter innominate osteotomy
Pemberton innominate osteotomy
Dega innominate osteotomy
Triple innominate osteotomy
Staheli shelf procedure

Correct Answer: Staheli shelf procedure

Explanation:

DISCUSSION: All of the reorientation innominate osteotomies require a concentric reduction of the hip. The Staheli shelf procedure may be performed even with the hip subluxated, but it is a salvage procedure that covers a portion of the femoral head with capsular fibrocartilage rather than hyaline cartilage.
REFERENCES: Staheli LT, Chew DE: Slotted acetabular augmentation in childhood adolescence. J Pediatr Orthop 1992;12:569-580.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 618-650.

Question 59:

Options:

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

Correct Answer: HLA-B27

Explanation:

Question 60:

Options:

Degenerative lumbar spine changes
Ipsilateral ankle pain and stiffness
Ipsilateral hip joint degenerative changes
Contralateral hip joint degenerative changes
Ipsilateral medial knee degenerative changes

Correct Answer: Degenerative lumbar spine changes

Explanation:

CORRECT
DISCUSSION: A significant malunion of the distal tibia has important consequences for patient outcome, including pain, gait changes, and cosmesis.
The first referenced article by Milner et al looked at long-term outcomes of tibial malunions and noted that varus malunion led to increased ankle/subtalar stiffness and pain regardless of the amount of radiographic degenerative changes.
The second referenced article by Puno et al reinforced the concept of decreased functional outcomes of the ankle with tibial malunions, and noted that other lower extremity joints (ipsilateral and contralateral) do not have increased rates of degeneration from such a malunion.

Question 61:

Options:

ipsilateral foot/calcaneus
ipsilateral hip
contralateral hip
ipsilateral tibia/fibula
thoracic spine

Correct Answer: ipsilateral foot/calcaneus

Explanation:

Question 62:

Options:

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

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

Explanation:

Question 63:

Options:

less than 10%.
30%.
50%.
70%.
greater than 90%.

Correct Answer: greater than 90%.

Explanation:

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.
J Trauma 1982;22:691-693.

Question 64:

All of the following are considered contraindications to the use of functional bracing of a humeral shaft fracture EXCEPT:

Options:

Mid-diaphyseal segmental fracture with ipsilateral pilon fracture
Mid-diaphyseal fracture with radial nerve palsy from penetrating injury
Proximal one-third oblique fracture
Mid-diaphyseal closed fracture with a radial nerve palsy on presentation
Mid-diaphyseal fracture with a L1 burst fracture and paraplegia on presentation

Correct Answer: Mid-diaphyseal segmental fracture with ipsilateral pilon fracture

Explanation:

Question 65:

Options:

Lunotriquetral fusion
Distal radioulnar joint (DRUJ) tenodesis
Triangular fibrocartilage complex (TFCC) repair
Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Correct Answer: Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Explanation:

Question 66:

Options:

Insertional triceps tendinitis
Valgus extension overload
Medial epicondylitis
Stress fracture of the olecranon
Chronic olecranon bursitis

Correct Answer: Valgus extension overload

Explanation:

Question 67:

A 30-year-old patient has acetabular dysplasia and moderate secondary osteoarthrosis. Which of the following studies will best help predict the success of periacetabular osteotomy?

Options:

High-resolution CT with coronal and sagittal reconstructions
Glycosaminoglycan MRI
Functional radiographic or fluoroscopic evaluation
Gadolinium-contrast arthrography with MRI
Routine AP and lateral radiographs

Correct Answer: Functional radiographic or fluoroscopic evaluation

Explanation:

Question 68:

Options:

CT
MRI
Standing radiographs
Measurement of compartment pressures
Bone scan

Correct Answer: Standing radiographs

Explanation:

DISCUSSION: The patient has a suspected Lisfranc sprain based on the plantar ecchymosis. The first step in diagnosis is a dynamic radiographic study. This should include a physician-assisted midfoot stress examination or standing weight-bearing radiographs to evaluate for displacement. There is no evidence of compartment syndrome, and a bone scan, CT, and MRI are expensive tests that are not warranted.
REFERENCES: Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.
Hunt SA, Ropiak C, Tejwani NC: Lisfranc joint injuries: Diagnosis and treatment. Am J Orthop 2006;35:376-385.

Question 69:

A 14-year-old boy has an anteromedial distal thigh mass. A radiograph and MRI scan are shown in Figures 39a and 39b. An open biopsy of the mass should include

Options:

bone obtained through a knee arthrotomy with creation of a portal that will be used for retrograde femoral nailing.
bone obtained by going through the mass.
bone obtained through a posterior approach, dissecting out and protecting the sciatic nerve and popliteal artery.
soft tissue obtained through a longitudinal incision centered over the mass.
soft tissue obtained through a transverse incision on the medial thigh.

Correct Answer: soft tissue obtained through a longitudinal incision centered over the mass.

Explanation:

Question 70:

Options:

Decreased pitch count for 4 weeks
Continued play with close observation
Cessation of all throwing for 6 weeks
Arthroscopic repair
Mini-open repair

Correct Answer: Cessation of all throwing for 6 weeks

Explanation:

Question 71:

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 72:

Options:

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

Correct Answer: After 4 weeks

Explanation:

Question 73:

Options:

Occult traumatic osteochondral lesion of the lateral talar dome
Neurapraxia of the intermediate branch of the superficial peroneal nerve
Incompetence of the superior peroneal retinaculum with peroneal subluxation
Meniscoid lesion of the anterior talofibular ligament
Syndesmotic injury (high ankle sprain)

Correct Answer: Neurapraxia of the intermediate branch of the superficial peroneal nerve

Explanation:

Question 74:

Options:

Continued nonsurgical management to include long-acting narcotic analgesics
Referral for vertebral axial decompression
Referral to interventional pain management for a spinal cord stimulator
Intradiskal electrothermal therapy (IDET) at L5-S1
Lumbar spinal fusion at L5-S1

Correct Answer: Lumbar spinal fusion at L5-S1

Explanation:

DISCUSSION: The MRI scans reveal advanced degenerative disk disease at L5-S1. Nonsurgical management has failed to provide relief and the patient is quite debilitated as a result of her back pain. Fritzell and associates demonstrated that in a well-informed and selected group of patients with severe low back pain, lumbar fusion can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatments. In a recent updated Cochrane Review of surgery for degenerative lumbar spondylosis, it was noted that while Fritzell and associates appeared to provide strong evidence in favor of fusion, a more recent trial by Brox and associates demonstrated no difference between those patients undergoing lumbar fusion compared to those receiving cognitive intervention and exercise. The Cochrane Review suggests that this may reflect a difference between the control groups. Fritzell and associates compared lumbar fusion to standard 1990s “usual care,” whereas Brox and associates compared lumbar fusion to a “modern rehabilitation program.” Bear in mind that this patient is a certified athletic trainer and runs a hospital health fitness department; therefore, at least for purposes of this question, it can be assumed that she has participated in a “modern rehabilitation program.” The Cochrane Review goes on to state that preliminary results of three small trials of intradiskal electrotherapy suggest that it is ineffective and that preliminary data from three trials of disk arthroplasty do not permit firm conclusions.
REFERENCES: Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: Updated Cochrane Review. Spine 2005;30:2312-2320.
Fritzell P, Hagg O, Wessberg P, et al: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521-2532.
Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.

Question 75:

What is the correct order of the elastic modulus of the following materials from greatest to least?

Options:

Stainless steel, cobalt-chromium, titanium, polymethylmethacrylate (PMMA), alumina ceramic.
Cobalt-chromium, stainless steel, titanium, alumina ceramic, PMMA
Alumina ceramic, titanium, cobalt-chromium, stainless steel, PMMA
Alumina ceramic, cobalt-chromium, stainless steel, titanium, PMMA
Titanium, cobalt-chromium, alumina ceramic, stainless steel, PMMA

Correct Answer: Alumina ceramic, cobalt-chromium, stainless steel, titanium, PMMA

Explanation:

Question 76:

Which of the following types of exercise used to increase flexibility is considered most beneficial in increasing joint range of motion?

Options:

Ballistic stretching
Static stretching
Proprioceptive neuromuscular facilitation (PNF)
Isokinetic
Eccentric

Correct Answer: Proprioceptive neuromuscular facilitation (PNF)

Explanation:

Question 77:

- A 14-year-old patient who has homocystinuria and is Risser 3 is referred for surgical treatment of scoliosis. In addition to the usual risks associated with posterior spinal fusion, the family should be advised that the patient ‘s underlying condition significantly increases the perioperative risk of

Options:

Spinal pseudoarthrosis
Spinal cord traction injury with paralysis
Arterial and venous thromboses
Superior mesenteric artery syndrome
Crankshaft phenomenon

Correct Answer: Arterial and venous thromboses

Explanation:

Question 78:

Options:

Serial physical examinations
Angiography
Duplex ultrasound examination
Ankle-brachial index (ABI)
Measurement of compartment pressures

Correct Answer: Ankle-brachial index (ABI)

Explanation:

DISCUSSION: The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations.
REFERENCES: Levy BA, Zlowodzki MP, Graves M, et al: Screening for extremity arterial injury with the arterial pressure index. Am J Emerg Med 2005;23:689-695.
Abou-Sayed H, Berger DL: Blunt lower-extremity trauma and politeal artery injuries: Revisiting the case for selective arteriography. Arch Surg 2002;137:585-589.
Mills WJ, Barei DP, McNair P: The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. J Trauma 2004;56:1261-1265.

Question 79:

Which of the following structures are found in the anterior tarsal tunnel?

Options:

Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve
Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, superficial peroneal nerve
Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve
Extensor hallucis brevis, extensor hallucis longus, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve
Dorsalis pedis artery, deep peroneal nerve, superficial peroneal nerve

Correct Answer: Extensor hallucis longus, tibialis anterior, extensor digitorum longus, dorsalis pedis artery, deep peroneal nerve

Explanation:

Question 80:

In the majority of patients with chronic anterior cruciate ligament (ACL)-deficient knees, analysis of the gait pattern during level walking will most likely reveal which of the following changes?

Options:

No significant differences in gait from the contralateral knee
No change in knee flexion-extension moment with balancing of quadriceps and hamstring activity
A change in knee flexion-extension moment with decreased hamstring activity
A change in knee flexion-extension moment with decreased demand on the quadriceps and a net increase in hamstring activity
A change in knee flexion-extension moment with increased demand on the quadriceps

Correct Answer: A change in knee flexion-extension moment with decreased demand on the quadriceps and a net increase in hamstring activity

Explanation:

Question 81:

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Options:

Titanium
Cobalt-chrome alloy
Alumina
Zirconia
Stainless steel

Correct Answer: Cobalt-chrome alloy

Explanation:

Question 82:

Options:

Synovial fluid adhesion-cohesion
Negative intra-articular pressure
Concavity-compression of the humeral head in the glenoid
Decreased functional arc of motion as a result of a Hill-Sachs lesion
Poor rehabilitation of scapulothoracic rhythm

Correct Answer: Concavity-compression of the humeral head in the glenoid

Explanation:

Question 83:

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

Options:

AIDS
Polytrauma
Pelvic fracture
Pilon fracture
Acute myocardial infarction (AMI)

Correct Answer: Pilon fracture

Explanation:

DISCUSSION: Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).
REFERENCE: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 84:

Options:

Long-arm cast
Percutaneous screw fixation
Open reduction and internal fixation (ORIF) with bone graft
Proximal row carpectomy

Correct Answer: Open reduction and internal fixation (ORIF) with bone graft

Explanation:

Question 85:

Options:

Induced osteoporosis
Acquired osteomalacia
Calcitonin effect
Hyperparathyroidism
Disuse osteoporosis

Correct Answer: Acquired osteomalacia

Explanation:

Question 86:

Which of the following diagnostic studies best distinguishes Ewing’s sarcoma from small cell osteosarcoma?

Options:

Bone scan
Cytogenetics
DNA ploidy analysis
Sentinel node biopsy
L-lactate dehydrogenase (LDH)

Correct Answer: Cytogenetics

Explanation:

Question 87:

Primary chondrosarcoma of bone most commonly occurs in which of the following locations?

Options:

Hand
Knee
Shoulder
Spine
Pelvis

Correct Answer: Pelvis

Explanation:

Question 88:

Options:

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

Correct Answer: Physical therapy

Question 89:

Options:

Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension
Immobilization of the hand with the MCP joints in extension and the IP joints in extension
Percutaneous pinning of the proximal phalanx
Open reduction and internal fixation of the proximal phalanx
Early motion and pain management

Correct Answer: Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension

Explanation:

DISCUSSION: Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 90:

Following a radial nerve neurapraxia at or above the elbow, return of muscle function can be expected to start at the brachioradialis and return along which of the following progressions?

Options:

Extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum comminus, extensor indicis proprious
Extensor carpi radialis brevis, extensor carpi radialis longus, extensor indicis proprious, extensor digitorum comminus
Extensor carpi radialis longus, extensor carpi radialis brevis, extensor indicis proprious, extensor digitorum comminus
Extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum comminus, extensor indicis proprious
Extensor carpi radialis longus, extensor digitorum comminus, extensor carpi radialis brevis, extensor indicis proprious

Correct Answer: Extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum comminus, extensor indicis proprious

Explanation:

DISCUSSION: Following a radial nerve neurapraxia above the elbow, muscle recovery can be expected in a predictable pattern. Although variations will occur, the return of function or reinnervation usually occurs in the following order: brachioradialis, extensor carpi radialis longus, supinator, extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum comminus, extensor digiti minimi, extensor indicis proprious, extensor pollicis longus, abductor pollicis longus, and extensor pollicis brevis.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ,
Ciba-Geigy, 1991, vol 8, p 53.
Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA,
Harper and Row, 1982, vol 3, pp 428-429.

Question 91:

Which of the following is not a reported mode of failure for a constrained acetabular component?

Options:

Loosening of the acetabular component
Disengagement of the constraining ring (with or without redislocation)
Increased abrasive (polyethylene) wear
Dissociation of the femoral head from the neck
Dissociation of the polyethylene liner from the acetabular shell

Correct Answer: Increased abrasive (polyethylene) wear

Explanation:

Question 92:

What is the goal of surgical treatment in this scenario?

Options:

To cure cancer
To prolong life
To relieve pain
To reverse neurologic symptoms

Correct Answer: To relieve pain

Explanation:

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.
View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 93:

Options:

Left upper thoracic curve 16 degrees and right main thoracic curve 18 degress, Risser stage in figure B
Right thoracolumbar curve 35 degrees, Risser stage in figure C
Left upper thoracic curve 15 degrees and right main thoracic curve 30 degrees, Risser stage in figure B
Left upper thoracic curve 26 degrees and right main thoracic curve 51 degrees, Risser stage in figure A
Left thoracolumbar curve 19 degrees, Risser stage in figure A

Correct Answer: Left upper thoracic curve 16 degrees and right main thoracic curve 18 degress, Risser stage in figure B

Explanation:

Question 94:

Options:

Subacromial corticosteroid injection
Aspiration of the subacromial and glenohumeral joint spaces
Nonsteroidal anti-inflammatory drugs
Extensive surgical debridement
Diagnostic arthroscopy

Correct Answer: Aspiration of the subacromial and glenohumeral joint spaces

Explanation:

Question 95:

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Options:

Neoadjuvant chemotherapy
En bloc resection
Observation
Amputation
Chemotherapy followed by radiation therapy

Correct Answer: Observation

Explanation:

Question 96:

Options:

continued fluid bolus.
methylprednisolone.
insertion of a Swan-Ganz catheter.
immediate intubation.
beta blockers to decrease peripheral resistance.

Correct Answer: insertion of a Swan-Ganz catheter.

Explanation:

DISCUSSION: The patient’s heart rate is not responding to hypotension with tachycardia, as would be expected in the event of hypovolemic shock. Additionally, the adequate urine
output suggests proper fluid resuscitation. Instead, she is bradycardic, possibly indicating neurogenic shock and loss of sympathetic tone to the heart. A Swan-Ganz catheter should be used to help differentiate these problems and guide appropriate fluid resuscitation and use of vasopressor agents.
REFERENCES: Hadley MN: Management of acute spinal cord injuries in an intensive care unit or other monitored setting. Neurosurgery 2002;50:S51-S57.
Vaccaro
AR
, An HS, Betz RR, et al: The management of acute spinal trauma: Prehospital and in-hospital emergency care. Instr Course Lect 1997;46:113-125.

Question 97:

Options:

Sciatic nerve
Internal iliac vessels
External iliac vessels
Femoral vessels
Obturator vessels

Correct Answer: External iliac vessels

Explanation:

Question 98:

Options:

normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
administration of IV steroids and placement of a soft cervical collar for 24 hours.
placement of both deep and superficial surgical drains prior to wound closure.
administration of IV mannitol and placement of a soft collar.
maintaining intubation for up to 24 to 48 hours.

Correct Answer: maintaining intubation for up to 24 to 48 hours.

Explanation:

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 99:

Acral metastases are most commonly seen in what type of carcinoma?

Options:

Renal cell
Lung
Thyroid
Breast
Ovarian

Correct Answer: Lung

Explanation:

DISCUSSION: Metastatic lesions to bone are usually located in the axial and proximal appendicular skeleton. Metastases below the elbow and knee are rare, but when they do occur they are most commonly from lung carcinoma.
REFERENCES: Hayden RJ, Sullivan LG, Jebson PJ: The hand in metastatic disease and acral manifestations of paraneoplastic syndromes. Hand Clin 2004;20:335-343.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 313.

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

Orthopedic Surgery Board Review MCQs: Trauma, Arthroplasty & Hip | Part 247

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 247

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index