OITE Orthopedic Surgery Board Review MCQs: Part 249

About This Board Review Set

This is Part 249 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 249

This module focuses heavily on: Ankle, Arthroplasty, Fracture, Infection, Knee, Revision.

Sample Questions from This Set

Sample Question 1: A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution...

Sample Question 2: A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic...

Sample Question 3: Ayear-oldmanhasadrainingsinusandrecurrentinfectionofhisrighttotalkneearthroplasty.Hehashadtwopriorrevisionsurgeriesaftertheprimaryprocedureandthreeothersurgeriesbeforehisinitial replacement,includingaproximaltibialosteotomyandsubsequenthard...

Sample Question 4: A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment sho...

Sample Question 5: Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?...

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

A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution

Explanation

DISCUSSION
Proximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied by
metaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.
Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.
RECOMMENDED READINGS
Harrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, Parsons BO, Flatow EL. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012 Jul 3;94(13):1223-8. doi: 10.2106/JBJS.J.01371. View Abstract at PubMed
Iannotti JP, Ramsey ML, Williams GR Jr, Warner JJ. Nonprosthetic management of proximal humeral fractures. Instr Course Lect. 2004;53:403-16. Review. View Abstract at PubMed
Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021. Review. View Abstract at PubMed
Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review. View Abstract at PubMed
Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Br. 2011 Jul;93(7):937-41. View Abstract at PubMed
Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov;90(11):1407-13. doi: 10.1302/0301-620X.90B11.21070. Review. PubMed PMID: 18978256. View Abstract at PubMed
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 67 THROUGH 70
Figure 67 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had full active painless shoulder range of motion.

Question 2

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

Explanation

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

Question 3

A year-old man has a draining sinus and recurrent infection of his right total knee arthroplasty. He has had two prior revision surgeries after the primary procedure and three other surgeries before his initial replacement, including a proximal tibial osteotomy and subsequent hardware removal. On clinical examination, he has a draining sinus in the mid portion of his surgical scar and a range of motion of 5° to 85°. AP and lateral radiographs of the right knee are shown in below. During surgery, the femoral component is found to be grossly loose, but the tibial component is well fixed. What is the most appropriate extensile approach that would provide adequate exposure and aid in tibial component extraction?

Explanation

DISCUSSION:
Extended tibial tubercle osteotomy is an extensile approach to revision total knee arthroplasty that affords excellent exposure and can facilitate removal of tibial sleeves and cones. This patient has had multiple surgeries, including a proximal tibial osteotomy, as well as poor range of motion, patella baja, and a well- fixed metaphyseal sleeve component. Classically, an extended tibial tubercle osteotomy provides outstanding exposure for component removal in the setting of prior high tibial osteotomy and patella baja. For this patient, it is important to recognize the patella baja on the radiographs, as well as the tibial sleeve. In many of these cases the osteotomy provides access to the sleeve to help with extraction, because the stem will not pull through the sleeve or detach from the tray to allow visualization of the sleeve. The extended medial parapatellar approach is just a long medial approach that typically yields good exposure
but would not help with the patella baja or extraction of the tibial sleeve. The quadriceps snip would give good exposure to the knee but would not aid in tibial component removal. Lastly, the medial epicondyle osteotomy could help with exposure and tensioning of the medial complex of the knee but would not help
with tibial component extraction.

Question 4

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of Review Topic

Explanation

The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.

Question 5

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Explanation

DISCUSSION: Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.
Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of compartment syndrome."
Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

Question 6

Figures 34a and 34b show the clinical photographs of a 46-year-old woman who has a painful deformity of the second toe. Surgical treatment consisting of metatarsophalangeal capsulotomy and proximal interphalangeal joint resection arthroplasty resulted in satisfactory correction, but the toe remains unstable at the metatarsophalangeal joint. What is the next most appropriate step?

Explanation

DISCUSSION: Crossover second toes are attributed to attenuation or rupture of the plantar plate and lateral collateral ligament and are associated with varying degrees of instability. Flexor-to-extensor transfer (Girdlestone/Taylor procedure) can provide intrinsic stability to the toe. Although plantar metatarsal head condylectomy can increase stability by resulting in scarring of the plantar plate, excision of the entire second metatarsal head carries a high risk of transfer metatarsalgia. Removal of the base of the proximal phalanx destabilizes the toe and should be reserved as a salvage procedure. Simple flexor tenotomy alone will not improve stability, and arthrodesis of the second metatarsophalangeal joint will limit motion and impair function.
REFERENCES: Coughlin MJ: Crossover second toe deformity. Foot Ankle 1987;8:29-39.
Thompson FM, Deland JT: Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385-388.

Question 7

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

Explanation

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

Question 8

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Explanation

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 9

Figures 25a and 25b show the clinical photographs of a 19-year-old baseball outfielder who has shoulder pain after sliding headfirst into second base. He reports pain while batting, sliding, and catching. Examination reveals a posterior prominence during midranges of forward elevation, which then disappears with a palpable clunk during terminal elevation and abduction. What is the most likely diagnosis?

Explanation

DISCUSSION: A headfirst slide with the arm extended can injure the posterior shoulder. Winging of the scapula is dynamic and is considered a compensatory effort to prevent subluxation; it is not related to nerve injury. Posterior glenohumeral subluxation can be present during the initiation of a bat swing. Rotator cuff function, interval tears, and superior labrum tears can be painful but do not produce winging.
REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.
Fiddian NJ, Kling RJ: The winged scapula. Clin Orthop 1984;185:228-236.

Question 10

The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is primarily mediated through

Explanation

DISCUSSION: Etanercept is a fusion protein that combines the ligand-binding domain of the TNF-α receptor to the Fc portion of human immunoglobulin G (IgG). Protein serves as a competitive inhibitor of TNF-α signaling. COX2 is the target of NSAIDs, including newer formulations that are more COX2-specific. The remaining responses are not direct targets of etanercept.
REFERENCES: Weinblatt ME, Kremer JM, Bankhurst AD, et al: A trial of etanercept, a recombinant tumor necrosis factor receptor: Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate. N Engl J Med 1999;340:253-259.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 489-530.

Question 11

A 19-year-old man who plays college volleyball undergoes a routine preparticipation physical examination. Figure 35 shows a posterior view of his dominant shoulder. An electromyogram shows that this is a chronic injury, and an MRI scan shows no abnormalities. The best course of action should be

Explanation

DISCUSSION: Isolated palsy of the infraspinatus portion of the suprascapular nerve is common in volleyball players and is seen frequently in the throwing arm of baseball players. The exact cause is not known, but it may be the result of either tethering or traction on the nerve at the spinoglenoid notch. Synovial cysts in the spinoglenoid notch also can be a cause, but the patient’s negative MRI findings rule out that entity. Because many isolated nerve palsies of the infraspinatus branch are asymptomatic, initial management should always be nonsurgical. Surprisingly, many athletes with this injury can participate fully in sports. Surgical treatment with decompression at the notch is unpredictable and generally is indicated only if nonsurgical management fails.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 12

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

Explanation

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

Question 13

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 14

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

Explanation

DISCUSSION: Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options.
REFERENCES: Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584.
Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Pochatko DJ, Schlehr FJ, Murphey MD, Hamilton JJ: Distal chevron osteotomy with lateral release for treatment of hallux valgus deformity. Foot Ankle Int 1994;15:457-461.

Question 15

A 10-year-old girl reports activity-related bilateral arm pain. Examination reveals no soft-tissue masses in either arm, and she has full painless range of motion in both shoulders and elbows. The radiograph and bone scan are shown in Figures 20a and 20b, and biopsy specimens are shown in Figures 20c and 20d. What is the most likely diagnosis?

Explanation

DISCUSSION: Based on these findings, the most likely diagnosis is fibrous dysplasia. Twenty percent of patients with fibrous dysplasia have multifocal disease. The lesions show a typical ground glass appearance. Fibrous dysplasia frequently involves the diaphysis of the long bones. There is no associated soft-tissue mass and no periosteal reactions to these lesions, suggesting a benign lesion. The histology shows proliferating fibroblasts in a dense collagen matrix. Trabeculae are arranged in an irregular or “Chinese letter” appearance. Osteogenic sarcoma and Ewing’s sarcoma have a much different radiographic appearance of malignant osteoid and small round blue cells. Periosteal chondroma does occur in the proximal humerus but is not typically multifocal. It appears as a surface lesion with saucerization of the underlying bone and a bony buttress adjacent to the lesion. Some patients with multifocal lesions have associated endocrine abnormalities (McCune-Albright syndrome).
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 118-119.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 197.

Question 16

A 13-year-old boy hyperextends his knee while playing basketball and reports a pop that is followed by a rapid effusion. A lateral radiograph is shown in Figure 4. Initial management consists of attempted reduction with extension, with no change in position of the fragment. What is the next most appropriate step in management?

Explanation

DISCUSSION: Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw
REFERENCES: Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60.
Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292.
Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.
Vocke AK, Vocke AR: Cartilaginous avulsion fracture of the tibial spine. Orthopedics 2002;25:1293-1294.

Question 17

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

Explanation

Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.

Question 18

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Explanation

DISCUSSION: Left ventricular hypertrophy by voltage is a nonspecific diagnosis, especially in athletes with an asthenic body habitus. High vagal tone in endurance athletes may result in first degree or even type I second degree (ie, Wenckebach) AV block in endurance athletes. High vagal tone results in resting sinus bradycardia in many trained athletes. A I-II/IV systolic ejection murmur is occasionally found in healthy athletes; however, when the murmur increases in intensity with maneuvers that decrease ventricular filling, such as standing or the Valsalva maneuver, dynamic obstruction that is the result of hypertrophic obstructive cardiomyopathy should be suspected. Nonspecific STT wave changes in the lateral leads on ECG are not uncommon in highly trained athletes; thus, they are nonspecific for ischemic heart disease.
REFERENCES: Pelliccia A, Maron BJ, Culasso F, DiPaolo FM, et al: Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-284.
Maron BJ, Thompson PD, Puffer JC, McGrew CA: Cardiovascular preparticipation screening of competitive athletes: A statement for health professionals from the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association. Circulation 1996;94:850-856.

Question 19

What is the most common bacteria cultured from dog and cat bites to the upper extremity?

Explanation

DISCUSSION: To define bacteria responsible for dog and cat bite infections, a prospective study yielded a median of five bacterial isolates per culture. Pasteurella is most common from both dog bites (50%) and cat bites (75%). Pasteurella canis was the most frequent pathogen of dog bites, and Pasteurella multocida was the most common isolate of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria.
REFERENCE: Talan DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.

Question 20

An 11-year-old boy reports the acute onset of elbow pain and swelling after pushing his brother. The patient's mother and a younger sibling have experienced numerous fractures. You note that the patient and his mother have blue sclera and normal-appearing teeth. A radiograph of the elbow is shown in Figure 60. This patient's disorder is most likely the result of Review Topic

Explanation

Osteogenesis imperfecta (OI) is a genetically determined disorder of type I collagen synthesis characterized by bone fragility. This patient sustained a displaced fracture of the olecranon apophysis after relatively minor trauma. Physical examination reveals distinctly blue sclera. His mother and younger sibling have experienced numerous fractures suggesting a family history of bone fragility. The patient's history, clinical features, and family history are consistent with a diagnosis of Sillence type I-A OI. Type I OI is the mildest and most common form. Inheritance is autosomal dominant.
Type I is subclassified into the A type (absence of dentinogenesis imperfecta) and B type (presence of dentinogenesis imperfecta). These individuals have blue sclerae, and although the initial fracture usually occurs in the preschool years, it may occur at any age. Furthermore, olecranon apophyseal fractures that occur after relatively minor trauma have been associated with type I OI. Cells from individuals with type I OI largely demonstrate a quantitative defect of type I collagen; they synthesize and secrete about half the normal amount of type I procollagen. In this patient, there are no indications that the child has been subjected to abuse. Radiographs of the elbow show no evidence of osteopetrosis (due to abnormal osteoclast function) or rickets (due to a deficiency of vitamin D). Morquio syndrome (characterized by a defect of the enzyme N-Ac-Gal-6 sulfate sulfatase) is not associated with blue sclera.

Question 21

What tendon has an intra-articular (instrasynovial) location in the knee joint?

Explanation

DISCUSSION: The popliteal tendon arises from the posterior aspect of the tibia and courses through the knee joint through the popliteus hiatus of the lateral meniscus before attaching on the lateral femur anterior to the lateral collateral ligament. It is the only tendon in the knee joint that can be viewed directly on arthroscopy.
REFERENCES: Kimura M, Shirakura K, Hasegawa A, Kobayashi Y, Udagawa E: Anatomy and pathophysiology of the popliteal tendon area in the lateral meniscus: 1. Arthroscopic and anatomical investigation. Arthroscopy 1992;8:419-423.
Arnoczky SP, Skyhar MJ, Wickiewicz TL: Basic science of the knee, in McGinty JB (ed): Operative Arthroscopy. New York, NY, Raven Press, 1991, pp 155-182.

Question 22

4 mg/kg for 48 hours

Explanation

The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for 48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.

Question 23

A newborn girl with an isolated unilateral dislocatable hip is placed in a Pavlik harness with the hips flexed 100 degrees and at resting abduction. Figure 23 shows an ultrasound obtained 2 weeks later. What is the next step in management? Review Topic

Explanation

The infant has a well-positioned hip in the Pavlik harness and treatment should be continued in the current position. The success rate is over 90% with the use of this device for a dislocatable hip. Ultrasound is a useful tool to confirm appropriate positioning of the cartilaginous femoral head during treatment. If the femoral head is
not reduced after 2 to 3 weeks in the harness, this mode of treatment should be abandoned. Forceful extreme abduction can cause osteonecrosis of the femoral epiphysis and should be avoided. Closed reduction, arthrography, and spica casting are indicated if the hip cannot be maintained in a reduced position with the harness.

Question 24

A 52-year-old man who was a former high school pitcher now reports loss of elbow flexion and extension with pain at the extremes of motion. Nonsurgical management has failed to provide relief. Examination reveals movement from 50 degrees to 110 degrees and is painful only at the limits of motion. A radiograph is shown in Figure 12. Treatment should consist of

Explanation

DISCUSSION: Based on the history, examination, and radiograph, the patient has typical degenerative arthritis of the elbow. This condition is found almost exclusively in men, and there is almost universally a history of repetitive heavy use or overuse of the elbow. Patients report pain at terminal extension and usually have a flexion contracture. Radiographs reveal osteophytes on the coronoid and olecranon and in the coronoid and olecranon fossae. The osteophytes are often associated with loose bodies that sometimes are attached to the soft tissues. Treatment should consist of removal of all loose bodies and impinging osteophytes using open technique or by arthroscopy. The capsular contractures should be released at the same time.
REFERENCES: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
Morrey BF: Primary degenerative arthritis of the elbow: Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br 1992;74:409-413.
Redden JF, Stanley D: Arthroscopic fenestration of the olecranon fossa in the treatment of osteoarthritis of the elbow. Arthroscopy 1993;9:14-16.
O’Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg 1993;1:106-116.

Question 25

A 20-year-old minor league baseball pitcher is diagnosed with a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has

Explanation

High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.

Question 26

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Explanation

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 27

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 28

A 38-year-old woman is polytraumatized in a motor vehicle crash. She has multiple injuries including a unilateral femur fracture. The patient is felt to be borderline and, although she is currently stable, she could potentially deteriorate quickly. Which of the following parameters has been suggested as an indicator of which patients would benefit from damage control?

Explanation

Polytraumatized patients can be classified as stable, unstable, borderline, or in extremis. Management of the borderline patient is controversial because it is unclear which patients can safely undergo early definitive surgical stabilization of fractures, and which patients would benefit from temporizing "damage control" stabilization to allow adequate resuscitation and physiologic stabilization prior to definitive treatment. Although the question of damage control versus early total care is unresolved, there are several clinical parameters that have been suggested for use in deciding who should be treated with early damage control. These include Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with thoracic trauma, multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater. A hemoglobin of 9 g/dL is not included in these suggested parameters.

Question 29

A 51-year-old male truck driver has had progressive left hip pain for more than 2 years, and he reports that the pain has become severe in the past 9 months. He is now unable to work because of the pain. Examination reveals that range of motion of the hip is limited to 95 degrees of flexion, 0 degrees of internal rotation, and 20 degrees of external rotation. The plain radiograph, MRI scan, and intraoperative gross photographs are shown in Figures 9a through 9d. Management should consist of

Explanation

DISCUSSION: The diagnosis is synovial chondromatosis. While the plain radiograph fails to show any calcifications, the MRI scan shows an intra-articular mass that involves the capsule. Grossly multiple granular cartilage nodules are seen. Management should consist of removing all loose bodies along with the synovial membrane.
REFERENCE: Milgram JM: Synovial osteochondromatosis: A histopathological study of thirty cases. J Bone Joint Surg Am 1977;59:792-801.

Question 30

Figure 1 is the clinical photograph of a 64-year-old man who crashed while riding his motorcycle. An examination reveals his long-finger metacarpophalangeal (MP) joint is stuck in extension. He cannot passively or actively flex at the MP joint. A hand radiograph is seen in Figure 2. Which interposed structure is preventing reduction?

Explanation

EXPLANATION:
This patient has a dorsally dislocated MP joint. In these cases, the volar plate can be displaced dorsal to the metacarpal head, preventing reduction. Although early publications described a “noose effect” of the lumbrical and flexor tendons, the primary block to reduction is the volar plate. Simple MP dislocations can be reduced closed by flexing the wrist and then gently sliding the base of the proximal phalanx over the end of the metacarpal. Longitudinal traction on the finger will only incarcerate the volar plate further and should be avoided. Patients with complex dislocations that fail closed reduction require open
reduction.

Question 31

A 50-year-old patient underwent multiple debridements for an open radial shaft fracture with bone loss. The bed currently shows no evidence of infection but has a 14-cm diaphyseal bone defect. The most appropriate treatment includes open reduction and internal fixation along with

Explanation

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made using
A. clinical examination.
B. invasive pressure measurement.
C. arterial Doppler study.
D. MRI.
Compartment syndrome of the hand can result from a variety of factors, including a traumatic event such as crush injury, fracture, vascular insult, a high-pressure injection injury, or an insect or spider bite. The treatment involves decompressive fasciotomy of the involved compartments. The diagnosis of hand compartment syndrome is determined by history, examination, and objective testing. Patients experience pain out of proportion to the injury, along with swelling and tense skin. Pain may occur with passive motion of the metacarpophalangeal joints as the intrinsic muscles are stretched. Invasive intracompartmental pressures can be measured in the compartments of the hand but not in the fingers. Arterial Doppler studies assess arterial blood flow,
and an abnormality would be a late finding. 41
MRI would show edema of the hand and fingers, but the decision to perform surgical release is less likely made from the findings. The most appropriate method of determining the need for finger fasciotomy is the history and physical examination.
45- Figures 1 and 2 show the MRI studies of a 35-year-old manual laborer with persistent wrist pain despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes of the midcarpal joint are noted. What is the most appropriate procedure for this condition?
A. Local vascularized bone graft
B. Proximal row carpectomy
C. Midcarpal fusion
D. Total wrist arthroplasty
The T1-weighted MRI reveals decreased signal that is consistent with avascular necrosis (AVN) of the capitate. Figure 2 demonstrates increased signal of the capitate consistent with edema. The etiology of AVN of the capitate may be related to trauma, abnormal interosseous vascular supply, and hypermobility. Surgical treatment is considered for patients who have had persistent symptoms despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes would be treated most appropriately with a salvage procedure. A midcarpal fusion is a motion-preserving salvage procedure and is the most appropriate option given to address the pain associated with the midcarpal arthritic changes. The alternative options are not appropriate for this patient. Local vascularized bone grafts are considered for situations in which no evidence of capitate collapse or arthritis is observed.

Question 32

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Explanation

DISCUSSION: The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function.
REFERENCES: Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Montijo H, Ebert FR, Lennox DA: Treatment of proximal femur fractures associated with total hip arthroplasty. J Arthroplasty 1989;4:115-123.

Question 33

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Explanation

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:

OrthoCash 2020

Question 34

A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. What is the most likely diagnosis?

Explanation

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 35

Which of the following best describes the relationship of the anterior tibial artery and dorsalis pedis artery to the extensor hallucis longus (EHL) tendon as they progress from the level of the ankle to the dorsum of the foot?

Explanation

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 36

Which of the following properties apply to the human meniscus when compared with articular cartilage?

Explanation

DISCUSSION: The meniscal cartilage, like articular cartilage, possesses viscoelastic properties. The extracellular matrix is a biphasic structure composed of a solid phase (collagen, proteoglycan) that acts as a fiber-reinforced porous-permeable composite, and a fluid phase that may be forced through the solid matrix by a hydraulic pressure gradient. Although these properties are shared with articular cartilage, the meniscus is more elastic and less permeable than articular cartilage.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 3-23.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, AAOS, 1999, pp 349-354.

Question 37

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function. A pathognomonic radiographic feature of this injury is a

Explanation

Discussion: Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficulty
Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.
Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Question 38

A 79-year-old woman with a massive rotator cuff tear presents to the emergency department with pain and difficulty moving her arm 7 weeks after undergoing reverse TSA for a displaced 4-part proximal humerus fracture.

Explanation

DISCUSSION
The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with
glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA.
RECOMMENDED READINGS
Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283-

Question 39

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

Explanation

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

Question 40

-What do the T2-weighted, fat-saturated MRI scans shown in Figures 76a through 76d reveal?

Explanation

DISCUSSION--The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This “double PCL” sign is highly indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 41

A 50-year-old man reports left shoulder pain and weakness after undergoing a lymph node biopsy in his neck 2 years ago. Examination reveals winging of the left scapula. Electromyography shows denervation of the trapezius. Surgical treatment for this condition involves Review Topic

Explanation

The muscle transfer procedure most commonly performed for trapezius paralysis is the Eden-Lange procedure. Trapezius paralysis in this patient is secondary to iatrogenic injury to the spinal accessory nerve during lymph node biopsy. In this procedure, the levator scapulae and rhomboid minor and major muscles are transferred laterally. Pectoralis transfer to the inferior border of the scapula is used as a dynamic transfer for serratus anterior winging.

Question 42

The World Health Organization (WHO) developed specific criteria for osteoporosis in 1994 based on the T-score obtained by dual-energy absorptiometry (DEXA). The T-score represents the number of standard deviations that the individual's bone mineral density differs from the normal peak bone mass in young adults. Osteoporosis is defined as a T-score of 1 +2.5 or below. 2 -1.0 to -2.0.

Explanation

Osteoporosis is defined as a chronic, progressive disease characterized by low bone mass and decreased bone strength. Risk factors for osteoporosis include increasing age, postmenopausal women, long-term calcium deficiency, and excessive steroid or alcohol abuse. T-scores are defined as standard deviations from normal peak bone mass (young adults), whereas Z-scores compare bone density of the same age and size. Osteoporosis is defined as a T-score of -2.5 or below as defined by the WHO, and osteopenia is defined as a T-score between -1.0 and -2.5. Z-scores are not used to stratify patients into categories of "osteopenia" or "osteoporosis" in elderly patinets. They are used to aid in the diagnosis of metabolic bone disease in young patients.

Question 43

A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 36, the arrow is pointing at which of the following arteries?

Explanation

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 44

In addition to radiographs of the primary lesion and chest, MRI of the primary lesion, and CT of the chest, staging studies for Ewing’s sarcoma should include which of the following?

Explanation

DISCUSSION: A bone scan and bone marrow biopsy are part of the staging studies for Ewing’s sarcoma. Whole body MRI and PET scans are investigational and show promise of greater sensitivity than a bone scan.
REFERENCES: Schleiermacher G, Peter M, Oberlin O, Philip T, Rubie H, Mechinaud F, et al: Increased risk of systemic relapses associated with bone marrow micrometastasis and circulating tumor cells in localized ewing tumor. J Clin Oncol 2003;21:85-91.
Daldrup-Link HE, Franzius C, Link TM, Laukamp D, Sciuk J, Jurgens H, et al: Whole-body MR imaging for detection of bone metastases in children and young adults: Comparison with skeletal scintigraphy and FDG PET. Am J Roentgenol 2001;177:229-236.

Question 45

A 22-year-old woman has had progressive upper extremity weakness for the past several years. History reveals no pain in her neck or shoulders. Examination reveals scapular winging of both shoulders and weakness in external rotation. She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness. She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling. A clinical photograph is shown in Figure 14. What is the most likely diagnosis?

Explanation

DISCUSSION: Progressive weakness is a common sign with a large differential diagnosis. Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy. Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness. The weakness is usually bilateral, and scapular winging is common. If the scapular winging becomes pronounced, elevation of the shoulder can be affected. In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated. Duchenne muscular dystrophy is typically severe and progressive. The other diagnoses are not compatible with the history or the physical findings.
REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.
Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up. J Bone Joint Surg Am 1993;75:372-376.

Question 46

A 21-year-old man with neurofibromatosis and multiple cutaneous neurofibromas has a rapidly enlarging painless mass on his buttock. Examination reveals a nontender, well-defined 6- x 6-cm soft-tissue mass that is deep to the fascia. The best course of action should be to order

Explanation

DISCUSSION: Patients with neurofibromatosis are at risk for development of soft-tissue sarcomas (most commonly malignant peripheral nerve sheath tumors). Clinical indications of development of a neurofibrosarcoma include a rapidly enlarging soft-tissue mass; therefore, this patient should be considered to have a neurofibrosarcoma until proven otherwise. MRI is superior to CT in characterizing the anatomic location of soft-tissue masses and the signal characteristics of the lesion. Areas of necrosis within the tumor may be apparent on MRI that cannot be appreciated on CT, suggesting a malignant tumor. Local imaging studies of suspected malignant tumors should be performed prior to needle or open biopsy so that the biopsy site can be excised at the time of definitive resection. Additionally, postbiopsy changes may lead to MRI artifacts that alter the interpretation of the MRI.
REFERENCES: Demas BE, Heelan RT, Lane J, Marcove R, Hajdu S, Brennan MF: Soft-tissue sarcomas of the extremities: Comparison of MR and CT in determining the extent of disease. Am J Roentgenol 1988;150:615-620.
Kransdorf MJ, Jelinek JS, Moser RP Jr, et al: Soft-tissue masses: Diagnosis using MR imaging. Am J Roentgenol 1989;153:541-547.

Question 47

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Explanation

EXPLANATION:
Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.

Question 48

Varus intertrochanteric osteotomy for coxa valga commonly produces which of the following results?

Explanation

DISCUSSION: The greater trochanter is raised as a by-product of varus osteotomy, and a temporary abductor lag and lurch is common for 6 months following surgery. In the absence of hip joint subluxation, varus intertrochanteric osteotomy has no effect on the center edge angle of Wiberg. Varus osteotomy typically increases femoral offset, thereby improving the abductor lever arm and reducing the hip joint reaction force. Even without taking a wedge, varus osteotomy always produces some degree of shortening.
REFERENCE: Millis MB, Murphy SB, Poss R : Osteotomies about the hip for the prevention and treatment of osteoarthrosis. Instr Course Lect 1996;45:209-226.

Question 49

Botulinum toxin is used to treat vasospastic disorders of the hand such as the Raynaud phenomenon to improve digital perfusion and reduce pain. Botulinum toxin enables which transmitter to be unopposed, resulting in vasodilation?

Explanation

EXPLANATION:
Nitric oxide is the only transmitter listed that is not inhibited by botulinum toxin. Substance P and glutamate are inhibited by botulinum toxin from release by pain nociceptors, thus reducing pain. Fonseca and associates have postulated that botulinum toxin inhibits the RhoA kinase pathway by blocking reactive oxygen species, which in turn does not allow actin/myosin to activate, thus preventing vasoconstriction of smooth muscle. Blocking the RhoA kinase pathway allows the action of nitric oxide to be unopposed, causing vasodilation. Nitric oxide is a potent vasodilator. Thus, botulinum toxin promotes nitric oxide activity to increase vasodilation.

Question 50

A 2-day-old infant has the hyperextended knee deformity shown in Figure 7. No other deformities are found on examination. A radiograph shows that the ossified portion of the proximal tibia is slightly anterior to that of the distal femur. Management should consist of

Explanation

DISCUSSION: Congenital dislocation of the knee is an uncommon deformity that varies in presentation from simple hyperextension to complete anterior dislocation of the tibia on the femur. Treatment varies with the age at presentation and the severity of the deformity. Most authors recommend early nonsurgical management. A recent study of 24 congenital knee dislocations in 17 patients found that satisfactory results were obtained in most instances using closed treatment. Based on their findings, the authors concluded that immediate reduction or serial casting should be performed when the patient is seen early after birth. If the patient is seen late and correction cannot be achieved by serial casting, traction followed by closed or open reduction may be necessary. Early percutaneous quadriceps recession has been described for complex congenital knee dislocations associated with underlying disorders, such as arthrogryposis and Ehlers-Danlos syndrome.
REFERENCES: Ko JY, Shih CH, Wenger DR: Congenital dislocation of the knee. J Pediatr Orthop 1999;19:252-259.
Johnson E, Audell R, Oppenheim WL: Congenital dislocation of the knee. J Pediatr Orthop 1987;7:194-200.
Roy DR, Crawford AH: Percutaneous quadriceps recession: A technique for management of congenital hyperextension deformities of the knee in the neonate. J Pediatr Orthop

1989;9:717-719.

Question 51

Figure 45 shows the radiograph of a 2-year-old patient who has progressive lumbar scoliosis as the result of hemivertebra. Examination reveals no associated cutaneous lesions, and an MRI scan shows no associated intraspinal anomalies. Treatment should consist of

Explanation

DISCUSSION: In a retrospective review of 10 patients treated with hemivertebra excision for hemivertebra in the levels of T12 to L3, the procedure was found to be safe and effective. The procedure provided an average curve correction of 67° and was greatest in patients who were younger than age 4 years at the time of surgery. Long anterior and posterior fusion with instrumentation is not the treatment of choice at this age. Either anterior hemiepiphyseodesis or posterior hemiarthrodesis in this isolated hemivertebra setting would be inadequate. Brace treatment is ineffective in management of the primary curvature.
REFERENCE: Callahan BC, Georgopoulos G, Eilert RE: Hemivertebral excision for congenital scoliosis. J Pediatr Orthop 1997;17:96-99.

Question 52

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder. What is his most likely chief symptom?

Explanation

CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75
Figures 72a through 72e are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0 degrees
to 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Question 53

When performing a posterior cruciate ligament reconstruction with a tibial inlay-type approach, what is the approximate anatomic distance of the popliteal artery from the screws used for fixation of the bone block?

Explanation

DISCUSSION: Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm
(range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon’s finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle.
REFERENCES: Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804.
Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.
Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.

Question 54

An otherwise healthy 70-year-old man has back and bilateral leg pain in an L5 distribution that is aggravated by standing more than 10 minutes or walking more than 100 feet. He has to sit to get relief. Neurologic and pulse examinations are normal. A radiograph and MRI scan are shown in Figures 4a and 4b. Treatment should consist of

Explanation

DISCUSSION: The patient has a degenerative spondylolisthesis at L4-5 with associated spinal stenosis. His symptoms are consistent with neurogenic claudication. Based on these findings, the surgical treatment of choice is decompression and posterolateral fusion. Use of instrumentation is controversial. Laminectomy alone is reserved for the patient who is frail medically. There is no role for an anterior approach or for fusion alone without decompression.
REFERENCES: Fischgrund JS, Mackay M, Herkowitz HN, et al: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812.
Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802-808.

Question 55

Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Explanation

Injuries to underlying vascular structures associated with clavicle fractures require exploration and stabilization. Brachial plexus injuries recover spontaneously in two thirds of patients. Displaced and segmental fractures may undergo closed reduction. Open treatment of clavicle fractures have been discouraged secondary to technical difficulties and nonunion. A floating shoulder (displaced clavicle and scapular neck fractures is an indication for ORIF but not humeral neck fracture.)

Question 56

Figure 30a is the anteroposterior radiograph of a 20-year-old woman with mild right groin pain and intermittent “catching” in the hip region. What is the most appropriate next step? tear

Explanation

DISCUSSION
Because this patient is young, substantial bilateral acetabular dysplasia is present, and the joint space is well preserved, periacetabular osteotomy is the treatment of choice (Figure 30b). Arthroscopic evaluation and treatment is insufficient to address the mechanical deformity. Although a hip injection can be diagnostically helpful, it would not alter the treatment plan in this scenario. The patient’s young age would make observation and subsequent THA less desirable. Femoral osteotomies also were performed to address rotational deformity.

Question 57

When performing the exposure for an anterior approach to the cervical spine, the surgical dissection should not enter the plane between the trachea and the esophagus and excessive retraction should be avoided to prevent injury to the

Explanation

DISCUSSION: The recurrent laryngeal nerve lies between the trachea and the esophagus. The vagus nerve lies in the carotid sheath. The sympathetic trunk lies anterior to the longus colli muscles. The hypoglossal and superior laryngeal nerves are both at risk during the exposure but are not located between the trachea and the esophagus.
REFERENCES: Flynn TB: Neurologic complications of anterior cervical interbody fusion. Spine 1982;7:536-539.
Patel CK, Fischgrund JS: Complications of anterior cervical spine surgery. Instr Course Lect 2003;52:465-469.

Question 58

A 14-year-old girl reports a 3-week history of anterior thigh pain and a palpable mass after sustaining a soccer-related injury. Examination reveals a tender, firm mass in the midportion of the rectus femoris. MRI scans are shown in Figures 39a through 39c. What is the most appropriate management?

Explanation

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T₁-weighted MRI scan, the defined fluid signal on the T₂-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 59

What pharmacologic agents are preferred for the treatment of symptomatic active Paget’s disease?

Explanation

DISCUSSION: Recent medical literature supports the use of bisphosphonates as the treatment of choice for active Paget’s disease.
REFERENCE: Delman PD, Meunier PJ: The management of Paget’s disease. N Eng J Med 1997;336:558-566.

Question 60

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Explanation

DISCUSSION: The T2-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T2-weighted images and diminished signal intensity on Trweighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 61

A 7-year-old patient has had a painless limp for several months. Examination reveals pain and spasm with internal rotation, and abduction is limited to 10° on the involved side. Management consists of 1 week of bed rest and traction, followed by an arthrogram. A maximum abduction/internal rotation view is shown in Figure 40a, and abduction and adduction views are shown in Figures 40b and 40c. The studies are most consistent with

Explanation

DISCUSSION: The radiographs show classic hinge abduction. The diagnostic feature is the failure of the lateral epiphysis to slide under the acetabular edge with abduction, and the abduction view shows medial dye pooling because of distraction of the hip joint. Persistent hinge abduction has been shown to prevent femoral head remodeling by the acetabulum. Radiographic changes are characteristic of severe involvement with Legg-Calve-Perthes disease. The Catterall classification cannot be well applied without a lateral radiograph, but this degree of involvement would likely be considered a grade III or IV. Because the lateral pillar is involved, this condition would be classified as type C using the Herring lateral pillar classification scheme.
REFERENCE: Reinker KA: Early diagnosis and treatment of hinge abduction in Legg-Perthes disease. J Pediatr Orthop 1996;16:3-9.

Question 62

A 77-year-old man with a history of mild renal insufficiency and atrial fibrillation on warfarin therapy is scheduled to undergo a left total hip arthroplasty. He previously underwent a right total hip arthroplasty with development of significant heterotopic bone that resulted in limitation of motion. What is the most appropriate form of prophylactic treatment to minimize the formation of heterotopic bone on his left hip?

Explanation

DISCUSSION: This question centers on the prophylactic treatment to reduce the risk of heterotopic bone formation. Prophylaxis is indicated because he has already demonstrated bone formation with his prior hip arthroplasty, which places him at increased risk for developing heterotopic bone on the contralateral side. He is on warfarin and has renal insufficiency, which makes the use of NSAIDs contraindicated. The recommended dose is 600 to 800 centigrey of radiation given within 24 hours of surgery preoperatively or 72 hours postoperatively.
REFERENCES: Kolbl O, Knelles D, Barthel T, et al: Preoperative irradiation versus the use of nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossification following total hip replacement: The results of a randomized trial. Int J Radiat Oncol Biol Phys 1998;42:397-401.
Pakos EE, Ioannidis JP: Radiotherapy vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip surgery: A meta-analysis of randomized trials. Int J Radiat Oncol Biol Phys 2004;60:888-895.
Seegenschmiedt MH, Makoski HB, Micke O, et al: Radiation prophylaxis for heterotopic ossification about the hip joint: A multicenter study. Int J Radiat Oncol Biol Phys 2001 ;51:756-765.

Figure 23 a Figure 23b

Question 63

Figure 1 is the radiograph of an 18-year-old, right hand-dominant man who has right side thumb pain after a tackle during a rugby game. Examination shows ecchymosis and swelling of the right thumb along with tenderness to palpation about the thumb CMC joint and metacarpal base. What ligament is holding the small fracture fragment in anatomical location to the trapezium?

Explanation

EXPLANATION:
Bennett fractures are defined as intra-articular thumb metacarpal base fractures. The fracture is often caused by axial loading, and concomitant injuries to the thumb MCP joint and trapezium are common. The palmar ulnar aspect of the base of the metacarpal stays in place through its attachment to the trapezium by way of the anterior oblique ligament. The metacarpal shaft is displaced dorsally, proximally, and radially by the pull of the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and adductor pollicis brevis. These fractures are often considered unstable and are treated surgically.

Question 64

Figure 42 shows the radiograph of a patient with spinal muscular atrophy. Examination reveals good upper extremity function, and she can tie her shoes and propel a manual wheelchair. Posterior instrumentation and fusion may result in

Explanation

DISCUSSION: Spinal muscular atrophy is caused by an abnormal survival motor neuron gene that prevents apoptosis of the motor nerves. Spinal fusion results in better sitting balance, stabilized or improved pulmonary function, and high parental satisfaction, but it may result in at least temporary loss of upper extremity function.
REFERENCES: Bentley G, Haddad F, Bull TM, Seingry D: The treatment of scoliosis in muscular dystrophy using modified Luque and Harrington-Luque instrumentation. J Bone Joint Surg Br 2001;83:22-28.
Furumasu J, Swank SM, Brown JC, Gilgoff I, Warath S, Zeller J: Functional activities in spinal muscular atrophy patients after spinal fusion. Spine 1989;14:771-775.
Granata C, Cervellati S, Ballestrazzi A, Corbascio M, Merlini L: Spine surgery in spinal muscular atrophy: Long-term results. Neuromuscul Disord 1993;3:207-215.

Question 65

Disadvantages of anterior-inferior plate fixation for acute clavicular fractures relative to superior plating include

Explanation

Anterior-inferior plate fixation of midshaft clavicular fractures has evolved to be an alternative plate location compared to superior plating. The advantages of anterior-interior plating are reduced prominence of the hardware compared to the subcutaneous superior plates; the potential for placement of longer screws as the clavicle is wider front to back than top to bottom, especially laterally; and a potential for decreased risk to the subclavian structures. A relative disadvantage of anterior-inferior plating is a need to detach a small portion of the deltoid origin. Union rates for anterior-inferior plating are similar to those with superior plating.

Question 66

A 41-year-old man is involved in a high-speed motor vehicle crash and sustains a closed femoral midshaft fracture and a unilateral pulmonary contusion with a hemothorax, requiring placement of a chest tube. He has an initial blood pressure of 90/50 mm Hg. After receiving two liters of crystalloid, he has a blood pressure of 115/70 mm Hg and a heart rate of 90 bpm. He has normal mentation and does not require ventilator support. An arterial blood gas reveals that his delta base is

Explanation

The patient responded to crystalloid resuscitation and hemodynamic parameters and the base deficit indicate that he is adequately resuscitated for definitive fracture care. In a resuscitated patient, a reamed nail is not detrimental in the setting of a pulmonary injury and is favorable for fracture union. An unreamed nail has a higher nonunion rate than a reamed nail for femoral fractures. In a skeletally mature patient with a midshaft fracture, an intramedullary nail is preferred to open reduction and internal fixation. In an adult patient, skeletal traction should be considered only as a temporary treatment prior to surgical fixation of the femoral fracture.

Question 67

An 8-year-old girl has a supracondylar fracture of the distal humerus. Her neurovascular status is intact. Radiographs show hyperextension of 10 degrees of the distal fragment and an angle between the humeral shaft and capitellar physis (Baumann’s angle) of 88 degrees. Management should consist of

Explanation

Supracondylar fracture of the humerus accounts for 3 percent of childhood fractures. It is the commonest fracture of the elbow region in children and accounts for 80% of elbow injuries. Common complications include cubitus varus, ischemic contracture, and neurovascular lesions. This question chooses closed reduction with Kwire fixation as the correct method of treatment. However, the literature discusses olecranon screw traction and open reduction as legitimate options in treatment. This study recommends olecranon traction for severely displaced fractures left unstable by closed reduction.

Question 68

A 78-year-old woman undergoes her third lumbar decompression and fusion from L3 to L5 without complication. On the morning of postoperative day 3, examination reveals painless, flaccid weakness of both lower extremities. She also has an absent bulbocavernous reflex and a mild saddle paresthesia. MRI scans of the lumbar spine are shown in Figures 26a and 26b. What is the most appropriate management at this time?

Explanation

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 69

The most appropriate treatment for this fracture is

Explanation

DISCUSSION
Tibial fractures are classified on the basis of their anatomical location and the status of the prosthesis fixation. Type I fractures involve the tibial plateau, type II fractures occur adjacent to the stem of the tibial component, type III fractures are distal to the tibial stem, and type IV fractures involve the tibial tubercle. Subclassifications include A with a well-fixed implant; B with a loose implant; and C, which occur intraoperatively.
Treatment of periprosthetic tibial fractures is based on the location of the fracture and the status of the component fixation. Types II or III fractures associated with prosthetic loosening or instability are best managed with revision arthroplasty, usually with a diaphyseal-engaging intramedullary tibial stem. Supplemental internal fixation may be necessary. Type III fractures with well-fixed and stable implants are treated using the standard principles of tibial fracture management.

Question 70

A 56-year-old man who tripped and fell out of his golf cart onto his right shoulder 4 days ago now reports mild pain while chipping. Examination reveals mild bruising over the lateral clavicle but good shoulder range of motion and strength. A radiograph is shown in Figure 9. Appropriate treatment at this time should include which of the following?

Explanation

Treatment of this minimally displaced distal clavicle fracture should begin with nonsurgical management consisting of sling therapy followed by gentle motion therapy. Any form of surgical intervention at this time is unnecessary because this fracture pattern has a high incidence of union. A bone stimulator may be used if healing becomes delayed.

Question 71

Which of the following statements is most accurate regarding undetected intraoperative surgical glove perforation?

Explanation

DISCUSSION: The incidence of undetected intraoperative surgical glove perforation has been demonstrated at approximately 8.5%, occurring most frequently on the index finger or left hand of the assistant surgeon. The frequency of glove perforation is higher in surgeries lasting longer than 3 hours.
REFERENCES: Al-Habdan I, Sadat-Ali M: Glove perforation in pediatric orthopaedic practice. J Pediatr Orthop 2003;23:791-793.
Sadat-Ali M, Al-Othman A: Glove perforations in orthopaedic practice. Saudi Med J 1996;17:811-813.

Question 72

When comparing the overall outcomes of surgical versus nonsurgical treatment of stable thoracolumbar burst fractures in patients without neurologic injury, 5 years following injury, the principle differences lie in Review Topic

Explanation

When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.

Question 73

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

Explanation

DISCUSSION: The risk of synostosis is imminent with any technique for repairing a distal biceps tendon rupture. However, the risk is quite low for all approaches that avoid exposure of the ulna, including the muscle-splitting two-incision technique.
REFERENCE: Norris TR: Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, p 342.

Question 74

A 56-year-old woman underwent a total knee arthroplasty 2 years ago and now has pain and swelling. Radiographs of her knee are unremarkable. Her C-reactive protein (CRP) level is 3.0 (reference range [rr], 0.08–3.1 mg/L), and her erythrocyte sedimentation rate (ESR) is 18 mm/h (rr, 0-20 mm/h). Aspiration of the knee reveals a white blood cell (WBC) count of 1200/mm3 with a differential of 30% neutrophils and 70% monocytes. Cultures will not be available for several days, and the patient has not been taking antibiotics. Based on these findings, the most appropriate next step is

Explanation

DISCUSSION
ESR and CRP level are recommended as starting points in the workup for the diagnosis or exclusion of periprosthetic joint infection (PJI). When both the ESR and CRP findings are within defined limits, PJI is unlikely. When both test findings are positive, PJI must be considered and further investigation is warranted. Clinicians need to be aware of other inflammatory conditions such as rheumatoid arthritis that can lead to elevation of inflammatory markers.
A high likelihood of infection is noted when the knee aspirate contains more than 2500 WBCs per high-powered field (HPF) with a differential count exceeding 60% neutrophils. Using these criteria, Mason demonstrated a sensitivity of 98% and a specificity of 95% for infection diagnosis.
For this patient, the inflammatory markers are within normal limits. The aspiration result is below 2500 WBC/HPF with a low percentage of neutrophils. The likelihood of infection is remote, and further nonsurgical treatment should not include antibiotics. There is no indication for surgery based upon the information presented.

Question 75

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

Explanation

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

Question 76

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

Explanation

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

Question 77

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

Explanation

DISCUSSION: The sural nerve crosses near the midline at the level of the musculotendinous junction before descending to its more lateral location distally. The saphenous nerve and vein are further medial and at less risk. The posterior tibial nerve is at risk only during deep dissection, such as harvesting flexor hallucis longus tendon graft. The plantaris muscle lies in this area but is of little clinical significance.
REFERENCES: Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477.
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.

Question 78

Figures A and B are post-operative radiographs of a 54-year-old female. In the first 6 months after this procedure, what is the most likely factor for functional impairment in this patient?

Explanation

A residual deficit in muscle performance and anterior knee pain are expected in the majority of patients at 6 months after surgical fixation of their patella fractures.
Anterior knee pain is reported to be a common symptom following treatment of patellar fractures. A likely contributing factor to the anterior knee pain is scarring and tightness of the structures surrounding the knee, as well as patella maltracking due to quadricep/hamstring weakness and/or poor muscle synchrony. Other factors for anterior knee pain may include symptomatic hardware, which may be treated with removal of fixation after union has been achieved.
Lazaro et al. looked at the outcome data on thirty patients with isolated unilateral patellar fractures. Anterior knee pain during activities of daily living was experienced by twenty-four (80%) of the patients. The knee extensor mechanism on the injured side had deficits in strength (-41%), power (-47%), and endurance (-34%) as compared with the uninjured side.
Lebrun et al. reviewed a series of 40 operatively treated patella fractures and found that at over 6 years postoperatively, significant symptomatic complaints and functional deficits persisted based on validated outcome measures as well as objective physical evaluations. Removal of symptomatic fixation was required in 52% of the patients treated with osteosynthesis, whereas 38% of those with retained fixation self-reported implant-related pain at least some of the time.
Figure A and B show AP and lateral radiographs of a comminuted patella fracture treated with a tension band repair construct. The articular surface looks well reduced.
Incorrect Answers:

Question 79

A 25-year-old man is unresponsive at the scene of a high-speed motor vehicle accident and remains obtunded. Initial evaluation in the emergency department reveals a left-sided femoral shaft fracture and a right-sided humeral shaft fracture. The cervical spine remains immobilized in a semi-rigid cervical collar, and the initial AP and lateral radiographs obtained in the emergency department are unremarkable. What is the most appropriate management at this time? Review Topic

Explanation

Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity.

Question 80

A patient falls off a roof and sustains the fracture shown in Figure 29. What is the most likely complication that results from injury to the structure that is located at the arrow?

Explanation

The arrow points to the sustentaculum tali, which is fractured off the tuberosity of the calcaneus. The flexor hallucis longus (FHL) tendon runs directly under this structure. An injury to this structure could cause stenosis around the FHL tendon which would cause pain with great toe flexion. Paresthesias on the plantar aspect of the foot refers to the medial plantar nerve. Loss of the arch refers to the plantar fascia which attaches at the calcaneal tuberosity. Inability to flex the lesser toes refers to the flexor digitorum longus tendon which runs superior to the sustentaculum. The spring ligament runs from the navicular to the calcaneus, but does not attach under the sustentaculum tali.

Question 81

-Figures a and b are the anteroposterior and lateral plain radiographs of a 45-year-old woman who had severe bilateral leg pain for 6 months. Figures 5c and 5d are her sagittal and axial T2-weighted MRI scans. After attempting nonsurgical treatment including physical therapy and epidural injections, she continued to experience persistent pain. What is the most appropriate treatment?

Explanation

Question 82

A 30-year-old man underwent replantation of his dominant thumb at the metacarpophalangeal joint level 2 days ago. Since replantation, the temperature of the thumb has been between 87.8 F (31 C) and 93.2 F (34 C). The temperature is now 82.4 F (28 C), and there is brisk capillary refill and venous engorgement. Management at this time should include

Explanation

Discussion: The patient is experiencing impending failure of the replanted thumb. In a study by Moneim and Chacon, they found that vascular thrombosis in the postoperative period is the major factor in failure after replantation. When it occurs, it has to be aggressively dealt with by surgical exploration and revision of the vascular repair. The best results are obtained within 11 hours of the repair and nonsurgical management uniformly led to failure.

Question 83

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Explanation

DISCUSSION
Gamma irradiation produces free radicals. Although these free radicals can form cross-links with other polyethylene chains, the free radicals can also form a bond with oxygen, resulting in early oxidation. Gamma irradiation in air produces the highest risk for oxidized polyethylene, resulting in the highest risk for wear, delamination, and subsequent osteolysis.
This patient demonstrates severe periarticular osteolysis. When she is asymptomatic, this suggests the acetabular and femoral components remain well fixed to the bone. Consequently, she can be treated by removing the wear generator (polyethylene exchange), along with bone grafting of the osteolytic defect. Considering the extensive amount of osteolysis, observation for 1 year would not be appropriate.
The psoas is the anatomic structure that runs anterior to the acetabulum. The femoral neurovascular structures are at risk if the retractor is placed anterior and inferior to the psoas tendon.
The patient develops a foot drop 2 days after surgery. As a result, it can be assumed that the nerve was not injured directly during the surgical procedure. Although MR imaging or a CT scan may be indicated to identify an evolving hematoma, the immediate concern is to minimize pressure on the sciatic nerve. Tension on the nerve can be decreased by flexing the surgical knee and positioning the bed flat.

Question 84

A football player sustains a traumatic anterior inferior dislocation of the shoulder in the last game of the season. It is reduced 20 minutes later in the locker room. The patient is neurologically intact and has regained motion. If the patient undergoes arthroscopic evaluation, what finding is seen most consistently?

Explanation

DISCUSSION: In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.
Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic,

first-time shoulder dislocations. Am J Sports Med 2002;30:576-580.

Question 85

-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 86

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Explanation

A serum albumin level of below 3.5 g/dl indicates malnourished patient. An absolute lymphocyte count below 1500/mm3 is a sign of immune deficiency. If possible, amputation surgery should be delayed in such patients. An absolute Doppler pressure of 70 mm Hg is the minimum inflow level. The ischemic index is the ratio of the Doppler pressure at the level being tested to the brachial systolic pressure. Genreally accepted to require an ischemic index of 0.5 or greater. Transcutaneous partial pressure of oxygen (TcpO2) is the present gold standard of vascular inflow. TcpO2 values of 40 mm Hg correlate with acceptable wound healing
(eliminates false positive predictions with using area under the Doppler waveform). Pressures less than 20 mm Hg are predictive of poor healing. Miller 505-6
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Question 87

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Explanation

DISCUSSION: The patient has severe acetabular protrusio, a condition that is frequently associated with Marfan syndrome. An echocardiogram is necessary to rule out the most serious consequence of this syndrome, aortic root widening, which can lead to aortic valve dysfunction or fatal aortic rupture. An electromyogram may be indicated for Charcot-Marie-Tooth disease, which is associated with acetabular dysplasia, but not protrusio. The renal ultrasound, the MRI scan, and the biopsy would be of no value in this patient. Protrusio can also be seen in patients with osteogenesis imperfecta and juvenile rheumatoid arthritis.
REFERENCES: Steel HH: Protrusio acetabuli: Its occurrence in the completely expressed Marfan syndrome and its musculoskeletal component and a procedure to arrest the course of protrusion in the growing pelvis. J Pediatr Orthop 1996;16:704-718.
Wenger DR, Ditkoff TJ, Herring JA, Mauldin DM: Protrusio acetabuli in Marfan’s syndrome. Clin Orthop 1980;147:134-138.

Question 88

Figure 35 shows the AP radiograph of a patient who underwent a previous upper tibial osteotomy (UTO). The patient may be at risk for which of the following during total knee arthroplasty (TKA)?

Explanation

DISCUSSION: The results of TKA for patients with a prior UTO are reported to be slightly suboptimal. The major problems are patella baja, difficulty in exposure, and instability. Most of the patients exhibit some degree of instability prior to TKA, and ligamentous balancing may be difficult. Ligamentous structures are at risk of rupture during the difficult exposure. The problem of ligamentous balancing is exacerbated by the change in the joint slope that can occur after UTO.
REFERENCES: Parvizi J, Hanssen AD, Spangehl MJ: Total knee arthroplasty following proximal tibial osteotomy: Risk factors for failure. J Bone Joint Surg Am 2004;86:474-479.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy: A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 89

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

Explanation

DISCUSSION: Neer and associates focused on mechanical and nutritional factors as the etiology of rotator cuff arthropathy. McCarty and associates, in describing a similar syndrome known as Milwaukee shoulder, focused on an inflammatory cause in proposing the pathogenic role of hydroxyapatite, a basic calcium phosphate.
REFERENCES: Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy. J Bone Joint Surg Am 1983;65:1232-1244.
McCarty DJ, Halverson PB, Carrera GF, Brewer BJ, Kozin F: Milwaukee shoulder: Association of microspheroids containing hydroxyapatite crystals, active collagenase, and neutral protease with rotator cuff defects. I: Clinical aspects. Arthritis Rheum 1981;24:464-473.

Question 90

What is the primary immediate source of energy for muscle?

Explanation

The basic source of energy for muscle contraction is ATP. ATP is also the immediate energy source for muscle. The body then utilizes glucose to produce ATP. Glycolysis splits glucose to form two molecules of pyruvic acid and two ATP.
Almost 90% of the total ATP formed by glucose metabolism is formed during oxidative phosphorylation. This is accomplished by a series of enzymatically catalyzed reactions in the mitochondria. When the body’s stores of carbohydrates decrease below normal, glucose can be formed from the breakdown of protein and fat via gluconeogenesis to yield more ATP.

Question 91

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

Explanation

DISCUSSION: Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation end points: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 92

What is the most common surgical cause of the foot deformity shown in Figure 9?

Explanation

DISCUSSION: The radiograph shows a hallux varus deformity. Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both. It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection.
REFERENCES: Donley BG: Acquired hallux varus. Foot Ankle Int 1997;18:586-592.
Myerson MS, Komenda GA: Results of hallux varus correction using an extensor brevis tenodesis. Foot Ankle Int 1996;17:21-27.

Question 93

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Explanation

DISCUSSION: Convex hemiarthrodesis and hemiepiphysiodesis are procedures designed to gradually reduce curve magnitude in congenital scoliosis because of hemivertebrae. They are used to surgically create an anterior and posterior bar to arrest growth on the convexity of the existing deformity. Success of the technique is predicated on continued growth on the concave side of the deformity. Prerequisites for this procedure include curves of limited length (less than or equal to five vertebrae), curves of reasonable magnitude (less than 70°), absence of kyphosis, concave growth potential, and appropriate age (younger than age 5 years).
REFERENCE: Winter RB, Lonstein JE, Denis F, Sta-Ana de la Rosa H: Convex growth arrest for progressive congenital scoliosis due to hemivertebrae. J Pediatr Orthop 1988;8:633-638.

Question 94

When a Workers' Compensation patient recovers after an injury to a point that further restoration of function is no longer anticipated, he or she is said to have reached which of the following?

Explanation

This is the definition of maximum medical improvement (MMI). The patient has essentially reached the plateau of his improvement.
Functional capacity evaluations (FCE) are based upon a theoretical model of comparing job demands to worker capabilities. The results of FCEs are often used to determine musculoskeletal capacity to return to work.
Strong et al. reported on the use of FCE in the Workers' Compensation system, and note how these FCE results are required by employers to determine the level of return to work of their employees. They also mention that the reports are frequently perceived with a negative tone. The employees reported a wider range of restrictions in their varied life roles than did the FCE reports, which deal more narrowly with work roles.
Pransky et al. reported that although FCE's are relied upon for determination of ability to perform physical work, several scientific, legal, and practical concerns persist. They note that test criteria often do not accurately reflect real-life job requirements or performance, and subjective evaluation remains common. They conclude that more research into predictive linking of FCE outcomes with occupational outcomes is necessary to determine their role in the Workers' Compensation system.
Incorrect Answers:
1: A functional capacity evaluation (FCE) is set of tests, practices and observations that are combined to determine the ability of the evaluated to function in a variety of circumstances (most often employment) in an objective manner. 3: Permanent disability is any lasting disability that results in a reduced earning capacity after maximum medical improvement is reached; this implies that MMI must be reached before this is determined. 4: Impairment rating is an objective data point obtained by a physician reviewing the patient's overall condition during a functional capacity evaluation. 5: This is the process a patient uses to tell their employer they want a personal physician to treat them for a work injury.

Question 95

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Explanation

DISCUSSION: In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally.
REFERENCES: Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685.
Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996.

Question 96

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan reveals a large chronic rotator cuff tear with retraction and fatty infiltration atrophy of the supraspinatus and infraspinatus tendons. This tear is responsible for the patient’s severe weakness and inability to elevate the arm.
REFERENCE: Gerber C, Myer DC, Schneeberger AG, et al: Effect of tendon release and delayed repair on the structure of the muscles of the rotator cuff: An experimental study in sheep. J Bone Joint Surg Am 2004;86:1973-1982.

Question 97

A 38-year-old woman with metastatic thyroid carcinoma has had increasing pain in the left hip for the past 3 months. An AP radiograph and coronal T 1 -weighted MRI scan are shown in Figures 28a and 28b. Management should consist of

Explanation

DISCUSSION: The radiograph and MRI scan reveal a lytic lesion in the left femoral neck region that extends to the lesser trochanter. Although external beam radiation and radioactive iodine infusion may be helpful in controlling the local disease, the patient is at high risk for femoral neck fracture given the location of the lesion. Prophylactic surgery is indicated; therefore, the treatment of choice is a cemented bipolar hemiarthroplasty. The use of a compression hip screw and side plate or an intramedullary nail has a high likelihood of failure with disease progression. Postoperative treatment with radiation therapy and bisphosphonates is also indicated.
REFERENCES: Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.
Swanson KC, Pritchard DJ, Sim FH: Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg 2000;8:56-65.
Clarke HD, Damron TA, Sim FH: Head and neck replacement endoprosthesis for pathologic proximal femoral lesions. Clin Orthop 1998;353:210-217.

Question 98

A 28-year-old woman fell on her right wrist while rollerblading 2 days ago. She was seen in the emergency department at the time of injury and was told she had a sprain. Examination now reveals dorsal tenderness in the proximal wrist but no snuffbox or ulnar tenderness. Standard wrist radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: When considering the diagnosis of scapholunate ligament injury, standard radiographic views of the hand will not always reveal widening of the scapholunate gap. Although MRI may reveal injury to the ligaments, the PA clenched fist view can be obtained in the office during the initial patient visit. Arthroscopy is not a first-line diagnostic tool.
REFERENCES: Walsh JJ, Berger RA, Cooney WP: Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg 2002;10:32-42.
Browner BD, Levine AM, Jupiter JB, et al (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1366-1367.

Question 99

A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include

Explanation

Scheuermann’s Disease classically presents with >45o thoracic kyphosis and anterior wedging (5o or more) at three sequential vertebrae. Disc narrowing, end-plate irregularities, scoliosis, spondylosis, and Schmorl’s nodes are also seen. It’s more common in adolescents and males. Normally, these patients are treated (1) in a brace if the curve is progressive and Risser 3 or less,
(2) with surgical fusion if >75o and Risser 3 or less, (3) with surgical fusion if >65o and Risser 4/5 if necessary or symptomatic. Posterior instrumentation, anterior release and interbody fusion is the treatment of choice for curves >75o, or those >55o on hyperextension. Other causes of kyphosis include trauma, infection, spondylitis, bone dysplasia, neoplasia, neurofibromatosis.

Question 100

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Explanation

The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.

Full Question & Answer Text (for Search Engines)

Question 1:

A 50-year-old woman with a 2-part surgical neck proximal humerus fracture and metaphyseal comminution

Options:

Initial period of sling immobilization followed by physical therapy
Open reduction and internal fixation with or without bone grafting
Reverse total shoulder arthroplasty (rTSA)
Hemiarthroplasty
Unconstrained (TSA)
Closed reduction and Kirschner wire (K-wire) stabilization

Correct Answer: Open reduction and internal fixation with or without bone grafting

Explanation:

DISCUSSION
Proximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied by
metaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.
Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.
RECOMMENDED READINGS
Harrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, Parsons BO, Flatow EL. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012 Jul 3;94(13):1223-8. doi: 10.2106/JBJS.J.01371.
View Abstract at PubMed
Iannotti JP, Ramsey ML, Williams GR Jr, Warner JJ. Nonprosthetic management of proximal humeral fractures. Instr Course Lect. 2004;53:403-16. Review.
View Abstract at PubMed
Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021. Review.
View Abstract at PubMed
Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review.
View Abstract at PubMed
Bae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Br. 2011 Jul;93(7):937-41.
View Abstract at PubMed
Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov;90(11):1407-13. doi: 10.1302/0301-620X.90B11.21070. Review. PubMed PMID: 18978256.
View Abstract at PubMed
Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 67 THROUGH 70
Figure 67 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had full active painless shoulder range of motion.

Question 2:

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

Options:

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

Correct Answer: Bone bruise

Explanation:

Question 3:

Options:

Extended medial parapatellar approach
Quadriceps snip
Extended tibial tubercle osteotomy
Medial epicondyle osteotomy

Correct Answer: Extended tibial tubercle osteotomy

Explanation:

Question 4:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

Question 5:

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Options:

pulselessness
palor
paresthesia
paralysis
increasing analgesia requirement

Correct Answer: pulselessness

Explanation:

Question 6:

Options:

Flexor digitorum longus tenotomy
Resection of the metatarsal head and pin fixation
Transfer of the flexor digitorum longus to the extensor tendon
Excision at the base of the proximal phalanx and syndactyly with the third toe
Arthrodesis of the second metatarsophalangeal joint

Correct Answer: Transfer of the flexor digitorum longus to the extensor tendon

Explanation:

Question 7:

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

Options:

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

Correct Answer: Most liposarcomas occur below the fascia.

Explanation:

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

Question 8:

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Options:

increased bone turnover in the cortical area.
inhibition of osteoclast-mediated bone resorption.
improved mineralization of cortical bone.
improved osteoblast organic matrix production.
improved organization of collagen matrix.

Correct Answer: inhibition of osteoclast-mediated bone resorption.

Explanation:

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 9:

Options:

Superior labrum anterior and posterior (SLAP) lesion
Bankart lesion
Rotator cuff interval tear
Rotator cuff tendinitis
Posterior glenohumeral subluxation

Correct Answer: Posterior glenohumeral subluxation

Explanation:

Question 10:

The therapeutic effect of etanercept in the treatment of rheumatoid arthritis is primarily mediated through

Options:

antagonism of tumor necrosis factor-alpha (TNF-α).
antagonism of matrix metalloproteinases (MMPs).
inhibition of COX2.
stimulation of interleukin-1 (IL-1).
stimulation of tissue inhibitors of metalloproteinases (TIMPs).

Correct Answer: antagonism of tumor necrosis factor-alpha (TNF-α).

Explanation:

Question 11:

Options:

a program of shoulder strengthening exercises.
decompression of the nerve at the spinoglenoid notch.
decompression of the nerve at the transverse suprascapular ligament.
release of the fascial elements of the muscle tethering the nerve.
arthroscopy, repair of the posterior labrum lesion, and an anterior capsular shift.

Correct Answer: a program of shoulder strengthening exercises.

Explanation:

Question 12:

Options:

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

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

Explanation:

Question 13:

Options:

Bone scan
Curettage and bone grafting of the cyst
Cast immobilization
Observation with reduced activity
Skeletal survey

Correct Answer: Observation with reduced activity

Explanation:

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 14:

Options:

Chevron osteotomy to correct hallux valgus
Custom orthosis to prevent further deformity
Observation only
Steroid injection to decrease inflammation
Extra-depth shoes

Correct Answer: Chevron osteotomy to correct hallux valgus

Explanation:

Question 15:

Options:

Enchondroma
Fibrous dysplasia
Osteogenic sarcoma
Aneurysmal bone cyst
Periosteal chondroma

Correct Answer: Fibrous dysplasia

Explanation:

Question 16:

Options:

A long leg cast in 90° of knee flexion for 6 weeks
Open reduction and internal fixation with a transphyseal 6.5-mm screw and washer
Arthroscopic anterior cruciate ligament reconstruction with hamstring tendons
Arthroscopic debridement and staged anterior cruciate ligament reconstruction when skeletally mature
Open reduction and internal fixation with suture or intra-epiphyseal screw placement

Correct Answer: Open reduction and internal fixation with suture or intra-epiphyseal screw placement

Explanation:

DISCUSSION: Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals. This injury is the equivalent of ruptures of the anterior cruciate ligament in adults. These fractures are classified as types 1 through 3. Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation. The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion. Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures. Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest. Preferred techniques would be with suture or an intra-epiphyseal screw
REFERENCES: Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60.
Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries. Injury 1999;30:289-292.
Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes. Am J Orthop 2003;32:103-105.
Vocke
AK, Vocke AR: Cartilaginous avulsion fracture of the tibial spine. Orthopedics 2002;25:1293-1294.

Question 17:

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

Options:

Subscapularis tear
Bursal-sided rotator cuff tear
Articular-sided rotator cuff tear
Tight anterior capsule
Laxity of the posterior capsule

Correct Answer: Articular-sided rotator cuff tear

Explanation:

Question 18:

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Options:

Left ventricular hypertrophy by voltage on electrocardiography (ECG)
Primary AV block on ECG
II/IV systolic murmur increased with standing and Valsalva maneuver
Nonspecific STT wave changes in the lateral leads on ECG
Resting sinus bradycardia at 40 beats per minute

Correct Answer: II/IV systolic murmur increased with standing and Valsalva maneuver

Explanation:

Question 19:

What is the most common bacteria cultured from dog and cat bites to the upper extremity?

Options:

Pasteurella
Streptococcus
Staphylococcus
Bacteroides
Moraxella

Correct Answer: Pasteurella

Explanation:

DISCUSSION: To define bacteria responsible for dog and cat bite infections, a prospective study yielded a median of five bacterial isolates per culture. Pasteurella is most common from both dog bites (50%) and cat bites (75%). Pasteurella canis was the most frequent pathogen of dog bites, and Pasteurella multocida was the most common isolate of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria.
REFERENCE: Talan DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med 1999;340:85-92.

Question 20:

Options:

parental abuse.
abnormal osteoclast function.
defective N-Ac-Gal-6 sulfate sulfatase enzyme.
a quantitative defect of type I collagen synthesis.
vitamin D deficiency.

Correct Answer: a quantitative defect of type I collagen synthesis.

Explanation:

Question 21:

What tendon has an intra-articular (instrasynovial) location in the knee joint?

Options:

Patellar
Popliteal
Semitendinosus
Semimembranosus
Biceps femoris

Correct Answer: Popliteal

Explanation:

Question 22:

4 mg/kg for 48 hours

Options:

Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours

Correct Answer: Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours

Explanation:

Question 23:

Options:

Reposition the harness to hold the hips in 70 degrees of abduction
Closed reduction and arthrography under anesthesia
Open reduction and a spica cast
Continued harness treatment in the current position
Spica cast

Correct Answer: Continued harness treatment in the current position

Explanation:

Question 24:

Options:

excision of the osteophytes and loose bodies and anterior and posterior capsular releases.
removal of the loose bodies.
anterior capsular release.
anterior and posterior capsular releases.
interposition arthroplasty.

Correct Answer: excision of the osteophytes and loose bodies and anterior and posterior capsular releases.

Explanation:

Question 25:

Options:

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

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

Question 26:

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Options:

Ability to sit independently by age 2 years
Ability to creep by age 2 years
Ability to roll by age 2 years
Pattern of cerebral palsy (quadriplegia, diplegia, hemiplegia)
Type of motor dysfunction (spastic, ataxic, dyskinetic, hypotonic)

Correct Answer: Ability to sit independently by age 2 years

Explanation:

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 27:

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 28:

Options:

Normothermia
Hemoglobin of less than 9 g/dL
Unilateral lung contusion evident on CT only
Injury severity score of greater than 40 without thoracic injury
Injury Severity Score of less than 18 with a pulmonary contusion

Correct Answer: Injury severity score of greater than 40 without thoracic injury

Explanation:

Question 29:

Options:

synovectomy.
local excision with arthroplasty.
radiation synovectomy.
radiation therapy.
radical resection.

Correct Answer: synovectomy.

Explanation:

Question 30:

Options:

Flexor tendons
Lateral band
Lumbrical
Volar plate

Correct Answer: Volar plate

Explanation:

Question 31:

Options:

free vascularized fibula.
calcium sulfate pellets.
corticocancellous autograft.
demineralized bone matrix. The patient developed a large bone defect after undergoing multiple débridements for an open fracture. The most appropriate graft in this setting is a vascularized bone graft. Considering the length of the defect, a free vascularized fibular graft would be a suitable graft. The indications for a vascularized bone graft include infection, inadequate vascularity of the surrounding tissues, bone defects larger than 6 centimeters, and previous failed bone grafts. The osteocytes survive in the vascularized graft, allowing primary bone healing and thereby limiting a loss of graft strength. In contrast, nonvascularized bone graft heals by creeping substitution with a loss of its initial strength. Calcium sulfate pellets and calcium phosphate cement are synthetic bone substitutes with osteoconductive properties. Their role in fracture healing is limited. Demineralized bone matrix is the matrix remaining after allograft undergoes decalcification processing. These products alone would not be optimal in the treatment of such a large bone defect.

Correct Answer: free vascularized fibula.

Explanation:

Question 32:

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Options:

a total hip arthroplasty with a long-stem prosthesis.
a resection arthroplasty with skeletal traction.
hemiarthroplasty with a long-stem prosthesis.
retention of the prosthesis and open reduction and internal fixation.
closed treatment with skeletal traction.

Correct Answer: a total hip arthroplasty with a long-stem prosthesis.

Explanation:

Question 33:

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Options:

Early post-operative knee range of motion
Delayed weightbearing
Short working length of the construct
Bridge plate fixation
Plate-screw density less than 0.5

Correct Answer: Plate-screw density less than 0.5

Explanation:

Question 34:

Options:

Renal osteodystrophy
Pyogenic osteomyelitis
Osteoarthritis
Osteonecrosis
Tuberculosis osteomyelitis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 35:

Options:

Artery medial, then lateral
Artery lateral, then medial
Artery always medial
Artery always lateral
Artery always deep

Correct Answer: Artery medial, then lateral

Explanation:

DISCUSSION: At the ankle level, the anterior tibial artery lies medial to the EHL tendon. The artery becomes the dorsalis pedis after crossing onto the dorsum of the foot. At this point, the artery lies lateral to the tendon.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 36:

Which of the following properties apply to the human meniscus when compared with articular cartilage?

Options:

Less elastic and less permeable
Less elastic and more permeable
Of the same elasticity and permeability
More elastic and more permeable
More elastic and less permeable

Correct Answer: More elastic and less permeable

Explanation:

Question 37:

Options:

radiocapitellar joint dislocation.
fat pad sign.
proximal radioulnar joint dislocation.
double arc sign.

Correct Answer: double arc sign.

Explanation:

Question 38:

Options:

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

Correct Answer: - Avascular necrosis, head collapse, and screw penetration

Explanation:

Question 39:

Options:

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

Correct Answer: Staging studies to assess the extent of disease

Explanation:

Question 40:

-What do the T2-weighted, fat-saturated MRI scans shown in Figures 76a through 76d reveal?

Options:

Posterior cruciate ligament (PCL) tear, isolated
PCL tear and medial meniscus tear
Anterior cruciate ligament (ACL) tear, isolated
ACL tear and medial meniscus tear

Correct Answer: ACL tear and medial meniscus tear

Explanation:

Question 41:

Options:

pectoralis transfer to the medial border of the scapula.
pectoralis transfer to the inferior border of the scapula.
lateral transfer of the levator scapulae only.
lateral transfer of the levator scapulae and rhomboid minor and major.
latissimus dorsi transfer.

Correct Answer: lateral transfer of the levator scapulae and rhomboid minor and major.

Explanation:

Question 42:

Options:

-2.5 or below.
-3.0 or below. 5 +1.0 to +2.0.

Correct Answer: -2.5 or below.

Explanation:

Question 43:

Options:

Brachiocephalic
Innominate
Subclavian
Axillary
Circumflex scapular

Correct Answer: Axillary

Explanation:

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 44:

In addition to radiographs of the primary lesion and chest, MRI of the primary lesion, and CT of the chest, staging studies for Ewing’s sarcoma should include which of the following?

Options:

Bone scan and gallium scan
Bone scan and sentinel node biopsy
Bone scan and bone marrow biopsy
Bone marrow and sentinel node biopsy
Gallium scan and sentinel node biopsy

Correct Answer: Bone scan and bone marrow biopsy

Explanation:

Question 45:

Options:

Bilateral long thoracic nerve palsies
Central cervical disk herniation
Duchenne muscular dystrophy, adult onset
Fascioscapulohumeral dystrophy
Disuse atrophy as the result of deconditioning

Correct Answer: Fascioscapulohumeral dystrophy

Explanation:

Question 46:

Options:

MRI of the buttock.
CT of the buttock.
a needle biopsy.
an incisional biopsy.
an excisional biopsy.

Correct Answer: MRI of the buttock.

Explanation:

Question 47:

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Options:

Long-arm thumb spica casting
Bracing and bone stimulation
Scaphoid excision with intercarpal fusion
Bone grafting with screw placement

Correct Answer: Bone grafting with screw placement

Explanation:

Question 48:

Varus intertrochanteric osteotomy for coxa valga commonly produces which of the following results?

Options:

Decreased abductor lever arm
Increased hip joint reaction force
Increased center edge angle
Abductor lag and lurch
Lengthening of the leg

Correct Answer: Abductor lag and lurch

Explanation:

Question 49:

Options:

Substance P
Glutamate
Rho kinase
Nitric oxide

Correct Answer: Nitric oxide

Explanation:

EXPLANATION:
Nitric oxide is the only transmitter listed that is not inhibited by botulinum toxin. Substance P and glutamate are inhibited by botulinum toxin from release by pain nociceptors, thus reducing pain. Fonseca and associates have postulated that botulinum toxin inhibits the RhoA kinase pathway by blocking reactive oxygen species, which in turn does not allow actin/myosin to activate, thus preventing vasoconstriction of smooth muscle. Blocking the RhoA kinase pathway allows the action of nitric oxide to be unopposed, causing vasodilation. Nitric oxide is a potent vasodilator. Thus, botulinum toxin
promotes nitric oxide activity to increase vasodilation.

Question 50:

Options:

gentle stretching and serial casting.
Bryant traction for 1 to 2 weeks, followed by closed reduction.
percutaneous quadriceps recession, followed by serial casting.
delayed open reduction at age 6 months to avoid iatrogenic damage to either the distal femoral or proximal tibial physes.
a renal ultrasound.

Correct Answer: gentle stretching and serial casting.

Explanation:

Question 51:

Options:

hemivertebra excision.
anterior and posterior spinal fusion with instrumentation from T4 to L4.
convex anterior hemiepiphyseodesis.
convex posterior hemiarthrodesis.
an orthosis.

Correct Answer: hemivertebra excision.

Explanation:

Question 52:

Figures 71a and 71b/ are the MR images of a 65-year-old man who dislocated his shoulder. What is his most likely chief symptom?

Options:

Numbness in the anterior aspect of his shoulder
Recurrent instability
Difficulty raising his arm
Biceps muscle deformity

Correct Answer: Difficulty raising his arm

Explanation:

DISCUSSION
This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation. Loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction and external rotation, which results in difficulty raising an arm. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve that supplies sensation to the lateral aspect of the shoulder, not the anterior aspect. Recurrent instability is uncommon unless there is a labral tear or massive subscapularis tear. The biceps muscle is not viewed in the MR images, and a complete proximal biceps tendon rupture would be uncommon in the setting of an anterior shoulder dislocation.
CLINICAL SITUATION FOR QUESTIONS 72 THROUGH 75
Figures 72a through 72e are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0 degrees
to 90 degrees and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted.

Question 53:

Options:

5 mm
10 mm
15 mm
20 mm
25 mm

Correct Answer: 20 mm

Explanation:

Question 54:

Options:

laminectomy.
hemilaminectomy.
laminectomy and posterolateral fusion.
anterior interbody fusion.
posterolateral fusion.

Correct Answer: laminectomy and posterolateral fusion.

Explanation:

Question 55:

- Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Options:

Injury to the subclavian artery
Injury to the brachial plexus
Segmental fracture
100% displacement
Associated displaced surgical neck fracture of the humerus

Correct Answer: Injury to the subclavian artery

Explanation:

Question 56:

Figure 30a is the anteroposterior radiograph of a 20-year-old woman with mild right groin pain and intermittent “catching” in the hip region. What is the most appropriate next step? tear

Options:

Arthroscopic evaluation and treatment of the hypertrophic labrum and a possible labral
A hip injection to confirm an intra-articular source of the pain
Nonsurgical treatment and subsequent total hip arthroplasty (THA) when the patient is
sufficiently symptomatic
Periacetabular osteotomy

Correct Answer: sufficiently symptomatic

Explanation:

Question 57:

Options:

vagus nerve.
recurrent laryngeal nerve.
superior laryngeal nerve.
hypoglossal nerve.
sympathetic trunk.

Correct Answer: recurrent laryngeal nerve.

Explanation:

Question 58:

Options:

Incision and drainage of the abscess
Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks
Open biopsy
Hematoma evacuation and musculotendinous repair
Primary wide resection followed by radiation therapy

Correct Answer: Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks

Explanation:

DISCUSSION: The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T
1
-weighted MRI scan, the defined fluid signal on the T
2
-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.
REFERENCES: Hughes C IV, Hasselman CT, Best TM, et al: Incomplete, intrasubstance strain injuries of the rectus femoris muscle. Am J Sports Med 1995;23:500-506.
Temple HT, Kuklo TR, Sweet DE, et al: Rectus femoris muscle tear appearing as a pseudotumor. Am J Sports Med 1998;26:544-548.

Question 59:

What pharmacologic agents are preferred for the treatment of symptomatic active Paget’s disease?

Options:

Nasal calcitonin
Bisphosphonates
Nonsteroidal anti-inflammatory drugs
Furosemide
Antiviral therapy

Correct Answer: Bisphosphonates

Explanation:

Question 60:

Which of the following physical examination findings is most likely present in the condition producing the MRI findings shown in Figure 92?

Options:

Valgus laxity at 30 degrees of knee flexion
Varus laxity at 30 degrees of knee flexion
Posterior drawer
Pivot shift
Patellar apprehension

Correct Answer: Pivot shift

Explanation:

DISCUSSION: The T
2
-weighted sagittal MRI scan shows the classic “bone bruise” pattern seen with an anterior cruciate ligament (ACL) tear. These lesions are thought to represent subcortical trabecular hemorrhages and are manifested as an increase in signal intensity on T
2
-weighted images and diminished signal intensity on T
r
weighted images. They are classically located in the mid-portion of the lateral femoral condyle and posterior aspect of the lateral tibial plateau. This is due to the fact that an ACL tear typically is the result of a valgus-extemal rotation of the femur on the fixed tibia. This places most of the weight-bearing stress on the lateral femoral condyle, which rotates laterally and impacts the posterior lip of the lateral tibial plateau. This may result in an impaction fracture if the force is great enough, but more frequently causes merely a microfracture of the involved subcortical trabeculae.
REFERENCES: Vellet AP, Marks PH, Fowler PJ, et al: Occult posttraumatic osteochondral lesions of the knee: Prevalence, classification, and short-term sequelae evaluated with MR imaging. Radiology 1991;178:271-276.
Cone R: Imaging sports-related injuries of the knee, in DeLee J, Drez D, Miller M (eds): DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 2, pp 1595-1652.

Question 61:

Options:

Catterall II involvement.
tubercular synovitis.
Herring type A involvement.
hinge abduction.
osteochondritis dissecans.

Correct Answer: hinge abduction.

Explanation:

Question 62:

Options:

Postoperative indomethacin for 3 weeks
Postoperative indomethacin for 6 weeks
No treatment indicated; can treat later if heterotopic bone forms
800 centigrey of radiation given to the periprosthetic soft tissues preoperatively on the morning of surgery
400 centigrey of radiation given to the periprosthetic soft tissues day 2 postoperatively

Correct Answer: 800 centigrey of radiation given to the periprosthetic soft tissues preoperatively on the morning of surgery

Explanation:

Question 63:

Options:

Posterior oblique
Dorsal radial
Anterior oblique
Dorsal trapeziometacarpal

Correct Answer: Anterior oblique

Explanation:

Question 64:

Options:

decreased longevity.
worsening of sitting balance.
worsening of pulmonary function.
temporary loss of upper extremity function.
poor patient or parent satisfaction.

Correct Answer: temporary loss of upper extremity function.

Explanation:

Question 65:

Disadvantages of anterior-inferior plate fixation for acute clavicular fractures relative to superior plating include

Options:

more prominent implants leading to higher rate of reoperation for implant removal.
a higher nonunion rate.
inferior fixation due to shorter screw lengths laterally.
an increased need to detach the deltoid origin.
an increased risk for injury to subclavian structures.

Correct Answer: an increased need to detach the deltoid origin.

Explanation:

Question 66:

Options:

Skeletal traction
Temporizing external fixation
Reamed intramedullary nailing
Unreamed intramedullary nailing
Open reduction and internal fixation

Correct Answer: Reamed intramedullary nailing

Explanation:

Question 67:

- An 8-year-old girl has a supracondylar fracture of the distal humerus. Her neurovascular status is intact. Radiographs show hyperextension of 10 degrees of the distal fragment and an angle between the humeral shaft and capitellar physis (Baumann’s angle) of 88 degrees. Management should consist of

Options:

Olecranon pin traction
Closed reduction and pin fixation
Open reduction and internal fixation
Cast immobilization in this position
An arteriogram to rule out an occult intimal tear of the brachial artery

Correct Answer: Closed reduction and pin fixation

Explanation:

Question 68:

Options:

Continued serial neurologic examinations
CT with a myelogram of the lumbar spine
Immediate surgical exploration and hematoma drainage
Electromyography of bilateral lower extremities
IV antibiotics for 24 hours, followed by surgical exploration if symptoms persist

Correct Answer: Immediate surgical exploration and hematoma drainage

Explanation:

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 69:

The most appropriate treatment for this fracture is

Options:

revision TKA.
revision of the tibial component with a stem extension.
cast immobilization.
open reduction and internal fixation of the fracture.

Correct Answer: open reduction and internal fixation of the fracture.

Explanation:

Question 70:

Options:

Intramedullary pinning
Bone stimulator
Sling for comfort, followed by gentle range-of-motion exercises
Open reduction and internal fixation with a plate and screws
Arthroscopic distal clavicle resection

Correct Answer: Sling for comfort, followed by gentle range-of-motion exercises

Explanation:

Question 71:

Which of the following statements is most accurate regarding undetected intraoperative surgical glove perforation?

Options:

Undetected intraoperative surgical glove perforation is rare.
The index finger and left hand are the most common sites of surgical glove perforation.
The primary surgeon is more likely to sustain an undetected surgical glove perforation, as opposed to the scrub nurse or surgical assistant.
Surgical time is not related to the frequency of surgical glove perforation.
Undetected surgical glove perforation is rare in surgeries lasting 3 hours or longer.

Correct Answer: The index finger and left hand are the most common sites of surgical glove perforation.

Explanation:

Question 72:

Options:

fracture kyphosis.
reduction of retropulsed bone.
pain reduction.
incidence of complications.
return to work.

Correct Answer: incidence of complications.

Explanation:

Question 73:

Options:

Single incision, anterior approach with fixation through drill holes in the radius
Single incision, anterior approach with suture anchor fixation to the radius
Single incision, anterior approach through a drill hole in the radius with sutures tied over bolster or button on the posterior forearm
Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes
Dual incision, limited anterior and posterior muscle-splitting approach (supinator and extensor muscles) with attachment through drill holes

Correct Answer: Dual incision, limited anterior and posterior approach along the ulna with attachment through drill holes

Explanation:

Question 74:

Options:

arthrotomy, irrigation, and tibial polyethylene exchange.
parenteral antibiotics.
nonsurgical treatment without antibiotics.
removal of the implant and a 2-stage procedure.

Correct Answer: nonsurgical treatment without antibiotics.

Explanation:

Question 75:

Options:

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

Correct Answer: Aspiration of the left hip

Explanation:

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

Question 76:

Options:

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

Correct Answer: Excise the spacer

Explanation:

Question 77:

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

Options:

Saphenous vein
Saphenous nerve
Posterior tibial nerve
Sural nerve
Plantaris muscle

Correct Answer: Sural nerve

Explanation:

Question 78:

Figures A and B are post-operative radiographs of a 54-year-old female. In the first 6 months after this procedure, what is the most likely factor for functional impairment in this patient?

Options:

Osteonecrosis
Anterior knee pain
Re-fracture
Hardware failure
Non-union

Correct Answer: Osteonecrosis

Explanation:

Question 79:

Options:

Lateral radiographs with passive flexion/extension views
Helical CT scan of the cervical-thoracic region
Careful manual palpation of the cervical spine for subtle defects or step-offs
MRI of the cervical spine
Continued use of the cervical collar until the patient becomes responsive for examination

Correct Answer: Helical CT scan of the cervical-thoracic region

Explanation:

Question 80:

A patient falls off a roof and sustains the fracture shown in Figure 29. What is the most likely complication that results from injury to the structure that is located at the arrow?

Options:

Paresthesias on the plantar aspect of the foot
Pain or popping with great toe flexion
Loss of the arch
Inability to flex the lesser toes
Spring ligament rupture

Correct Answer: Pain or popping with great toe flexion

Explanation:

Question 81:

Options:

Open biopsy
Incision and debridement
Decompression
Decompression and instrumented fusion
Decompression and uninstrumented fusion

Correct Answer: Decompression and instrumented fusion

Question 82:

- A 30-year-old man underwent replantation of his dominant thumb at the metacarpophalangeal joint level 2 days ago. Since replantation, the temperature of the thumb has been between 87.8 F (31 C) and 93.2 F (34 C). The temperature is now 82.4 F (28 C), and there is brisk capillary refill and venous engorgement. Management at this time should include

Options:

Surgical exploration
Application of leeches
Stellate ganglion blocks
Intra-arterial streptokinase
Elevation and reevaluation in 1 hour

Correct Answer: Surgical exploration

Explanation:

Question 83:

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Options:

lying completely supine in bed.
remaining seated and placing the postsurgical leg on a stool.
transferring back to bed with the head of the bed no lower than 60 degrees.
transferring back to bed with the head of the bed level and the surgical knee flexed.

Correct Answer: transferring back to bed with the head of the bed level and the surgical knee flexed.

Explanation:

Question 84:

Options:

Superior labral detachment
Engaging Hill-Sachs lesion
Large glenoid rim fracture
Avulsion of the inferior glenohumeral ligament from the humerus
Avulsion of the anterior inferior glenoid labrum

Correct Answer: Avulsion of the anterior inferior glenoid labrum

Explanation:

DISCUSSION: In an acute first-time dislocation, arthroscopy has been shown to reveal a Bankart lesion in most shoulders. The classic finding of labral detachment from the anterior inferior glenoid along with occasional hemorrhage within the inferior glenohumeral ligament is the most common sequelae of a traumatic anterior inferior dislocation. Acute treatment, if chosen, is repair of the labral tissue back to the glenoid plus or minus any capsular plication to address potential plastic deformation of the glenohumeral ligament. Acute treatment of a patient sustaining a first-time dislocation remains controversial. The potential indications may be patients whose dislocation occurs at the end of a season and when the desire to minimize risk of future instability outweighs the risks of surgical intervention.
REFERENCES: Taylor DC, Arciero RA: Pathologic changes associated with shoulder dislocations: Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25:306-311.
DeBerardino TM, Arciero RA, Taylor DC, et al: Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes: Two- to five-year follow-up. Am J Sports Med 2001;29:586-592.
Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic,
first-time shoulder dislocations. Am J Sports Med 2002;30:576-580.

Question 85:

Options:

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

Correct Answer: Physical therapy

Question 86:

04 Which of the following laboratory studies is predictive of wound healing prior to performing a lower extremity amputation?

Options:

Total protein level
Calcium level
Serum albumin level
Platelet count
ESR back answer Question 11.04

Correct Answer: Serum albumin level

Explanation:

Question 87:

Figure 44 shows the radiograph of an 11-year-old girl who has hip pain. Further diagnostic workup should include

Options:

a renal ultrasound.
an echocardiogram.
an electromyogram.
an MRI scan of the spine.
an iliac crest biopsy.

Correct Answer: an echocardiogram.

Explanation:

Question 88:

Figure 35 shows the AP radiograph of a patient who underwent a previous upper tibial osteotomy (UTO). The patient may be at risk for which of the following during total knee arthroplasty (TKA)?

Options:

Bone loss
Patella alta
Myositis ossificans
Fracture
Instability

Correct Answer: Instability

Explanation:

DISCUSSION: The results of TKA for patients with a prior UTO are reported to be slightly suboptimal. The major problems are patella baja, difficulty in exposure, and instability. Most of the patients exhibit some degree of instability prior to TKA, and ligamentous balancing may be difficult. Ligamentous structures are at risk of rupture during the difficult exposure. The problem of ligamentous balancing is exacerbated by the change in the joint slope that can occur after UTO.
REFERENCES: Parvizi J, Hanssen AD, Spangehl MJ: Total knee arthroplasty following proximal tibial osteotomy: Risk factors for failure. J Bone Joint Surg Am 2004;86:474-479.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy: A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 89:

Which of the following is considered the cause of Milwaukee shoulder, a joint disease similar to rotator cuff arthropathy?

Options:

Abundance of basic calcium phosphate crystals
Abundance of calcium pyrophosphate crystals
Gout
Rheumatoid arthritis
Osteonecrosis

Correct Answer: Abundance of basic calcium phosphate crystals

Explanation:

Question 90:

- What is the primary immediate source of energy for muscle?

Options:

Glycolytic pathway
Oxidative phosphorylation
Breakdown of fat
Breakdown of protein
Breakdown of adenosine triphosphate

Correct Answer: Breakdown of adenosine triphosphate

Explanation:

Question 91:

Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?

Options:

The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.

Correct Answer: Aerobic metabolism has been restored in all tissue beds.

Explanation:

DISCUSSION: Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation end points: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 92:

What is the most common surgical cause of the foot deformity shown in Figure 9?

Options:

Medial tibial sesamoid subluxation
Overcorrection of the intermetatarsal angle
Excessive postoperative dressing application
Excessive medial eminence resection
Excessive lateral soft-tissue release and lateral sesamoidectomy

Correct Answer: Excessive lateral soft-tissue release and lateral sesamoidectomy

Explanation:

Question 93:

Which of the following clinical scenarios represents an appropriate indication for convex hemiepiphysiodesis/hemiarthrodesis in the treatment of a child with a congenital spinal deformity?

Options:

A 3-year-old child with a hemivertebra opposite a contralateral bar and thoracic scoliosis that measures 53°
A 4-year-old child with a fully segmented L1 hemivertebra and scoliosis that measures 80°
A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°
A 4-year-old child with a posterolateral hemivertebra at the thoracolumbar junction and a kyphoscoliotic deformity that measures 45°
A 10-year-old child with a hemivertebra and scoliosis that measures 50°

Correct Answer: A 4-year-old child with a fully segmented T10 hemivertebra and scoliosis that measures 50°

Explanation:

Question 94:

When a Workers' Compensation patient recovers after an injury to a point that further restoration of function is no longer anticipated, he or she is said to have reached which of the following?

Options:

Functional capacity
Maximum medical improvement
Permanent disability
Impairment rating
Predesignation

Correct Answer: Maximum medical improvement

Explanation:

Question 95:

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Options:

a Pavlik harness.
observation.
closed reduction and a spica cast.
open reduction and femoral shortening.
open reduction.

Correct Answer: open reduction.

Explanation:

Question 96:

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

Options:

Axillary nerve injury
Anterior dislocation
Extension of a chronic large rotator cuff tear
Suprascapular nerve entrapment from a ganglion cyst
Greater tuberosity avulsion

Correct Answer: Extension of a chronic large rotator cuff tear

Explanation:

Question 97:

Options:

external beam radiation.
curettage and cementation of the lesion with a compression hip screw and side plate fixation.
curettage and cementation of the lesion with intramedullary fixation.
cemented bipolar hemiarthroplasty.
radioactive iodine infusion.

Correct Answer: cemented bipolar hemiarthroplasty.

Explanation:

Question 98:

Options:

Arthroscopy of the wrist
CT of the wrist
PA clenched fist radiograph
Electromyography and nerve conduction velocity studies
AP and lateral radiographs of the forearm

Correct Answer: PA clenched fist radiograph

Explanation:

Question 99:

- A 15-year-old girl has a thoracic kyphosis that causes mild pain. Examination reveals a sagittal curve measuring 55 degrees and wedging of the eighth through tenth vertebrae. The iliac apophyses are Risser 4. Management should include

Options:

observation and exercises
bracing with a thoracolumbar orthosis
fusion of the posterior spine
fusion of the anterior spine
fusion of the anterior and posterior spine

Correct Answer: observation and exercises

Explanation:

Question 100:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

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

Orthopedic Surgery Board Review MCQs: Trauma & Arthroplasty | Part 249

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 249

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index