Orthopedic Board Review MCQs: Spine, Fracture & Ligament

Orthopedic Board Review MCQs: Spine, Fracture & Ligament | Part 257

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Comprehensive 100-Question Exam

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Question 1

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Explanation

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 2

Initial postoperative management after repair of an acute rotator cuff tear includes

Explanation

DISCUSSION: In the immediate postoperative period following repair of an acute rotator cuff tear, passive forward elevation and external rotation should be performed within the safe zone determined at surgery. Early active range of motion (prior to tendon healing), internal rotation behind the back, and resistive exercises increase the risk of rupture of the repair.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tear: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Bigliani LU, Cordasco FA, McIlveen ST, et al: Operative repair of massive rotator cuff tears: Long-term result. J Shoulder Elbow Surg 1992;1:120-130.

Question 3

A patient with myelopathy underwent a one-level corpectomy 1 day ago and is now home. In the middle of the night he calls to report markedly increased difficulty in swallowing, diaphoresis, a change in his voice, and difficulty lying flat. What is the best course of action?

Explanation

DISCUSSION: The patient has respiratory distress as manifested by his difficulty in lying flat. In addition, the diaphoresis and the change in his voice indicate retropharyngeal edema or hematoma that is compressing his larynx. The only appropriate treatment is hospital admission and elective intubation. During intubation it is possible to cause laryngospasm in a patient with a hyperacute airway; therefore, the surgeon should be prepared to perform a cricothyroidotomy. Often a fiberoptically guided intubation is the only way to find the airway in the presence of retropharyngeal edema or hematoma.
REFERENCES: Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.
McAfee PC, Bohlman HH, Riley LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am 1987;69:1371-1383.

Question 4

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Explanation

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658. View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666. View Abstract at
PubMed

Question 5

A patient with Pott's disease, tuberculosis of the spine, is more likely to have which of the following early findings? Review Topic

Explanation

Tuberculosis of the spine typically has an indolent presentation. Unlike pyogenic infections of the spine, the disk space is usually preserved. Most commonly, the thoracic and lumbar spine are affected. Laboratory studies may be nonspecific. Delayed presentation usually results in neurologic compromise and a kyphotic deformity. Treatment includes a multidrug regimen. Surgery is indicated for deformity correction or failure of medical treatment.

Question 6

Which structure is indicated by the arrow in Figure 33?

Explanation

DISCUSSION
The posterior position of the sciatic nerve in relation to the acetabulum and the lateral peroneal division makes the peroneal division of the sciatic nerve the portion of the nerve that is most likely to be injured in a posterior traumatic hip dislocation, accounting for up to 10% of concomitant nerve injuries with posterior hip dislocation. The corona mortis is an anatomic variant that results in vascular anastomosis between the obturator and either the external iliac or inferior epigastric arteries. This variant occurs in approximately 80% of patients and varies in its position, being located 4 cm to 9 cm lateral to the symphysis pubis. The obturator vascular bundle is situated in the fat medial to the obturator internus muscle and must be mobilized to access the quadrilateral plate. Dissection may be carried out both above and below this vascular leash. The Kocher-Langenbeck approach is indicated for fractures involving the posterior wall and/or posterior column of the acetabulum and for both column fractures that require direct posterior visualization. This approach is not indicated for direct reduction of the anterior wall or column when direct visualization is required anteriorly. The L5 nerve root is located on the anterior sacrum and is indicated by the arrow.
The position of this neural structure must be considered whether the surgeon is stabilizing 31 the sacroiliac (SI) joint with percutaneous iliosacral screws or with anterior SI plating through the lateral window of the ilioinguinal approach.
RECOMMENDED READINGS
Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91. Review. PubMed PMID: 10943188. View Abstract at PubMed
Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat. 2007 May;20(4):433-9. PubMed PMID: 16944498. View Abstract at PubMed
Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PubMed PMID: 21368098. View Abstract at PubMed
Rommens P. The Kocher-Langenbeck approach for the treatment of acetabular fractures. Operat Orthop Traumatol 2004; 16:59-74.
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013 Aug;21(8):458-68. doi: 10.5435/JAAOS-21-08-458. Review. PubMed PMID: 23908252.View Abstract at PubMed

Question 7

A year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Explanation

DISCUSSION:
This situation represents a definitively and chronically infected knee replacement. Antibiotic therapy alone might suppress the infection but would not eradicate it. Debridement and polyethylene exchange would be appropriate treatment for an early postoperative infection. The treatment of choice is to perform a two-stage debridement and reconstruction. Although not among the listed choices, an aspiration or culture could be done presurgically and might help clinicians identify the best antibiotics to treat the condition. Antibiotic selection would not affect the need for the two-stage reconstruction, however.

Question 8

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Explanation

DISCUSSION: Unstable pelvic fractures can be devastating injuries often resulting in significant morbidity and even death.
According to the referenced study by Smith et al, fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased ISS or RTS scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours).
Incorrect Answers: Choices 1-4 are not as predictive of mortality as choice 5.

Question 9

A 43-year-old man sustained a closed, intra-articular pilon fracture. It has now been 1 year since he underwent open reduction and internal fixation. Which of the following statements most accurately describes his perceived outcome? Review Topic

Explanation

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of

Question 10

Figure 46 shows the radiograph of a 65-year-old man who reports restricted range of motion and pain with sitting 18 months after undergoing right side revision total hip arthroplasty. What is the most appropriate management? L Intensive physiotherapy

Explanation

DISCUSSION: The presence of Brooker grade 1 or 2 heterotopic ossification (HO) does not influence the outcome of total hip arthroplasty, whereas restricted range of motion and pain may occur in patients with more severe grade 3 or 4 HO. Treatment may be nonsurgical or surgical. Nonsurgical management includes intensive physiotherapy during the maturation phase of the disease in an attempt to limit the final stiffness. There appears to be no data regarding the effectiveness of this treatment. There is no role for NSAIDs or radiotherapy as a treatment for preexisting HO. Surgical treatment involves excision of the heterotopic bone and can be expected to improve the functional outcome. Bisphosphonates have been used in the past, but their use has been discontinued as they only postpone ossification until treatment is stopped.
REFERENCES: Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 2007;89:434-440.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative
Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Question 11

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

Explanation

DISCUSSION: Low-molecular-weight heparin is highly bioavailable with a half-life
to 18 hours. This is greater than the 1 hour half-life of unfractionated heparin.

Low-molecular-weight heparin offers an advantage over unfractionated heparin by selectively targeting Factor Xa while having a lesser effect on circulating thrombin (Factor IIa). Circulating thrombin Factor IIa is needed for local hemostasis at the site of the surgical wound. Clinical studies have shown a reduction by one third in the incidence of thrombocytopenia with the use of low-molecular-weight heparin. Low-molecular-weight heparin has been shown to demonstrate similar clinical results compared to warfarin with respect to preventing thromboembolic disease after total hip arthroplasty and complications such as bleeding.
REFERENCES: Zimlich RH, Fulbright BM, Friedman RJ: Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996;4:54-62.
Colwell CW Jr, Spiro TE, Trowbridge AA, et al: Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Torholm C, Broeng L, Jorgensen PS, et al: Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery: A placebo controlled study. J Bone Joint Surg Br 1991;73:434-438.

Question 12

A 21-year-old man sustains multiple gunshot wounds to his right upper extremity. He can not extend his digits or his thumb but can extend and radially deviate his wrist. An injury to the radial nerve or one of its branches has most likely occurred at which of the following locations?

Explanation

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 13

In the treatment of rheumatoid arthritis, which medication is an antagonist of tumor necrosis factor-alpha?

Explanation

Etanercept is a biochemically designed tumor necrosis factor receptor immunoglobulin G fusion protein, which binds to TNF-alpha and is thus a TNF-alpha antagonist.
TNF-alpha is considered to be one of the major cytokines involved in rheumatoid arthritis pathology. As a result, many biologic agents used to treat rheumatoid arthritis (RA) are manufactured to block TNF-alpha or its receptors. This has been shown to reduce inflammation and stop disease progression. In the USA, Etanercept is approved to treat rheumatoid arthritis, juvenile rheumatoid arthritis and psoriatic arthritis, plaque psoriasis and ankylosing spondylitis. The route of administration is subcutaneous.
Bongartz et al. used a randomized control trial to asses the risk of infection and malignancy rates in RA treated with TNF-alpha antagonist. Overall, patients with RA appear to have an approximately 2-fold increased risk of serious infection compared to the general population and non-RA controls, irrespective of TNF-alpha antagonist use. The pooled odds ratio for malignancy was 3.3 (95% confidence interval [CI], 1.2-

Question 14

A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?

Explanation

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 15

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Explanation

DISCUSSION: The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.
The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."

Question 16

Which of the following best describes the resultant forces on an increased offset stem when compared with a standard offset stem?

Explanation

DISCUSSION: The increased emphasis on restoring offset in total hip arthroplasty has implications for the forces applied to the components and the fixation interfaces. Static analysis has shown that with an increased affect, joint reaction force on the articulation is decreased. When the resultant load on the hip is “out of plane” (ie, directed anterior to posterior), there is increased torsion where the stem is turned into more retroversion.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 134-180.
Hurwitz DE, Andriaacchi TP: Biomechanics of the hip, in Callaghan J, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven , 1998.
Pauwels F: Biomechanics of the Normal and Diseased Hip. New York, NY, Springer-Verlag, 1976.

Question 17

A 19-year-old rugby player has severe knee pain after being injured in a game 2 weeks ago. Examination reveals a knee effusion, limited motion, and increased 3+ Lachman’s test and anterior drawer. There is also increased external rotation at 30 degrees of knee flexion when the patient is placed in the prone position. Based on these findings, which of the following actions would most likely increase the risk of anterior cruciate ligament (ACL) reconstruction failure?

Explanation

DISCUSSION: The patient has a combined ACL and posterolateral corner injury. Failure to diagnose and treat an injury of the posterolateral corner in a patient who has a tear of the anterior or posterior cruciate ligament can result in failure of the reconstructed cruciate ligament. The tibial external rotation test is best performed with the patient in the prone position. A 10-degree side-to-side difference of external rotation at 30 degrees of knee flexion indicates injury to the posterolateral corner. Acute grade III isolated or combined injuries of the posterolateral corner are best treated early by direct repair or by augmentation or reconstruction of all injured ligaments. Postoperative arthrofibrosis after an ACL reconstruction has been observed with preoperative deficiencies of knee motion.
REFERENCES: Veltri DM, Warren RF: Posterolateral instability of the knee. J Bone Joint Surg Am 1994;76:460-472.
Covey DC: Injuries of the posterolateral corner of the knee. J Bone Joint Surg Am

2001;83:106-118.

Question 18

4A 4B 4C A 30-year-old man was involved in a high-speed motorcycle collision and sustained the injury shown in Figure 4a. Hypotension ensued shortly after arrival in the emergency department. Figure 4b is the initial contrast pelvic CT image with an unrecognized blush consistent with arterial bleeding. During surgical repair, the patient was noted to have active bleeding and an angiogram was obtained (Figure 4c). Which structure is the likely cause of his bleeding?

Explanation

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678. View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733. View Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871. View Abstract at PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8

5B
- 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
Please choose from the responses to identify the most likely complication in each scenario.

Question 19

A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding. Review Topic

Explanation

A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 20

Which of the following statements best describes the anatomic considerations of the popliteal artery posterior to the knee joint?

Explanation

DISCUSSION: Popliteal artery injury during total knee arthroplasty is relatively rare. Knee flexion, the position that occurs during most of the arthroplasty procedure, allows the popliteal vessels to fall posteriorly, further away from harm. Anatomically, the popliteal artery lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in

90 degrees of flexion.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 151.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-53.

Question 21

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured?

Explanation

DISCUSSION: The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.
REFERENCES: Schenck CD: Anatomy of the innervation of the upper extremity, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, MO, Mosby-Year Book, 1991.
Hershman EB: Brachial plexus injuries. Clin Sports Med 1990;9:311-329.

Question 22

A healthy, active collegiate soccer player returns to your office approximately 10 months after returning to full play and 18 months after undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) autograft. The patient reports landing awkwardly after a jumping for a ball and felt his knee give way. He presents with pain, worse with weight bearing. On physical exam, there is a mild effusion and a grade 2B Lachman. Radiographs are shown in Figure A. What is the likely underlying cause of his current diagnosis? Review Topic

Explanation

The most common cause for early failure following ACL reconstruction is a malpositioned tunnel.
Ideal tunnel placement on the femoral side should be at the approximately 2 o'clock (for a left knee) or 10 o'clock (for a right knee) position on the lateral wall, which facilitates a more horizontal, anatomic graft. On the tibial side, the tunnel trajectory in the coronal plane should be about 60-75 degrees from the horizontal and the tunnel entrance should be approximately 10-11mm from the anterior border of the PCL.
Noyes et al. emphasize the importance of anatomic reconstruction. They recommended against using a transtibial tunnel to make the femoral tunnel because it will result in a vertical orientation. The authors summarized and recommended the use of individual drilling of each tunnel, and using a anteromedial portal to obtain the ideal femoral tunnel.
Driscoll et al. compared the rotational properties of a BTB graft placed centrally in the tibial footprint in both groups, but on the femoral side, placed in the anteromedial aspect versus central portion of the ACL femoral origin. They noted a significantly stronger resistance to rotational failure when placed centrally. Thus, noting the importance of placing the graft anatomically, within the central areas of both the tibial footprint and femoral origin.
Figure A exhibits malpositioned tunnels, both of which are too vertical. Illustration A exhibits well-placed tunnels, with the horizontality exhibited on the femoral side and approximately 75 degrees from the horizontal on the tibial side.
Incorrect answers:

Question 23

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

Explanation

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

Question 24

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Explanation

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci? Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 25

A 37-year-old man who works in a factory has isolated, lateral unicompartmental pain about his knee with activities. Nonsurgical management has failed to provide relief. The radiograph shown in Figure 45 reveals a tibiofemoral angle of approximately 15 degrees which is clinically correctable to neutral. What is the best surgical option in this patient?

Explanation

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 26

Figure 6 shows the lateral radiograph of a 22-year-old woman who has painful Scheuermanns’s kyphosis in the middle and lower thoracic spine. When planning surgical correction using instrumentation, the distal aspect of the instrumentation should ideally extend to the

Explanation

DISCUSSION: Posterior constructs for Scheuermann’s kyphosis ideally should extend from the most superior to the most inferior aspect of the Cobb angulation. However, the most distal fusion level must be in a stable or lordotic position to avoid the development of junctional kyphosis. Lowe reported that failure to incorporate the first lordotic segment of the lumbar spine is associated with a higher risk of junctional kyphosis. The first lordotic segment of the lumbar spine is typically at least one level below the distal aspect of the curve as measured by the Cobb technique and most commonly is in the upper part of the lumbar spine.
REFERENCES: Lowe TG: Scheuermann’s disease. Orthop Clin North Am 1999;30:475-487.
Lenke LG: Kyphosis of the thoracic and thoracolumbar spine in the pediatric patients: Prevention and treatment of surgical complications. Instr Course Lect 2004;53:501-510.

Question 27

Which of the following imaging modalities is most accurate in locating a toothpick in the plantar arch of the foot?

Explanation

DISCUSSION: Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot.
REFERENCES: Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.
Jacobson JA, Powell A, Craig JG, et al: Wooden foreign bodies in soft tissue: Detection at US. Radiology 1998;206:45-48.

Question 28

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

Explanation

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

Question 29

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

Explanation

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

Question 30

In the treatment of acetabular dysplasia, what type of pelvic osteotomy leaves the “teardrop” in its original position and redirects the acetabulum?

Explanation

DISCUSSION: The dial or spherical osteotomy leaves the medial wall or teardrop in its original position and, as a result, is intra-articular. The other pelvic osteotomies (except Chiari) redirect the acetabulum, including the medial wall. The Chiari osteotomy improves coverage without redirecting the acetabulum within the pelvis, and it leaves the teardrop in the same place.
REFERENCES: Lack W, Windhager R, Kutschera HP, Engel A: Chiari pelvic osteotomy for osteoarthritis secondary to hip dysplasia: Indications and long-term results. J Bone Joint Surg Br 1991;73:229-234.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Ninomija S, Tagwa H: Rotational acetabular osteotomy for the dysplastic hip. J Bone Joint Surg Am 1984;66:430.

Question 31

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

Explanation

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

Question 32

Figure 16a shows the radiograph of a 34-year-old woman who sustained a basicervical fracture of the femoral neck. The fracture was treated with a compression screw and side plate. Seven months postoperatively, she continues to have significant hip pain and cannot bear full weight on her hip. A recent radiograph is shown in Figure 16b. Management should now consist of

Explanation

DISCUSSION: The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.
REFERENCES: Marti RK, Schuller HM, Raaymakers EL: Intertrochanteric osteotomy for non-union of the femoral neck. J Bone Joint Surg Br 1989;71:782-787.
Ballmer FT, Ballmer PM, Baumgaertel F, et al: Pauwels osteotomy for nonunions of the femoral neck. Orthop Clin North Am 1990;21:759-767.

Question 33

The MRI scans and diagnostic ultrasound shown in Figures 2a through 2c show what pathologic condition? Review Topic

Explanation

The MRI scans and ultrasound show an articular surface partial-thickness rotator cuff tear of the supraspinatus tendon. This condition most commonly involves the supraspinatus tendon and is usually found on the articular surface where the blood supply is less robust. There are multiple intrinsic and extrinsic factors contributing to this condition which include age-related metabolic and vascular changes that lead to degenerative tearing, subacromial impingement, shoulder instability (typically anterior), internal impingement, and repetitive microtrauma. Acute trauma is less often the cause. The physical examination for this condition is often nonspecific and requires supplemental imaging studies for diagnosis.

Question 34

Which of the following patients is more likely to have an overall poorer outcome following a lower extremity amputation?

Explanation

Many factors influence the outcome of lower extremity amputations with worse outcomes noted in patients with lower socioeconomic status, preexisting medical conditions, and low self-efficacy. Patients with amputations performed in a zone of injury, especially if this was a through-the-knee amputation, have a significantly poorer outcome than those with either above-the-knee or below-the-knee amputations. Patients with above-the-knee amputations have similar outcomes to those with below-the-knee amputations, although those with below-the-knee amputations have faster self-selected walking speeds. Gender and sophistication of the prosthesis have no bearing on outcome. The type of muscle anchoring technique used also plays no role in outcome.

Question 35

This image represents the end stage of an uncompensated rotator cuff tear.

Explanation

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187. View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 36

A 58-year-old woman has had a painless periscapular mass for the past year. An MRI scan and biopsy specimen are shown in Figures 4a and 4b. What is the most likely diagnosis?

Explanation

DISCUSSION: Elastofibroma is a rare tumor that most commonly occurs in adults who are older than age 55 years. The lesions usually grow between the chest wall and the scapula, and 10% are bilateral. Histologic analysis shows that they are composed of equal amounts of elastin and collagen with occasional fibroblasts.
REFERENCES: Briccoli A, Casadei R, Di Renzo M, Favale L, Bacchini P, Bertoni F: Elastofibroma dorsi. Surg Today 2000;30:147-152.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby Year Book, 1995, pp 165-201.

Question 37

A 30-year-old man who sustained a work-related injury 6 weeks ago reports persistent back and left-sided buttock pain that has been attributed to lumbar transverse process fractures. A pelvic radiograph and CT scans obtained 2 days ago are seen in Figures 17a through 17c. What is the best treatment for his injury?

Explanation

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 38

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Explanation

Medoff described the radiographic teardrop of the distal radius. This radiographic landmark matches the critical volar ulnar corner of the distal radius. A malreduction of the volar ulnar corner of the distal radius in an intra-articular distal radius fracture leads to volar subluxation of the lunate and the rapid development of posttraumatic arthritis at the distal radioulnar and radiolunate joints. Knowledge of the specific shape and appearance of this radiographic landmark helps the surgeon when he or she is critically analyzing postreduction imaging. The volar portion of the ulnar head may be mistaken for this teardrop sign and should be separately identified as distinct from the distal radius. The radial styloid and Lister tubercle are not part of the volar aspect of the lunate facet.

Question 39

Internal impingement of the shoulder and posterosuperior labral pathology in throwers has been most clearly associated with which of the following? Review Topic

Explanation

Posterior capular contracture has been recognized to be the primary pathologic process resulting in internal impingement. Internal impingement of the shoulder describes contact between the posterosuperior glenoid labrum and the undersurface of the rotator cuff at the level of the posterior supraspinatus when the shoulder comes into abduction and external rotation. This contact may be physiologic or pathologic and is frequently seen in overhead throwing athletes, possibly resulting in articular-sided rotator cuff tears, glenoid labral tears, tendinitis of the long head of the biceps, anterior instability, glenohumeral internal rotation deficit, and dysfunction of scapular rhythm. Nonsurgical management is the initial treatment of choice with an emphasis on increasing range of motion and improving scapular mechanics. Anterior capsular laxity may be present with internal impingement but is variable and less directly associated with internal impingement than posterior capsular contracture.
Coracoacromial arch stenosis is associated with subacromial impingement and unrelated to internal impingement. Bennett's lesion refers to exostosis or calcification at the posterior capsule and while potentially associated with overhead throwing athletes who may have internal impingement, a causal link between the two has not been established and therefore posterior capsular contracture is the preferred response.

Question 40

A 17-year-old high school soccer player sustains an anterior cruciate ligament (ACL) tear at the beginning of the season. An MRI scan confirms a complete ACL tear with no meniscal injuries. The patient plans an early return to play and would like to avoid surgery. Therefore, the patient and family should be advised that nonsurgical management consisting of rehabilitative exercises and the use of a functional knee brace will most likely result in

Explanation

DISCUSSION: While there are athletes who can function at a full level with an ACL tear, they are in the minority. As yet, there is no reliable way to predict the patients who will be able to compensate for the loss of the ACL. Studies have confirmed the risk of recurrent instability and meniscal injury in athletes with an ACL-deficient knee who participate in cutting sports. One study showed that only 12 of 43 patients who attempted rehabilitation and bracing were able to return successfully for the season. Another study showed that 17 of 31 athletes who were able to return to their sport sustained 23 meniscal tears because of recurrent instability.
REFERENCES: Shelton WR, Barrett GR, Dukes A: Early season anterior cruciate ligament tears: A treatment dilemma. Am J Sports Med 1997;25:656-658.
Snyder-Mackler L, Fitzgerald GK, Bartolozzi AR III, Ciccotti MG: The relationship between passive joint laxity and functional outcome after anterior cruciate ligament injury. Am J Sports Med 1997;25:191-195.

Question 41

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

Explanation

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

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

Question 42

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Explanation

DISCUSSION: Epithelioid sarcoma is a rare soft-tissue sarcoma that most commonly arises in the hand or upper extremity, and it is frequently misdiagnosed as an infection or granuloma. It tends to have a higher incidence of lymph node metastasis than other soft-tissue sarcomas. The mainstay of treatment is wide surgical excision, even if amputation is necessary.
REFERENCES: Gupta TD, Chaudhuri P (eds): Tumors of the Soft Tissues, ed 2. Stamford, CT, Appleton and Lange, 1998, p 475.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St. Louis, MO, Mosby-Year Book, 1995, p 1074.

Question 43

What structure (arrow) is shown in Figure 24?

Explanation

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 44

A 71-year-old woman who reports long-term use of oral steroids for asthma is referred for treatment of a distal humerus fracture. Radiographs reveal diffuse osteopenia and a severely comminuted intra-articular fracture. What is the most appropriate treatment?

Explanation

DISCUSSION: Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.
REFERENCES: Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947.
Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the elderly: The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84:812-816.

Question 45

A 74-year-old man with ankylosing spondylitis falls off a step stool and now has a minimally displaced T10-T11 extension-type fracture. He is initially treated with percutaneous pedicle screw fixation from T8-L1 and has good pain relief. The next day, however, he experiences increased back pain and loss of strength in his lower extremities.

Explanation

DISCUSSION
Cauda equina syndrome, typically the result of severe central canal stenosis in the lower lumbar region, often is caused by a large central disk herniation. Symptoms include severe back or leg pain, perineal numbness, possible motor weakness, and initial urinary retention followed by an overflow incontinence. When bowel or bladder deficits are present, this is considered a surgical emergency because successful recovery is most likely if decompression occurs within the first 48 hours.
Ankylosing spondylitis can lead to progressive autofusion of the vertebrae and significant limitation in motion. Any sudden improvement in motion should be considered a fracture until proven otherwise. These fractures are commonly missed when using plain radiographs or even CT scan because minimal or no displacement often is noted. MR imaging can be useful to identify edema at
the fracture site. These fractures are typically very unstable and necessitate surgery to avoid displacement and potential neurologic injury.
Some fractures associated with ankylosing spondylitis can be effectively treated with percutaneous pedicle screw fixation. However, because of the highly vascular nature of some of these fractures, they pose risk for an epidural hematoma, potential neurologic deficit, and emergent decompression.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778. View Abstract at PubMed
Mathews M, Bolesta MJ. Treatment of spinal fractures in ankylosing spondylitis. Orthopedics. 2013 Sep;36(9):e1203-8. doi: 10.3928/01477447-20130821-25. PubMed PMID: 24025014.
View Abstract at PubMed
McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine (Phila Pa 1976). 2007 Jan 15;32(2):207-

Question 46

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Explanation

DISCUSSION: The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1009-1149.

Question 47

-An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is100 and blood pressure is 104/62. The best means with which to evaluate true hemodynamic status is

Explanation

Question 48

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Explanation

Question 49

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

Explanation

DISCUSSION: Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice. When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief. Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff. Open synovectomy is appropriate in early rheumatoid disease before articular changes are present. Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability.
REFERENCES: Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-337.
Neer CS II: Glenohumeral arthroplasty, in Neer CS II (ed): Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 143-271.
Pollock RG, Deliz ED, McIlveen ST, et al: Prosthetic replacement in rotator cuff deficient shoulders. J Shoulder Elbow Surg 1992;1:173-186.
Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Anderson NH: Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening. J Shoulder Elbow Surg 1996;5:47-52.

Question 50

A 36-year-old man was injured in a motorcycle collision and sustained the injury shown in Figure 70. He has a blood pressure (BP) of 70/40 mm Hg, pulse of 148 beats per minute (bpm), and Glasgow Coma Scale score of 6 (scores lower than 8 indicate severe brain injury), and there is negligible urine output. His airway is secure and intravenous (IV) access is obtained. Two liters of warm crystalloid solution are given; repeated vital signs reveal the same BP and a pulse of 142 bpm. What is the best next step?

Explanation

DISCUSSION
This patient has an anteroposterior compression pelvic fracture associated with shock. In patients with closed pelvic fractures and hypotension, mortality rises to approximately 1 in 4 (10%-42%) and hemorrhage is the major reversible contributing factor. Initial management of a major pelvic disruption associated with hemorrhage requires hemorrhage control and rapid fluid resuscitation. A pelvic binder should be placed to reduce pelvic volume. The patient has signs and symptoms of class IV hemorrhage, which include marked tachycardia exceeding 140, a significant decrease in BP, and a very narrow pulse pressure. Urinary output is negligible, and mental status is markedly depressed. The skin is cold and pale. The degree of exsanguination with class IV hemorrhage is immediately life threatening, and rapid transfusion and immediate surgical intervention are necessary. Nonresponse to fluid administration indicates persistent blood loss. Blood preparation should be emergency blood release. Type and cross-match of blood can be used for additional resuscitation in transient responders.
RECOMMENDED READINGS
Olson SA, Reilly MC, eds. Acetabular and Pelvic Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:15-42.
Advanced Trauma Life Support for Doctors, ed 8. Chicago, IL, American College of Surgeons, 2008.
RESPONSES FOR QUESTIONS 71 THROUGH 74
- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates
Which treatment option listed is best for each patient described?

71A

B
C

A 54-year-old healthy man with the condition seen in Figures 71a through 71d
- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

Question 51

Which of the following are considered characteristic features of degeneration of a disk?

Explanation

DISCUSSION: Gradual dessication of the disk begins in the third decade as glycosaminoglycan levels within the nucleus begin to decline. The original water content of 88% decreases to 70% in the sixth decade and beyond. As glycosaminoglycan content decreases, there is a corresponding increase in noncollagen glycoprotein.
REFERENCES: Happey F, Weissman A, Naylor A: Polysaccharide content of the prolapsed nucleus pulposus of the human intervertebral disc. Nature 1961;192:868.
Naylor A, Shentall R: Biomechanical aspects of intervertebral discs in aging and disease, in Jayson M (ed): The Lumbar Spine and Back Pain. New York, NY, Grune and Stratton Inc, 1976, pp 317-326.
Watkins RG, Collis JS: Lumbar Discectomy and Laminectomy. Rockville, MD, Aspen, 1987, pp 2-3.

Question 52

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Explanation

DISCUSSION: The use of chemotherapy has dramatically improved survival rates of patients with Ewing’s sarcoma. Local disease is best handled with wide resection to decrease local recurrence and to avoid the complications of radiation therapy (ie, secondary sarcomas). Radiation therapy alone is reserved for unresectable lesions or poor surgical margins. Amputation generally is not necessary.
REFERENCES: Toni A, Neff JR, Sudanese A, et al: The role of surgical therapy in patients with non-metastatic Ewing’s sarcoma of the limbs. Clin Orthop 1991;286:225.
Picci P, Rougraff BT, Bacci G, et al: Prognostic significance of histopathologic response to chemotherapy in non-metastatic Ewing’s sarcoma of the extremities. J Clin Oncol 1993;11:1763.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant Bone Tumors. Instr Course Lect 2002;51:413-428.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 53

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

Explanation

DISCUSSION: Uneven resection of bone, typically leaving a retained posterolateral corner of the distal clavicle, can lead to failure of arthroscopic distal clavicle excision. The amount of bone resected, the gender of the patient, or the diagnosis (osteoarthritis versus osteolysis) does not appear to affect the results.
REFERENCE: Flatow EL, Duralde XA, Nicholson GP, Pollock RG, Bigliani LU: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 1995;4:41-50.

Question 54

A 45-year-old man reports right shoulder pain with overhead activities only. Figures 47a through 47d show the radiographs, bone scan, and MRI scan of a lesion of the proximal shoulder. What is the most appropriate treatment?

Explanation

DISCUSSION: The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T₂-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

Question 55

Lumbar disk replacement has been shown to offer which of the following results?

Explanation

DISCUSSION: There is no clear evidence that disk replacement results in pain relief that is superior to fusion. Pain relief appears to be equivalent with these two procedures. No study has clearly demonstrated that normal segmental motion has been consistently restored. Preexisting facet arthropathy is considered to be a contraindication to disk replacement. Comparative long-term data demonstrating a reduced incidence of adjacent segment disease compared to fusion are not yet available.
REFERENCES: Geisler FH, Blumenthal SL, Guyer RD, et al: Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature. J Neurosurg Spine 2004;1:143-154.
Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 56

Which of the following treatments for osteoporosis is a direct inhibitor of RANK ligand (RANK-L)?

Explanation

Prolia, or denosumab, is a newly approved drug used to treat osteoporosis and has a mechanism of action similar to osteoprotegerin (inhibits binding of RANKL to RANK).
RANKL (Receptor activator of nuclear factor kappa-B ligand) is a key molecule for osteoclast differentiation and activation. Inhibition of RANKL activity with anti-RANKL antibody reduces osteoclastogenesis, resulting in inhibition of bone resorption.
Capozzi et al. author a review article on denosumab. They state the medication confers improved bone mineral density and prevents new fragility fractures similar to alendronate. However, denosumab presents less risk of atypical femoral fractures and
osteonecrosis of the jaw.
Yasuda et al. present a review that details the creation of three elegant animal models to mimic metabolic bone disease and how the animal models can create a template to help cure human metabolic bone disease. These enable modeling of osteoporosis, hypercalcemia, and osteopetrosis by treating normal mice with soluble RANKL (sRANKL), adenovirus expressing sRANKL, and anti-mouse RANKL neutralizing antibody, respectively. They report that these animal models can be established in about 14 days using normal mice.
Illustration A demonstrates the mechanism of action of bisphosphonates and denosumab.
Incorrect Answers:
1: Romosozumab is the first humanized anti-sclerostin monoclonal antibody that has been demonstrated to increase bone formation. 2: Zoledronic acid (Reclast) is a nitrogen containing bisphosphonates that inhibits osteoclast resorption by inhibiting the enzyme farnesyl diphosphate synthase. 4: Teriparatide (Forteo) comprises the first 34 amino acids of the 84 amino acid parathyroid hormone (PTH) and can reproduce the primary effects of PTH by activating adenyl cyclase. 5: Blosozumab is an investigational monoclonal anti-sclerostin antibody showing osteoanabolic properties with the potential to improve clinical outcomes in patients with osteoporosis.

Question 57

This condition is most prevalent in people of which ancestry?

Explanation

DISCUSSION
The radiograph of the lateral lumbosacral spine reveals an isthmic spondylolysis with a Meyerding grade 1 spondylolisthesis. The incidence of spondylolysis in the general population is around 5%, and grade 1 or 2 slips are present in the majority of children with a spondylolysis. Many cases of spondylolysis are painless and discovered incidentally, but, when painful, hyperextension of the lumbar spine may stress the area of the pars defect and exacerbate a patient’s symptoms. A diagnosis can usually be determined with a lateral radiograph of the lumbar spine. Although oblique lumbar radiographs are frequently ordered, several studies have shown that they do not increase diagnostic or prognostic accuracy. Progression of an isthmic spondylolysis, with or without a grade 1 or 2 listhesis, to a serious slip that might
necessitate surgical intervention is rare and occurs in fewer than 5% of patients. Chance for progression diminishes with age, with patients at highest risk prior to the adolescent growth spurt. Spondylolysis may have a genetic component; an increased prevalence has been found in some families and in some ethnic groups, especially among the Native American population.

Question 58

A 75-year-old man has persistent radial sided hand and wrist pain. Radiographs demonstrate severe scaphotrapezial trapezoidal arthritis. His basal joint is unaffected. His pain has failed to improve with bracing, activity modification, and image-guided corticosteroid injection. He has elected surgical treatment. What longterm complication can arise from a distal scaphoid resection?

Explanation

EXPLANATION:
Resection of the distal pole of the scaphoid eliminates the arthritic contact at the scaphotrapeziotrapezoid joint; however, it functionally shortens the scaphoid. Theoretically, the lunate is at equilibrium between the extension moment of the capitate and the triquetrum and the flexion moment of the scaphoid. Shortening the scaphoid allows the extension moment of the triquetrum to predominate, pulling the lunate into extension and creating a DISI deformity. Concomitant capsulodesis or interposition is recommended by some authors to prevent this complication.

Question 59

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Explanation

DISCUSSION: In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome.
REFERENCES: Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137.
Hahn M, Strauss E, Yang EC: Gunshot wounds to the forearm. Orthop Clin North Am 1995;26:85-93.

Question 60

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

Explanation

DISCUSSION: Coleman block testing, performed by placing an elevation under the lateral border of the foot, is used to determine if the forefoot and/or plantar flexed first ray is causing a compensatory varus in the hindfoot. The block is placed under the lateral border of the foot, and therefore does not have any relation to the Achilles tendon and suppleness of the hindfoot.
REFERENCES: Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.
Thometz JG, Gould JS: Cavus deformity, in The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 61

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

Explanation

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

Question 62

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 63

Figures 86a through 86c are the radiographs and biopsy specimen of a 14-year-old boy who has had left knee pain for 4 weeks. What is the most likely diagnosis?

Explanation

Question 64

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?

Explanation

DISCUSSION: 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.
REFERENCES: Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: Technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105:E57.
Haynes RJ: Developmental dysplasia of the hip: Etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect 2001;50:535-540.

Question 65

Currently, what is the most common clinical study type in the orthopaedic literature?

Explanation

Although a recent push for prospective, randomized trials has been advocated by multiple orthopaedic journals, many studies published continue to be of Level 4 evidence (retrospective case series). Case series represented 64% of all studies reviewed by Freedman and associates in 2001 from the British and American volumes of Journal of Bone and Joint Surgery and from Clinical Orthopaedics and Related Research. Obremskey and associates published that 58.1% of all studies from nine orthopaedic journals were Level 4 evidence. Further investigation of more current trends is likely warranted with the current emphasis on publishing higher level-of-evidence studies in orthopaedic journals.

Question 66

A 40-year-old man has a palpable mass over the dorsum of the ankle. He reports no history of direct trauma but notes that he sustained a laceration to the middle of his leg 6 weeks ago. Examination reveals a 4-cm x 1-cm mass. T 1 - and T 2 -weighted MRI scans are shown in Figures 12a and 12b. An intraoperative photograph and biopsy specimen are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

DISCUSSION: The findings are most consistent with a rupture of the anterior tibial tendon. The damaged area of tendon should be resected, followed by tendon reconstruction or tenodesis. The histology is not consistent with giant cell tumor of the tendon sheath, gout, or synovial sarcoma. Fibromatosis is characterized by a large number of spindle cells within the collagen background.
REFERENCES: Otte S, Klinger HM, Loreaz F, Haerer T: Operative treatment in case of closed rupture of the anterior tibial tendon. Arch Orthop Traum Surg 2002;122:188-190.
Kausch T, Rutt J: Subcutaneous rupture of the tibialis anterior tendon: Review of the literature and case report. Arch Orthop Traum Surg 1998;117:290-293.

Question 67

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?

Explanation

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Question 68

A 33-year-old woman reports a 3-month history of pain in both feet while running. Examination reveals bilateral point tenderness over the plantar fascia at its origin, and the pain is accentuated when the ankle is dorsiflexed. Management should consist of

Explanation

This question refers to plantar fascitis. Heel spurs are noted in approximately 50% of the cases of subcalcaneal pain syndrome. In this patient, diagnosis should rule out lumbar radiculopathy since the symptoms are bilateral.
The most common site for heel pain is where the plantar fascia and intrinsic muscles arise from the medial calcaneal tuberosity on the anteromedial aspect of the heel.
First line treatment is NSAID’s, Physical therapy involving heel cord stretching and an orthosis. Second line therapy after these treatments are unsuccessful involve steroid injection and plaster immobilization. Surgical intervention should be the very last choice in the options given.

Question 69

Figure 42 shows the sagittal T2-weighted MRI scan of a patient’s right knee. These findings are most commonly seen with a complete tear of the

Explanation

DISCUSSION: The MRI scan reveals disruption of the lateral capsule and ligaments with

fluid in the soft tissues laterally. Additionally, there is a large bone bruise on the medial

femoral condyle. This combination indicates injury to the posterolateral complex. These injuries often have coexisting anterior and/or posterior cruciate ligament injuries. Failure to recognize the posterolateral corner injury can lead to failure of anterior or posterior cruciate ligament reconstructions.
REFERENCES: LaPrade RF, Gilbert TJ, Bollom TS, et al: The magnetic resonance imaging appearance of individual structures of the posterolateral knee: A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med 2000;28:191-199.
Ross G, Chapman AW, Newberg AR, et al: Magnetic resonance imaging for the evaluation of acute posterolateral complex injuries of the knee. Am J Sports Med 1997;25:444-448.

Question 70

Explanation

Question 71

A patient has a vertically and rotationally unstable hemipelvis following a motor vehicle accident. An indication for application of an anterior resuscitative pelvic external fixator is made. Two options with regard to pin insertion location are considered as seen in Figure 20. When compared to pins in position A, the pins in position B may be more advantageous because

Explanation

Pelvic external fixation can be used for the acute resuscitation of patients with pelvic fractures and for definitive treatment of certain injury patterns. Typically frames are constructed with anterosuperior half-pin placement within the iliac crest. Intracortical placement of these pins may be difficult and erroneous placement may render purchase inadequate. Recently, external fixation of the pelvic ring with half-pin placement into the dense supra-acetabular bone in the region of the anterior inferior iliac spine has gained popularity. Kim and associates, in a biomechanical model, demonstrated that anterior-inferior pin placement was biomechanically superior to conventional anterior-superior pin placement in rotationally and vertically unstable fracture patterns. Haidukewych and associates performed a cadaveric study that demonstrated the lateral femoral cutaneous nerve is at risk within a mean distance of 10 mm from the inferior half-pin site but the femoral nerve and femoral artery are not at risk. The average superior extent of the hip capsule was 16 mm above the joint. They suggested that these pins be inserted at least 2 cm above the hip to avoid potential hip capsule penetration. Poelstra and Kahler described a case during which the lower pins were inserted without the benefit of imaging using only palpable landmarks. However, this technique is better reserved for nonresusitative purposes permitting the use of multiplanar fluoroscopic imaging. Image guidance better ensures proper pin placement within the pelvic cortices, minimizing penetration of the hip joint and sciatic notch. No anterior external fixator, regardless of design or region of application, offers sufficient posterior stability to serve as definitive treatment for vertically unstable pelvic fracture variants.

Question 72

Figure 65 is the lumbar spine MR image of a 63-year-old woman who has a 3-year history of increasingly bothersome back pain and bilateral buttock and leg pain. She has performed 6 weeks of physical therapy, received epidural injections, and experienced some good short-term results, but her leg pain continues to worsen. What is the most appropriate course of treatment?

Explanation

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505. View Abstract at PubMed
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 Jul;73(6):802-8. PubMed PMID: 2071615. View Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657. View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 73

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 74

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

Explanation

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

Question 75

A 32-year-old man sustained a closed injury after falling 25 feet from a roof. His ankle and foot are severely swollen. Radiographs and CT scans are shown in Figures 29a through 29d. Initial management should consist of

Explanation

DISCUSSION: The patient has a severe high-energy injury from axial loading to the left ankle and distal tibia. This is a closed injury, but the soft tissues are injured and severely swollen. Initial treatment should focus on skeletal stabilization, and incisions directly over the fracture area should be avoided until soft-tissue stabilization has occurred. Immediate spanning external fixation with plans for a delayed reconstruction as needed for the joint surface is the treatment of choice. Closed reduction and application of a constrictive long leg cast may lead to increased risk of tissue necrosis. Immediate open procedures to internally fix the fracture add the risks of soft-tissue necrosis and are to be avoided. Percutaneous plating may be one of the delayed fixation options but should not be used immediately. Primary ankle arthrodesis is not indicated.
REFERENCES: Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265.
Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509.
Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.

Question 76

Spontaneous entrapment of the posterior interosseous nerve most commonly occurs in which of the following locations?

Explanation

DISCUSSION: The extensor carpi radialis brevis, supinator muscle, arcade of Frohse, and leash of Henry are potential sites of compression for the posterior interosseous nerve. The most common location of spontaneous entrapment is the arcade of Frohse. The lateral intermuscular septum is a site of compression for the radial nerve.
REFERENCE: Spinner RJ, Spinner M: Nerve entrapment syndromes, in Morrey BF: The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 839-862.

Question 77

A 32-year-old runner has pain in the medial arch that radiates into the medial three toes. He reports the presence of pain only when running. Examination reveals normal hindfoot alignment. There is a weakly positive Tinel’s sign over the posterior tibial nerve. Tenderness is noted with palpation over the plantar medial area in the vicinity of the navicular tuberosity. What is the most likely diagnosis?

Explanation

DISCUSSION: The examination findings reveal that there is specific involvement of the medial plantar nerve by the distribution of the pain medially. The symptoms exclude the possibility of plantar fasciitis and anterior tibial tendinitis. Sinus tarsi syndrome would produce anterolateral symptoms rather than medial symptoms.
REFERENCES: Rask MR: Medial plantar neurapraxia (jogger’s foot): Report of three cases. Clin Orthop 1978;134:193-195.
Murphy PC, Baxter DE: Nerve entrapment of the foot and ankle in runners. Clin Sports Med 1985;4:753-763.
Lutter LD: Surgical decisions in athletes’ subcalcaneal pain. Am J Sports Med 1986;14:481-485.

Question 78

Which of the following is considered a risk factor for the development of low back pain?

Explanation

DISCUSSION: Risk factors associated with low back pain include poor physical fitness, smoking, a history of repetitive bending or stooping on the job, or whole body vibration exposure. Some radiographic factors such as stenosis, spondyloarthropathy, severe deformity, or instability are also associated with low back pain. Gender, weight, transitional anatomy, or facet trophism are not associated with low back pain.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 627-643.

Question 79

Which of the following statements best describes labral tears in the hip?

Explanation

DISCUSSION: Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability.
The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.
REFERENCES: Beck M, Kalhor M, Leunig M, et al: Hip morphology influences the pattern of damage to the acetabular cartilage: Femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br 2005;87:1012-1018.
Ito K, Leunig M, Ganz R: Histopathologic features of the acetabular labrum in femoroacetabular impingement. Clin Orthop Relat Res 2004;429:262-271.
Crawford MJ, Dy CJ, Alexander JW, et al: The 2007 Frank Stinchfield Award. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res 2007;465:16-22.

Question 80

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Explanation

One of the most difficult aspects of posterior cruciate ligament reconstruction is placement of the tibial tunnel and passing of the graft through this tunnel. The tibial inlay technique requires a posteromedial approach to the tibia whereby the graft is directly fixed to the posterior aspect of the tibia. This obviates the need for a tibial tunnel. This technique has never been shown to be less invasive, more cosmetic, or require decreased surgical time. It has also never been shown in a published level I study to have superior clinical results. However, it does eliminate the need for the 90-degree critical "killer" turn and passing of the tibial graft through the tibial tunnel which may lead to graft failure.

Question 81

An 11-year-old boy sustained an injury to his arm in gym class. He denies prior pain in the arm. Radiographs are shown in Figures 48a and 48b. What is the next most appropriate step in the management of this lesion?

Explanation

DISCUSSION: This radiolucent lesion with a “fallen leaf sign” is typical for a unicameral bone cyst(UBC). The most appropriate treatment is to allow the fracture to heal with clinical and radiographic observation. Curettage and bone grafting is not the best initial management for UBC. Wide resection is not indicated for UBC. The proximal humerus is the most common site for UBC. While staging studies consisting of MRI, bone scan, and CT of the chest are appropriate for lesions suspected of being malignant, the classical appearance of this UBC is such that this work-up is not necessary initially. Following fracture healing, aspiration and injection of the cyst may be indicated.
REFERENCES: Dormans JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.
Deyoe L, Woodbury DF: Unicameral bone cyst with fracture. Orthopedics 1985;8:529-531.

Question 82

A patient who underwent a L4-L5 hemilaminotomy and partial diskectomy for radiculopathy 8 weeks ago now reports increasing low back pain without neurologic symptoms. A sagittal T2-weighted MRI scan is shown in Figure 13a, and a contrast enhanced T1-weighted MRI scan is shown in Figure 13b. What is the most appropriate management for the patient’s symptoms? Review Topic

Explanation

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding? Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 83

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

Explanation

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

Question 84

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 85

A 56-year-old woman undergoes an arthroscopic rotator cuff repair for a two-tendon retracted tear (supraspinatus and infraspinatus), requiring the use of four suture anchors placed in a double row technique. At her 1 month follow-up visit, what is the appropriate recommendation for her continued rehabilitation program? Review Topic

Explanation

Regardless of the technique of rotator cuff repair, the biology of tendon healing remains the same. Therefore, the repaired muscle tendon(s) must be protected from stress for a minimum of 6 weeks and more likely 8 weeks in a large two-tendon tear such as this patient had repaired. Therefore, at the 1 month follow-up visit, the patient should continue strict passive motion exercises and should perform no strengthening activities. Deltoid strengthening cannot be isolated from rotator cuff strengthening; therefore, deltoid strengthening is inappropriate as well. Because the infraspinatus is the primary shoulder external rotator, it should not be strengthened for 6 to 8 weeks. Supraspinatus strengthening at this time frame would likely ensure its disruption and result in failure of the surgery. Any resistance training at 1 month from surgery would likely result in tendon failure at the tendon-bone interface. The obligatory need to protect the muscles during healing will predictably result in atrophy but it is easier to strengthen healed muscles than it is to strengthen muscle/tendon units that have failed to heal.

Question 86

A construction worker sustained a comminuted calcaneus fracture 2 years ago. He now reports progressive hindfoot pain with the recent onset of anterior ankle pain. A lateral hindfoot radiograph is shown in Figure 31. Treatment should consist of

Explanation

DISCUSSION: The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20 . By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement.
REFERENCES: Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Myerson M, Quill GE Jr: Late complications of fractures of the calcaneus. J Bone Joint Surg Am 1993;75:331.

Question 87

A surgeon decides to report outcomes for a new surgical procedure that he has performed on 10 patients who have a rare type of arthritis. He provides data on the functional and subjective patient outcomes. This type of study design is best described as a

Explanation

The type of study design in which a series of cases is presented with outcomes (without a control population or comparison group) is known as a case series. This type of study design, although frequently seen in orthopaedic literature, provides the lowest level of evidence. There is no control group and the population is usually poorly defined. This type of study can be helpful as a starting point for further analysis. A randomized trial provides the highest level of evidence in medical research, featuring a comparison group and randomized (and usually blinded) placement of subjects into study groups. In case-control studies, cases are compared to a control group. The control group has not been randomized, but may be a naturally occurring group of subjects who have not had the same exposure or intervention as the case group. A cohort study can be retrospective or prospective and usually looks at a large group of people over time to assess exposures and incidence of disease.

Question 88

A 60-year-old woman reports a painful hip arthroplasty after undergoing surgery 18 months ago. Radiographs show stable cementless implants without signs of ingrowth. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h. Management should now consist of

Explanation

DISCUSSION: Significant elevation of the erythrocyte sedimentation rate in a patient with a painful hip arthroplasty mandates a complete work-up for infection prior to considering revision surgery. Reproducibility and reliability of ultrasonography as a diagnostic test still needs clarification. Aspiration is the easiest and most cost-effective test and should be performed prior to nuclear imaging. The latter is most valuable if the results are negative, strongly predicting the absence of infection.
REFERENCES: Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.
McAuley JP, Moreau G: Sepsis: Etiology, prophylaxis, and diagnosis, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 1295-1306.

Question 89

The radiographs shown in Figures 71a through 71c, and the CT scan shown in Figure 71d reveal an acetabular fracture that should be classified as

Explanation

The fracture shown represents a both column fracture described by Letournel and Judet. The fracture is a combination of a posterior column fracture and an anterior column fracture. T-type, transverse and hemitransverse all have a transverse element to them. The fracture shown involves more than just the anterior column.
Note the classic “Spur Sign” seen in these radiographs. This is pathognomonic of a both-column fracture of the acetabulum.
The other defining feature of the both column fx (as evident by these films) is that there is no intact acetabulum connected to the bone fragment which is connected to the ipsilateral SI joint.

Question 90

A 25-year-old man sustained an L1 compression fracture in a fall from his roof. He is neurologically intact and has no other injuries. Radiographs reveal a 25% loss of height anteriorly and 5 degrees of kyphosis at the fracture site. A CT scan reveals no compromise of the posterior column. Management should consist of

Explanation

DISCUSSION: The patient has a stable fracture that can be initially treated with bed rest, followed by bracing and quick mobilization. The outcome is good and surgery is not required. These fractures can be treated nonsurgically if there is less than 50% compression, 15 degrees of angulation, and intact posterior structures.
REFERENCES: Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971-976.
Rechtine GR II, Cahill D, Chrin AM: Treatment of thoracolumbar trauma: Comparison of complications of operative versus nonoperative treatment. J Spinal Disord 1999;12:406-409.

Question 91

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

Explanation

The fundamental structure of normal adult articular cartilage is divided into four different zones: superficial, transitional, deep, and calcified. These layers vary in chondrocyte morphology, size and orientation of collagen bundles, and water and proteoglycan content. The deep zone has the highest concentration of proteoglycans and the lowest concentration of water. The tidemark is a boundary between the calcified and uncalcified layers of articular cartilage.

Question 92

Figure A shows intraoperative images of a right knee in an 8-year-old boy after he sustained an injury. Which of the following is the most common indication for performing this procedure? Review Topic

Explanation

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment? Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 93

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

Explanation

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

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

Question 94

Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis of this bony lesion?

Explanation

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 95

A 68-year-old woman underwent a successful total right hip arthroplasty with a metal-on-metal articulation and cementless porous-coated components. Three months later, she underwent identical surgery on the left hip. Three months after surgery on the left hip, she reports groin pain on ambulation. Examination reveals significant groin discomfort with passive hip motion, particularly at the extremes of motion. Radiographs are shown in Figures 21a and 21b. Laboratory studies show an erythrocyte sedimentation rate of 35 mm/h and a C-reactive protein of 0.9. Aspiration yields scant growth of Staphylococcus epidermidis in the broth only, with no evidence of loosening on arthrography. A second aspiration yields scant growth of Staphylococcus epidermidis in the broth only. What is the most likely cause of the patient’s pain?

Explanation

DISCUSSION: The difference in the clinical results combined with the laboratory findings points to infection. While there is a significant risk of false-positive findings with aspiration, the fact that two successive aspirations grew the same organism strongly suggests infection. The radiograph shows that there is more radiolucency around the left acetabular component than the right component.
REFERENCES: White RE: Evaluation of the painful total hip arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998,

vol 2, pp 1377-1385.
Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.

Question 96

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

Explanation

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

Question 97

A 35-year-old man sustained a 10% compression fracture of the C5 vertebra in a diving accident. Radiographs show good alignment, and examination reveals no neurologic compromise. An MRI scan reveals no significant soft-tissue disruption posteriorly. Management should consist of

Explanation

DISCUSSION: The patient has a stable flexion-compression injury of the cervical spine. The fracture occurs as a result of compression failure of the vertebral body. If the force continues, a tension failure of the posterior structures occurs, leading to potential dislocation. Immobilization in a rigid cervical orthosis will allow this fracture to heal.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
Allen GL, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.

Question 98

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

Explanation

DISCUSSION: The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.
REFERENCE: An H: Diagnostic imaging of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 102-125.

Question 99

Recurrence of this deformity after initial treatment should be treated with

Explanation

Video 85
CLINICAL SITUATION FOR QUESTIONS 82 THROUGH 85
Figures 82a and 82b are the radiographs of a 10-year-old girl who was an unrestrained back seat passenger in a motor vehicle collision. Her sole injury is to her left leg. She has a deformed valgus knee with lateral swelling and bruising, and no wound is visible. Upon examination, she has symmetric pulses to her right leg but diminished sensation on the dorsum of the foot and in the first web space. She cannot dorsiflex her left foot or toes but can plantar flex and invert them. Weak ankle eversion is present. Sensation to the plantar foot, medial ankle, and lateral ankle is intact. She likely will reach skeletal maturity at age 14.

Question 100

What effect does deep freezing have on allograft tissue?

Explanation

DISCUSSION: Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue.
REFERENCES: Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in

knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.
Caspari RB, Botherfield S, Horwitz RL, et al: HIV transmission via allograft organs and tissues. Sports Med Arthroscopy Rev 1993;1:42-46.

Full Question & Answer Text (for Search Engines)

Question 1:

What root is most commonly involved with a segmental root level palsy after laminoplasty?

Options:

Correct Answer: C5

Explanation:

DISCUSSION: The postoperative incidence of C5 root palsy after laminoplasty ranges from 5% to 12%. Other roots also may be affected. The palsies tend to be motor dominant, although sensory dysfunction and radicular pain are also possible. The palsy may arise during the immediate postoperative period or up to 20 days later. C5 may be preferentially involved because it is at the apex of the cervical lordosis. Recovery usually occurs over weeks to months.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-249.
Uematsu Y, Tokuhashi Y, Matsuzaki H: Radiculopathy after laminoplasty of the cervical spine. Spine 1998;23:2057-2062.

Question 2:

Initial postoperative management after repair of an acute rotator cuff tear includes

Options:

active range of motion.
active abduction to prevent scarring.
passive forward elevation and external rotation within a safe zone determined at surgery.
eccentric strengthening exercises.
internal rotation behind the back.

Correct Answer: passive forward elevation and external rotation within a safe zone determined at surgery.

Explanation:

Question 3:

Options:

Reassure the patient that the symptoms should subside gradually and that he should remain as upright as possible and loosen his cervical collar.
Prescribe methylprednisolone and diazepam.
Admit the patient for observation.
Advise the patient to come to the office first thing in the morning for a lateral radiograph of the cervical spine.
Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Correct Answer: Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Explanation:

Question 4:

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Options:

Anterior cruciate ligament, anteromedial bundle
Anterior cruciate ligament, anterolateral bundle
Anterior cruciate ligament, posteromedial bundle
Anterior cruciate ligament, posterolateral bundle

Correct Answer: Anterior cruciate ligament, anteromedial bundle

Explanation:

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658.
View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666.
View Abstract
at
PubMed

Question 5:

A patient with Pott's disease, tuberculosis of the spine, is more likely to have which of the following early findings? Review Topic

Options:

Acute onset back pain and neurologic dysfunction
Preservation of the disk space between two affected adjacent end plates
Involvement of the cervical spine and torticollis
Elevated WBC count and markedly elevated erythrocyte sedimentation rate
Lordotic deformity in late stages of the disease

Correct Answer: Preservation of the disk space between two affected adjacent end plates

Explanation:

Question 6:

Which structure is indicated by the arrow in Figure 33?

Options:

Corona mortis
Tibial division, sciatic nerve
Sciatic nerve, peroneal division
Fifth lumbar nerve root
Kocher-Langenbeck approach
Stoppa approach
Obturator vessels
L4 nerve root

Correct Answer: Fifth lumbar nerve root

Explanation:

DISCUSSION
The posterior position of the sciatic nerve in relation to the acetabulum and the lateral peroneal division makes the peroneal division of the sciatic nerve the portion of the nerve that is most likely to be injured in a posterior traumatic hip dislocation, accounting for up to 10% of concomitant nerve injuries with posterior hip dislocation. The corona mortis is an anatomic variant that results in vascular anastomosis between the obturator and either the external iliac or inferior epigastric arteries. This variant occurs in approximately 80% of patients and varies in its position, being located 4 cm to 9 cm lateral to the symphysis pubis. The obturator vascular bundle is situated in the fat medial to the obturator internus muscle and must be mobilized to access the quadrilateral plate. Dissection may be carried out both above and below this vascular leash. The Kocher-Langenbeck approach is indicated for fractures involving the posterior wall and/or posterior column of the acetabulum and for both column fractures that require direct posterior visualization. This approach is not indicated for direct reduction of the anterior wall or column when direct visualization is required anteriorly. The L5 nerve root is located on the anterior sacrum and is indicated by the arrow.
The position of this neural structure must be considered whether the surgeon is stabilizing
31
the sacroiliac (SI) joint with percutaneous iliosacral screws or with anterior SI plating through the lateral window of the ilioinguinal approach.
RECOMMENDED READINGS
Cornwall R, Radomisli TE. Nerve injury in traumatic dislocation of the hip. Clin Orthop Relat Res. 2000 Aug;(377):84-91. Review. PubMed PMID: 10943188.
View
Abstract at PubMed
Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat. 2007 May;20(4):433-9. PubMed PMID: 16944498.
View Abstract at PubMed
Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PubMed PMID: 21368098.
View Abstract at PubMed
Rommens P. The Kocher-Langenbeck approach for the treatment of acetabular fractures. Operat Orthop Traumatol 2004; 16:59-74.
Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications and techniques for definitive surgical management. J Am Acad Orthop Surg. 2013 Aug;21(8):458-68. doi: 10.5435/JAAOS-21-08-458. Review. PubMed PMID: 23908252.
View Abstract at PubMed

Question 7:

A year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Options:

Vacuum-assisted wound closure dressing
Intravenous antibiotics for 6 weeks, followed by long-term oral antibiotic administration
Irrigation and debridement, followed by polyethylene exchange
Two-stage debridement and reconstruction

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 8:

For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable?

Options:

Length of hospital stay
Association with neurological deficit(s)
Length of intensive care stay
Cardiac collapse
Mortality

Correct Answer: Length of hospital stay

Explanation:

Question 9:

Options:

His clinical outcome will correlate closely with his initial reduction.
His outcome will correlate with his radiographic score on the Ankle Osteoarthritis Score.
He will likely require a late ankle arthrodesis.
He will demonstrate marked limitations with regard to recreational activities.
He will perceive improvements for a period of over 2 years.

Correct Answer: He will perceive improvements for a period of over 2 years.

Explanation:

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of

Question 10:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 11:

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

Options:

The incidence of thrombocytopenia is lower with low-molecular-weight heparin than with unfractionated heparin.
The half-life of low-molecular-weight heparin is less than that of unfractionated heparin.
Low-molecular-weight heparin affects circulating thrombin (Factor IIa) to a greater extent than unfractionated heparin.
The mechanism of action of low-molecular-weight heparin is primarily by targeting Factor Xa.
There is a significant decrease in postoperative bleeding with the use of low-molecular-weight heparin compared to warfarin.

Correct Answer: The mechanism of action of low-molecular-weight heparin is primarily by targeting Factor Xa.

Explanation:

DISCUSSION: Low-molecular-weight heparin is highly bioavailable with a half-life
to 18 hours. This is greater than the 1 hour half-life of unfractionated heparin.
Low-molecular-weight heparin offers an advantage over unfractionated heparin by selectively targeting Factor Xa while having a lesser effect on circulating thrombin (Factor IIa). Circulating thrombin Factor IIa is needed for local hemostasis at the site of the surgical wound. Clinical studies have shown a reduction by one third in the incidence of thrombocytopenia with the use of low-molecular-weight heparin. Low-molecular-weight heparin has been shown to demonstrate similar clinical results compared to warfarin with respect to preventing thromboembolic disease after total hip arthroplasty and complications such as bleeding.
REFERENCES: Zimlich RH, Fulbright BM, Friedman RJ: Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996;4:54-62.
Colwell CW Jr, Spiro TE, Trowbridge AA, et al: Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Torholm C, Broeng L, Jorgensen PS, et al: Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery: A placebo controlled study. J Bone Joint Surg Br 1991;73:434-438.

Question 12:

Options:

Spiral groove of the humerus
Midshaft of the radius
Radial neck
Anatomic neck of the humerus
Surgical neck of the humerus

Correct Answer: Radial neck

Explanation:

DISCUSSION: In this patient, the radial nerve is most likely injured at the level of the radial neck. The radial nerve emerges from the posterior cord of the brachial plexus and travels along the spiral groove of the humerus. At the level of the lateral humeral condyle, the radial nerve branches into the posterior interosseous nerve after giving off two cutaneous branches, the superficial radial and the posterior cutaneous. The posterior interosseous nerve travels through the supinator muscle and winds around the radial neck. At this level, the posterior interosseous nerve is vulnerable to injury, particularly following fracture or penetrating trauma.
REFERENCES: Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System, Part 1: Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy Corporation, 1987, vol 8, p 53.
Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 428-429.

Question 13:

In the treatment of rheumatoid arthritis, which medication is an antagonist of tumor necrosis factor-alpha?

Options:

Rituximab
Etanercept
Abatacept
Methotrexate
Leflunomide

Correct Answer: Etanercept

Explanation:

Question 14:

Options:

Metatarsophalangeal joint arthrodesis
Medial capsular release with lengthening of the abductor hallucis
Medial capsular release with lateral sesamoid excision
Proximal phalangeal lateral closing wedge osteotomy
Medial capsular lengthening and split extensor hallucis longus tendon transfer

Correct Answer: Medial capsular lengthening and split extensor hallucis longus tendon transfer

Explanation:

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 15:

The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?

Options:

Supraspinatus and infraspinatus
Supraspinatus and subscapularis
Infraspinatus and teres minor
Terers minor and teres major
Teres major and lattisimus

Correct Answer: Supraspinatus and infraspinatus

Explanation:

Question 16:

Which of the following best describes the resultant forces on an increased offset stem when compared with a standard offset stem?

Options:

Increased joint reaction force, increased torsional load
Increased joint reaction force, decreased torsional load
Decreased joint reaction force, increased torsional load
Decreased joint reaction force, decreased torsional load
No change in joint reaction force or torsional load

Correct Answer: Decreased joint reaction force, increased torsional load

Explanation:

Question 17:

Options:

Inadvertent rotation of the graft 90 degrees internally prior to its final fixation
Lack of full knee extension at the time of surgery
Persistent posterolateral corner injury
Leaving 1 to 2 mm of bone posterior to the femoral tunnel at the time of the ACL reconstruction
Placing the tibial tunnel within the ACL footprint

Correct Answer: Persistent posterolateral corner injury

Explanation:

Question 18:

Options:

- Superior gluteal artery
- Branch of the external iliac artery
- Branch of the pudendal artery
- Branch of the femoral artery

Correct Answer: - Branch of the pudendal artery

Explanation:

DISCUSSION
Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.
RECOMMENDED READINGS
Suzuki T, Smith WR, Moore EE. Pelvic packing or angiography: competitive or complementary? Injury. 2009 Apr;40(4):343-53. Epub 2009 Mar 17. Review.PubMed PMID: 19278678.
View Abstract at PubMed
Loffroy R, Yeguiayan JM, Guiu B, Cercueil JP, Krausé D. Stable fracture of the pubic rami: a rare cause of life-threatening bleeding from the inferior epigastric artery managed with transcatheter embolization. CJEM. 2008 Jul;10(4):392-5. PubMed PMID: 18652733.
View
Abstract at PubMed
White CE, Hsu JR, Holcomb JB. Haemodynamically unstable pelvic fractures.Injury. 2009 Oct;40(10):1023-30. Epub 2009 Apr 16. Review. PubMed PMID:19371871.
View Abstract at
PubMed
RESPONSES FOR QUESTIONS 5 THROUGH 8
5A
5B
- 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
Please choose from the responses to identify the most likely complication in each scenario.

Question 19:

Options:

Numbness over dorsal aspect of the foot, weakness to gluteus medius
Numbness over plantar foot, weakness to his gastrocsoleus complex
Numbness over medial malleolus, and weakness to quadriceps
Numbness over medial calf, weakness in his EHL
Numbness over lateral malleolus, weakness to hip adduction

Correct Answer: Numbness over medial calf, weakness in his EHL

Explanation:

The MRI demonstrates a left paracentral L4/5 disc protrusion which leads to compression of the traversing (descending) left L5 nerve root. Numbness over the dorsal aspect of the foot and weakness to gluteus medius is consistent with a L5
radiculopathy.
While nerve root innervation shows some variability by patient, L5 is "characteristically" responsible for the sensation to the dorsal aspect of the foot, ankle dorsiflexion (tibialis anterior - along with L4), great toe extension (EHL), and hip abduction (gluteus medius).
Suri et al. reported on specific physical exam findings that significantly increased the likelihood of nerve root impingement at specific lumbar levels. They found: L2 was associated with decreased anterior thigh sensation. L3 was associated with a positive femoral stretch test. L4 was associated with a blunted patellar reflex, decreased medial ankle sensation or a positive crossed femoral stretch test. L5 was associated with was associated with decreased hip abductor strength.
Luri et al. reported 8-year follow up on the patients in the spine patient outcomes research trial who underwent surgical vs. conservative care for treatment of lumbar herniated disc. They found that patients who underwent surgical treatment had superior results that were maintained at 8 years compared to patients who underwent conservative management.
Figure A is an axial MRI at the L4/5 disc space that shows a left paracentral disc herniation compressing the descending L5 nerve root. Illustration A identifies the structures in the MRI image. Illustration B demonstrates the dermatome, reflex and motor function associated with the L4, L5 and S1 nerve root.
Incorrect Answers:
(SBQ13PE.102) An 26-year-old male presents to your office complaining of bilateral hip and low back pain. On physical examination, he has 10 degree bilateral hip flexion contractures. An AP pelvis radiograph is demonstrated in figure A. Which of the following findings is consistent with this patient's presentation?
Review Topic
A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 20:

Which of the following statements best describes the anatomic considerations of the popliteal artery posterior to the knee joint?

Options:

It lies posterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies lateral to the popliteal vein and 15 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies medial to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies anterior to the popliteal vein and 15 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.

Correct Answer: It lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.

Explanation:

DISCUSSION: Popliteal artery injury during total knee arthroplasty is relatively rare. Knee flexion, the position that occurs during most of the arthroplasty procedure, allows the popliteal vessels to fall posteriorly, further away from harm. Anatomically, the popliteal artery lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in
90 degrees of flexion.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 151.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-53.

Question 21:

Options:

Fourth cervical nerve root
Upper trunk of the brachial plexus
Middle trunk of the brachial plexus
Lateral cord of the brachial plexus
Axillary nerve

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 22:

Options:

Inappropriately early return to play
Improper rehabilitation and conditioning
Unstable meniscal tear
Malpositioned tunnel
Inadequate graft sizing

Correct Answer: Inappropriately early return to play

Explanation:

Question 23:

Options:

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

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

Explanation:

Question 24:

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
(SBQ13PE.10) Which statement is true regarding discoid menisci?
Review Topic
Most commonly involves the medial meniscus
Bilateral in >75% of cases
Asymptomatic discoid meniscus should undergo saucerization
Radiographs will commonly show a hyperplastic lateral intercondylar spine
Radiographs will commonly show squaring of affected condyle with cupping of tibial plateau
Radiographs of knees with discoid menisci will commonly show squaring of affected condyle (lateral>medial) with cupping of tibial plateau.
Discoid meniscus refers to the abnormal development of a hypertrophic and discoid shaped meniscus. It occurs in 3-5% of the population and it is considered the most common cause of a symptomatic clicking or clunking in a childs knee. The lateral meniscus is most commonly affected and it will occur bilaterally in 25% of affected
people. The Watanabe Classification describes the 3 types of discoid menisci. Type 1
= Incomplete, Type 2 = Complete, Type 3 = Wrisberg (lack of posterior meniscotibial attachment to tibia)
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Lee et al. retrospectively reviewed 36 patients aged less than 15 years who underwent arthroscopic procedures for torn discoid menisci. The mean patient age at the time of surgery was 9.5 years. They showed that partial meniscectomy yielded better radiologic results than subtotal/total meniscectomy for torn discoid menisci in this population.
Illustration A shows the 3 classifications of discoid menisus as originally described by Watanabe. Type 4 is a ring type discoid that was not originally described by Watanabe in his 1978 paper. Illustration B shows an AP and lateral radiograph of a discoid meniscus knee. Note squaring of affected lateral condyle in the presence of a lateral discoid meniscus. Illustration C shows 4 consecutive sagittal MRI images with meniscus continuity. It is important to note that the diagnosis of discoid menisci can be made when 3 or more 5mm sagittal images show meniscal continuity.
Incorrect Answers:

Question 25:

Options:

Unicompartmental arthroplasty
Total knee arthroplasty
Lateral closing wedge proximal tibial osteotomy
Medial opening wedge proximal tibial osteotomy
Medial closing wedge supracondylar femoral osteotomy

Correct Answer: Medial closing wedge supracondylar femoral osteotomy

Explanation:

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 26:

Options:

first lordotic segment of the lumbar spine.
distal aspect of the curve as measured by the Cobb technique.
lower thoracic spine.
lower lumbar spine.
sacrum.

Correct Answer: first lordotic segment of the lumbar spine.

Explanation:

Question 27:

Which of the following imaging modalities is most accurate in locating a toothpick in the plantar arch of the foot?

Options:

Radiograph
CT
MRI
Ultrasound
Bone scan

Correct Answer: Ultrasound

Explanation:

DISCUSSION: Ultrasound is best at imaging abrupt changes in the density of adjacent tissue and therefore is best at imaging wood in the soft tissues of the foot.
REFERENCES: Mizel MS, Steinmetz ND, Trepman E: Detection of wooden foreign bodies in muscle tissue: Experimental comparison of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int 1994;15:437-443.
Jacobson JA, Powell A, Craig JG, et al: Wooden foreign bodies in soft tissue: Detection at US. Radiology 1998;206:45-48.

Question 28:

Options:

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

Correct Answer: External fixation

Explanation:

Question 29:

Options:

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

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

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

Question 30:

In the treatment of acetabular dysplasia, what type of pelvic osteotomy leaves the “teardrop” in its original position and redirects the acetabulum?

Options:

Steel
Chiari
Ganz periacetabular
Dial or spherical
Salter innominate

Correct Answer: Dial or spherical

Explanation:

Question 31:

Options:

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

Correct Answer: 9 degrees internal rotation

Explanation:

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

Question 32:

Options:

continued non-weight-bearing and a bone stimulator.
removal of the hardware, bone grafting of the femoral neck, and refixation.
removal of the hardware and hemiarthroplasty.
removal of the hardware and total hip arthroplasty.
removal of the hardware and a valgus osteotomy.

Correct Answer: removal of the hardware and a valgus osteotomy.

Explanation:

Question 33:

The MRI scans and diagnostic ultrasound shown in Figures 2a through 2c show what pathologic condition? Review Topic

Options:

Articular-sided supraspinatus tendon tear
Bursal-sided supraspinatus tear
Superior labral tear
Humeral avulsion of the anterior glenoid ligament
Avulsion of the anterior inferior glenohumeral ligament

Correct Answer: Articular-sided supraspinatus tendon tear

Explanation:

Question 34:

Which of the following patients is more likely to have an overall poorer outcome following a lower extremity amputation?

Options:

A male patient with a below-the-knee amputation
A male patient with a through-the-knee amputation performed in a zone of injury
A male patient treated with a myoplasty at the time of wound closure
A female patient with an above-the-knee amputation
A female patient using a less technologically sophisticated prosthesis

Correct Answer: A male patient with a through-the-knee amputation performed in a zone of injury

Explanation:

Question 35:

This image represents the end stage of an uncompensated rotator cuff tear.

Options:

Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.
Figure 59b is the radiograph of a 45-year-old man with acromiohumeral distance equal to 7 mm. He is able to actively raise his arm above shoulder level, has lateral arm pain,
and abduction and external rotation weakness. 56
Figures 59c and 59d are the radiographs of a 72-year-old man with night pain and reduced range of motion.

Correct Answer: Figure 59a is the CT image of an 86-year-old woman with acromiohumeral distance of less than 2 mm, night pain, and an inability to actively raise the affected arm above shoulder level.

Explanation:

DISCUSSION
Axillary lateral and anteroposterior (AP) images of the right shoulder (Figures 59c and 59d) reveal osteoarthrosis of the glenohumeral joint, which typically is not associated with significant rotator cuff pathology. An examination often shows limitations in range of motion, crepitance, and pain with motion. An AP radiographic image of the right shoulder (Figure 59b) reveals proximal humeral migration, which normally correlates with rotator cuff tear size. Tears extending into the infraspinatus tendon are associated with more humeral migration than is seen with isolated supraspinatus tears. Presenting complaints are usually of pain and weakness. Examination findings include subacromial crepitance and weakness during rotator cuff testing. Rarely, this may be associated with pseudoparalysis in large uncompensated rotator cuff tears. The CT image of the right shoulder (Figure 59a) shows superior migration of the humerus with respect to the glenoid surface and end-stage
degenerative changes at the glenohumeral joint. These changes are classified as rotator cuff arthropathy. Pain and weakness are common, as is the presence of pseudoparalysis and limited range of motion.
RECOMMENDED READINGS
Kelly JD Jr, Norris TR. Decision making in glenohumeral arthroplasty. J Arthroplasty. 2003 Jan;18(1):75-82. Review. PubMed PMID: 12555187.
View Abstract at PubMed
Keener JD, Wei AS, Kim HM, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009 Jun;91(6):1405-13. doi: 10.2106/JBJS.H.00854. PubMed PMID:

Question 36:

A 58-year-old woman has had a painless periscapular mass for the past year. An MRI scan and biopsy specimen are shown in Figures 4a and 4b. What is the most likely diagnosis?

Options:

Elastofibroma
Desmoid tumor
Nodular fasciitis
Malignant fibrous histiocytoma
Atrophic serratus anterior

Correct Answer: Elastofibroma

Explanation:

Question 37:

Options:

Continued nonsurgical management
Posterior open reduction and internal fixation with tension band plating
Posterior iliosacral screws
Anterior open reduction and internal fixation
Anterior open reduction and internal fixation and posterior fixation

Correct Answer: Anterior open reduction and internal fixation and posterior fixation

Explanation:

DISCUSSION: Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure.
REFERENCES: Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448.
Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.
McLaren AC, Rorabeck CH, Halpenny J: Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg 1990;33:492-494.

Question 38:

Figure 1 points to the "tear drop" of the wrist. This radiographic landmark represents which anatomic portion of the wrist?

Options:

Ulnar head
Volar ulnar corner
Radial styloid
Lister tubercle

Correct Answer: Volar ulnar corner

Explanation:

Question 39:

Internal impingement of the shoulder and posterosuperior labral pathology in throwers has been most clearly associated with which of the following? Review Topic

Options:

Posterior capsular contracture
Anterior capsular laxity
Coracoacromial arch stenosis
Rotator cuff disease
Bennet's lesion

Correct Answer: Posterior capsular contracture

Explanation:

Question 40:

Options:

recurrent buckling with a probable meniscal tear.
limitation of motion with a delay in recovery.
a full return to activity with no limitations.
an improvement in overall performance.
an uneventful completion of the soccer season.

Correct Answer: recurrent buckling with a probable meniscal tear.

Explanation:

Question 41:

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

Options:

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

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

Explanation:

Question 42:

Epithelioid sarcoma most commonly occurs in which of the following anatomic locations?

Options:

Upper extremity
Lower extremity
Pelvis and buttock
Retroperitoneum
Spine

Correct Answer: Upper extremity

Explanation:

Question 43:

What structure (arrow) is shown in Figure 24?

Options:

Ilioinguinal nerve
Sympathetic chain
Ureter
Iliac vein
L5 nerve

Correct Answer: Sympathetic chain

Explanation:

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 44:

Options:

Long arm cast immobilization
Total elbow arthroplasty
Open reduction and internal fixation
Osteoarticular allograft
Resection arthroplasty

Correct Answer: Total elbow arthroplasty

Explanation:

DISCUSSION: Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.
REFERENCES: Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947.
Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the elderly: The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84:812-816.

Question 45:

Options:

Fracture displacement or subluxation leading to neurologic injury
Symptomatic epidural hematoma
Sepsis and death
Permanent nerve root injury and neurologic deficit
Loss of bowel or bladder control
Spinal cord injury

Correct Answer: Symptomatic epidural hematoma

Explanation:

DISCUSSION
Cauda equina syndrome, typically the result of severe central canal stenosis in the lower lumbar region, often is caused by a large central disk herniation. Symptoms include severe back or leg pain, perineal numbness, possible motor weakness, and initial urinary retention followed by an overflow incontinence. When bowel or bladder deficits are present, this is considered a surgical emergency because successful recovery is most likely if decompression occurs within the first 48 hours.
Ankylosing spondylitis can lead to progressive autofusion of the vertebrae and significant limitation in motion. Any sudden improvement in motion should be considered a fracture until proven otherwise. These fractures are commonly missed when using plain radiographs or even CT scan because minimal or no displacement often is noted. MR imaging can be useful to identify edema at
the fracture site. These fractures are typically very unstable and necessitate surgery to avoid displacement and potential neurologic injury.
Some fractures associated with ankylosing spondylitis can be effectively treated with percutaneous pedicle screw fixation. However, because of the highly vascular nature of some of these fractures, they pose risk for an epidural hematoma, potential neurologic deficit, and emergent decompression.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.
View
Abstract at PubMed
Mathews M, Bolesta MJ. Treatment of spinal fractures in ankylosing spondylitis. Orthopedics. 2013 Sep;36(9):e1203-8. doi: 10.3928/01477447-20130821-25. PubMed PMID: 24025014.
View Abstract at PubMed
McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine (Phila Pa 1976). 2007 Jan 15;32(2):207-

Question 46:

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Options:

Anterior column
Anterior wall
Posterior column
Both column
Transverse

Correct Answer: Posterior column

Explanation:

DISCUSSION: The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1009-1149.

Question 47:

Options:

hematocrit.
serial heart rate.
serial blood pressure with a manual cuff.
serial blood pressure with an arterial line.
lactate and base deficit levels.

Correct Answer: lactate and base deficit levels.

Question 48:

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Options:

Patella alta
Medial mechanical axis deviation
Lateral mechanical axis deviation
Increased anatomic tibiofemoral angle
Translation of the anatomical axis of the femur

Correct Answer: Medial mechanical axis deviation

Question 49:

Options:

glenohumeral arthrodesis.
total shoulder arthroplasty.
humeral arthroplasty.
open synovectomy and rotator cuff repair.
anterior acromioplasty and rotator cuff repair.

Correct Answer: humeral arthroplasty.

Explanation:

Question 50:

Options:

- Administer IV fluids and then reassess vital signs before making further decisions
- Pelvic binder and IV fluids
- Pelvic binder and immediate transfusion
- Pelvic binder, IV fluids, type and cross-match, and then transfuse

Correct Answer: - Pelvic binder and immediate transfusion

Explanation:

Question 51:

Which of the following are considered characteristic features of degeneration of a disk?

Options:

Reduced water and glycosaminoglycan content and increased noncollagen glycoprotein
Reduced water and glycosaminoglycan content and reduced noncollagen glycoprotein
Reduced water content, increased glycosaminoglycan content, and increased noncollagen glycoprotein
Increased water and glycosaminoglycan content and increased noncollagen glycoprotein
Increased water and glycosaminoglycan content and reduced noncollagen glycoprotein

Correct Answer: Reduced water and glycosaminoglycan content and increased noncollagen glycoprotein

Explanation:

Question 52:

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Options:

chemotherapy and radiation therapy to the femur.
chemotherapy and wide resection.
chemotherapy and above-knee amputation.
hip disarticulation.
wide resection.

Correct Answer: chemotherapy and wide resection.

Explanation:

Question 53:

Which of the following factors is associated with failure of arthroscopic excision of the distal clavicle?

Options:

Removal of less than 2 cm of bone
Male gender
Female gender
Diagnosis of osteolysis
Uneven resection of bone

Correct Answer: Uneven resection of bone

Explanation:

Question 54:

Options:

Needle biopsy
Incisional biopsy
Curettage and grafting
Observation
En bloc resection

Correct Answer: Observation

Explanation:

DISCUSSION: The figures show a lesion of the proximal humerus consistent with an enchondroma. The lesion is calcified on the radiographs. There is no cortical destruction, significant endosteal scalloping, or soft-tissue mass. The bone scan shows mild uptake in the area of the proximal humerus, and the T
2
-weighted MRI scan shows a lesion with high uptake, suggesting a lesion with high water content. A CT scan could also be obtained to rule out bone destruction or periosteal reaction. Pain with overhead activities is likely related to the rotator cuff. A biopsy is unlikely to add information because of inherent difficulties interpreting low-grade cartilaginous lesions. Curettage and grafting and en bloc resection are excessive treatments for a benign lesion that is apparently asymptomatic. Observation with a follow-up radiograph in 3 to 6 months is appropriate.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.

Question 55:

Lumbar disk replacement has been shown to offer which of the following results?

Options:

Provides long-term pain relief superior to that achieved with lumbar fusion
Provides long-term pain relief equivalent to that achieved with lumbar fusion
Provides long-term pain relief in patients with symptomatic degenerative disk disease and facet arthropathy
Consistently prevents the development of adjacent segment disease
Consistently restores normal segmental motion

Correct Answer: Provides long-term pain relief equivalent to that achieved with lumbar fusion

Explanation:

Question 56:

Which of the following treatments for osteoporosis is a direct inhibitor of RANK ligand (RANK-L)?

Options:

Romosozumab
Zoledronic acid
Denosumab
Teriparatide
Blosozumab

Correct Answer: Denosumab

Explanation:

Question 57:

This condition is most prevalent in people of which ancestry?

Options:

Northern European
Asian
Native American
Sub-Saharan African

Correct Answer: Native American

Explanation:

Question 58:

Options:

Avascular necrosis of the proximal pole of the scaphoid
Dorsal intercalated segment instability (DISI)
Volar intercalated segment instability
Thumb metacarpophalangeal joint hyperextension

Correct Answer: Dorsal intercalated segment instability (DISI)

Explanation:

Question 59:

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Options:

Fracture comminution
Fracture of both the radius and ulna
Fracture of the proximal third of the forearm
Fracture displacement of more than 10 mm
Retained bullet fragments

Correct Answer: Fracture of the proximal third of the forearm

Explanation:

Question 60:

The Coleman block test is used to evaluate the cavovarus foot. What is the most important information obtained from this test?

Options:

Determines the patient’s ability to balance
Determines hindfoot flexibility
Determines forefoot flexibility
Assesses the patient for Achilles tendon contractures
Evaluates peroneus longus strength

Correct Answer: Determines hindfoot flexibility

Explanation:

Question 61:

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

Options:

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

Correct Answer: Pilon fracture

Explanation:

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

Question 62:

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 63:

Figures 86a through 86c are the radiographs and biopsy specimen of a 14-year-old boy who has had left knee pain for 4 weeks. What is the most likely diagnosis?

Options:

Chondroblastoma
Chondrosarcoma
Parosteal osteosarcoma
Osteoblastoma
Osteosarcoma

Correct Answer: Osteosarcoma

Question 64:

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:

DISCUSSION: 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.
REFERENCES: Lehmann HP, Hinton R, Morello P, et al: Developmental dysplasia of the hip practice guideline: Technical report. Committee on Quality Improvement, and Subcommittee on Developmental Dysplasia of the Hip. Pediatrics 2000;105:E57.
Haynes RJ: Developmental dysplasia of the hip: Etiology, pathogenesis, and examination and physical findings in the newborn. Instr Course Lect 2001;50:535-540.

Question 65:

Currently, what is the most common clinical study type in the orthopaedic literature?

Options:

Level 1 (prospective, randomized trial)
Level 2 (cohort trial)
Level 3 (retrospective case control)
Level 4 (retrospective case series)
Level 5 (expert opinion)

Correct Answer: Level 4 (retrospective case series)

Explanation:

Question 66:

Options:

Giant cell tumor of the tendon sheath
Gouty tophi
Aggressive fibromatosis
Tendon rupture
Synovial cell sarcoma

Correct Answer: Tendon rupture

Explanation:

Question 67:

Options:

Pain during sitting; flexion abduction and external rotation of the hip
Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°
Clicking; abductor lurch
Buttock pain; pain with hip extension, adduction, and external rotation while prone

Correct Answer: Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°

Explanation:

Question 68:

Options:

steroid injection
stretching of the heel cord
surgical release of the plantar fascia
application of a short leg cast for 6 to 8 weeks
wearing dorsiflexion night splints

Correct Answer: stretching of the heel cord

Explanation:

Question 69:

Figure 42 shows the sagittal T2-weighted MRI scan of a patient’s right knee. These findings are most commonly seen with a complete tear of the

Options:

patellar tendon.
lateral collateral ligament.
medial collateral ligament.
posterior cruciate ligament.
anterior cruciate ligament.

Correct Answer: lateral collateral ligament.

Explanation:

DISCUSSION: The MRI scan reveals disruption of the lateral capsule and ligaments with
fluid in the soft tissues laterally. Additionally, there is a large bone bruise on the medial
femoral condyle. This combination indicates injury to the posterolateral complex. These injuries often have coexisting anterior and/or posterior cruciate ligament injuries. Failure to recognize the posterolateral corner injury can lead to failure of anterior or posterior cruciate ligament reconstructions.
REFERENCES: LaPrade RF, Gilbert TJ, Bollom TS, et al: The magnetic resonance imaging appearance of individual structures of the posterolateral knee: A prospective study of normal knees and knees with surgically verified grade III injuries. Am J Sports Med 2000;28:191-199.
Ross G, Chapman AW, Newberg AR, et al: Magnetic resonance imaging for the evaluation of acute posterolateral complex injuries of the knee. Am J Sports Med 1997;25:444-448.

Question 70:

Options:

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

Correct Answer: 9 degrees internal rotation

Explanation:

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

Question 71:

Options:

there is less risk to regional neurologic structures.
of superior bone purchase.
they more definitively stabilize the posterior fracture.
they may be more easily applied in the emergency department setting.
there is less risk of intra-articular hip joint penetration.

Correct Answer: of superior bone purchase.

Explanation:

Question 72:

Options:

Anterior lumbar interbody fusion L4-5
L4-5 hemilaminotomy and diskectomy
Lumbar laminectomy L4-L5 posterior fusion
Lumbar laminectomy at L4-5

Correct Answer: Lumbar laminectomy L4-L5 posterior fusion

Explanation:

DISCUSSION
This patient has symptoms consistent with neurogenic claudication secondary to lumbar spinal stenosis and degenerative spondylolisthesis. Her symptoms are chronic and she has undergone an appropriate course of nonsurgical care. Nevertheless, her symptoms are worsening and surgical intervention is a
reasonable consideration. Studies have shown that patients with lumbar spinal stenosis with associated degenerative spondylolisthesis benefit most from decompression of the neural elements that are stenotic and subsequent fusion across the degenerative slip. Anterior lumbar interbody fusion likely will not address stenosis at the level of the slip and may not result in adequate neurologic decompression. Partial laminotomy and diskectomy likely will not provide adequate neural decompression because these procedures would only address unilateral compression and this patient has bilateral issues. Lumbar laminectomy without fusion could be performed but has been associated with results inferior to lumbar laminectomy with fusion when addressing stenosis with spondylolisthesis.
RECOMMENDED READINGS
Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun;91(6):1295-304. PubMed PMID: 19487505.
View Abstract at
PubMed
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 Jul;73(6):802-8. PubMed PMID: 2071615.
View
Abstract at PubMed
Lombardi JS, Wiltse LL, Reynolds J, Widell EH, Spencer C 3rd. Treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976). 1985 Nov;10(9):821-7. PubMed PMID: 4089657.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 66 THROUGH 69
Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure
Match the frequently encountered complication listed above with the appropriate clinical scenario below.

Question 73:

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 74:

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

Options:

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

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

Explanation:

Question 75:

Options:

closed reduction and application of a long leg cast.
open reduction and internal fixation with plate and screw fixation.
percutaneous plate fixation.
spanning external fixation with delayed limited open reduction and internal fixation.
primary ankle arthrodesis.

Correct Answer: spanning external fixation with delayed limited open reduction and internal fixation.

Explanation:

Question 76:

Spontaneous entrapment of the posterior interosseous nerve most commonly occurs in which of the following locations?

Options:

Lateral intermuscular septum
Extensor carpi radialis brevis
Arcade of Frohse
Midsubstance of the supinator
Leash of Henry

Correct Answer: Arcade of Frohse

Explanation:

DISCUSSION: The extensor carpi radialis brevis, supinator muscle, arcade of Frohse, and leash of Henry are potential sites of compression for the posterior interosseous nerve. The most common location of spontaneous entrapment is the arcade of Frohse. The lateral intermuscular septum is a site of compression for the radial nerve.
REFERENCE: Spinner RJ, Spinner M: Nerve entrapment syndromes, in Morrey BF: The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 839-862.

Question 77:

Options:

Plantar fasciitis
Sinus tarsi syndrome
Medial plantar nerve entrapment
Entrapment of the nerve to the abductor digiti quinti
Anterior tibial tendinitis

Correct Answer: Medial plantar nerve entrapment

Explanation:

Question 78:

Which of the following is considered a risk factor for the development of low back pain?

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 79:

Which of the following statements best describes labral tears in the hip?

Options:

They are unrelated to degenerative joint disease.
They lead to increased movement of the femur relative to the acetabulum.
They usually result from lesions of the ligamentum teres.
They only occur with abnormal bone morphology.
They commonly occur in the posteroinferior quadrant of the hip.

Correct Answer: They lead to increased movement of the femur relative to the acetabulum.

Explanation:

Question 80:

Which of the following is considered an advantage of the tibial inlay fixation compared to transtibial tunnel technique when used in posterior cruciate ligament reconstruction? Review Topic

Options:

Less invasive
Superior published clinical results
Decreased surgical time
Elimination of the critical 90-degree turn at the tibial aperture of the tunnel
Improved cosmesis

Correct Answer: Elimination of the critical 90-degree turn at the tibial aperture of the tunnel

Explanation:

Question 81:

Options:

Open biopsy followed by curettage and bone grafting
MRI, whole-body bone scan, CT of the chest, followed by incisional biopsy
Allow the fracture to heal with nonsurgical management and serial radiographs
Open biopsy followed by wide resection and reconstruction with osteoarticular allograft
Open biopsy followed by wide resection and endoprosthetic replacement

Correct Answer: Allow the fracture to heal with nonsurgical management and serial radiographs

Explanation:

DISCUSSION: This radiolucent lesion with a “fallen leaf sign” is typical for a unicameral bone cyst(UBC). The most appropriate treatment is to allow the fracture to heal with clinical and radiographic observation. Curettage and bone grafting is not the best initial management for UBC. Wide resection is not indicated for UBC. The proximal humerus is the most common site for UBC. While staging studies consisting of MRI, bone scan, and CT of the chest are appropriate for lesions suspected of being malignant, the classical appearance of this UBC is such that this work-up is not necessary initially. Following fracture healing, aspiration and injection of the cyst may be indicated.
REFERENCES: Dormans JP, Pill SG: Fractures through bone cysts: Unicameral bone cysts, aneurysmal bone cysts, fibrous cortical defects, and nonossifying fibromas. Instr Course Lect 2002;51:457-467.
Deyoe L, Woodbury DF: Unicameral bone cyst with fracture. Orthopedics 1985;8:529-531.

Question 82:

Options:

Physical therapy
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Physical therapy

Explanation:

The MRI scans show Modic changes in the L4-L5 vertebral bodies due to spondylosis. There is no increased fluid signal or enhancement in the L4-L5 disk to suggest infection or any other pathologic process. Therefore, the patient’s pain should be treated with a course of physical therapy and rehabilitation. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a
pseudomeningocele is not present. A revision diskectomy is useful for recurrent radiculopathy but would not be helpful for degenerative low back pain.
(SBQ12SP.29) A 17-year-old female is undergoing posterior instrumented fusion from T5-T12 for adolescent idiopathic scoliosis. At the time of the correction maneuver, the neurophysiologist notifies you of a 60% decrease in somatosensory evoked potential (SSEP) amplitude throughout bilateral lower extremities. Which of the following is an acceptable approach to manage this finding?
Review Topic
Immediate wake-up test with examination for clonus
Drop the mean arterial pressure (MAP) to ~60mmHg
Discontinue instrumentation and optimize MAP to 85mmHg or greater
Immediate infusion of intravenous corticosteroids
Modification of the anesthesia plan to include inhalational agents only followed by repeated SSEP testing
The patient has a significant drop in SSEP amplitudes at the completion of the corrective maneuver. The most appropriate response is to raise the MAP to 85 mmHg or greater, discontinue the instrumentation, re-evaluate the SSEPs, and if there is no improvement, to consider reversing the reduction of the deformity.
Intra-operative neurophysiologic monitoring is an effective method to monitor insults to the spinal cord and its exiting roots during spinal instrumentation. The common measurements include SSEPs, which monitor sensory potentials transmitted through the dorsal column system, and motor-evoked potentials (MEPs), which monitor motor response to a trans-cranial stimulus. Decreases in amplitude and latency of the circuits are recorded, however diminished signal amplitudes are more sensitive for neurologic injury, and decreases of of >50-60% being highly concerning. The wake-up test involves reversal of anesthesia so that an intra-operative neurologic examination can be performed.
Devlin et al. reviewed the basic science and practice of neurophysiologic monitoring in spine surgery. They proposed an algorithmic approach to managing intraoperative alerts which include discontinuation of inhalational anesthetics, increasing the MAP to >90 mmHg, discontinuing instrumentation, and performing a wake-up test if neurologic signals fail to normalize.
Herdmann et al. reviewed the practice of neurophysiologic monitoring and the effects of anesthesia upon signal transduction. They report that anesthesia affecting a neuron's intrinsic excitability can alter the results of monitoring. Inhalational anesthetics and decreased MAPs can be responsible for decreased amplitudes.
Vitale et. al. developed a consensus-based intraoperative checklist for management of lost neuromonitoring signals. In this checklist, the first steps across the surgical and anesthetic teams should include: stop the case and announce signal losses to the room, optimize the mean arterial pressure, discuss the status of anesthetic agents, and discuss reversible surgical actions just prior to signal loss.
Incorrect

Question 83:

Options:

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

Correct Answer: L5 nerve root

Explanation:

Question 84:

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 85:

Options:

Initiate isometric external rotation strengthening and continue passive range of motion.
Initiate eccentric supraspinatus strengthening and continue passive range of motion.
Initiate light resistance training to minimize atrophy and continue passive range of motion.
Continue passive range of motion and initiate concentric deltoid strengthening.
Continue passive range of motion with no active strengthening of the shoulder muscles.

Correct Answer: Continue passive range of motion with no active strengthening of the shoulder muscles.

Explanation:

Question 86:

Options:

in situ subtalar fusion.
tibiotalocalcaneal arthrodesis using an intramedullary rod.
ankle arthroscopy with debridement of osteophytes.
subtalar distraction bone block arthrodesis.
lateral wall ostectomy of the calcaneus.

Correct Answer: subtalar distraction bone block arthrodesis.

Explanation:

Question 87:

Options:

case series.
case-control study.
cohort study.
randomized clinical trial.

Correct Answer: case series.

Explanation:

Question 88:

Options:

a technetium Tc 99m scan.
an indium scan.
an ultrasound examination.
aspiration.
revision.

Correct Answer: aspiration.

Explanation:

Question 89:

- The radiographs shown in Figures 71a through 71c, and the CT scan shown in Figure 71d reveal an acetabular fracture that should be classified as

Options:

t-type
both column
transverse
anterior column
anterior column posterior hemitransverse

Correct Answer: both column

Explanation:

Question 90:

Options:

bed rest only for 6 weeks.
mobilization in a kinetic therapy bed for 6 weeks, followed by a hyperextension brace.
a total contact thoracolumbosacral orthosis and rapid mobilization.
anterior decompression, vertebral reconstruction, and stabilization.
posterior reduction, stabilization, and grafting.

Correct Answer: a total contact thoracolumbosacral orthosis and rapid mobilization.

Explanation:

Question 91:

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

Options:

Superficial
Transitional
Deep
Calcified
Tidemark

Correct Answer: Deep

Explanation:

Question 92:

Options:

Prevention of knee hyperextension
Correct of valgus instability
Correction of varus malalignment
Treatment of symptomatic meniscal tear
Treatment of an asymptomatic abnormally shaped meniscus

Correct Answer: Correct of valgus instability

Explanation:

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment?
Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 93:

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

Options:

Isometric
Isotonic
Concentric
Isokinetic
Eccentric

Correct Answer: Eccentric

Explanation:

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

Question 94:

Options:

Chondroblastoma
Enchondroma
Giant cell tumor
Fibrous dysplasia
Osteoblastoma

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 95:

Options:

Allergic metal synovitis
Aseptic loosening of the acetabular component
Septic loosening of the acetabulum
Deconditioning following hip arthroplasty
Iliopsoas tendinitis

Correct Answer: Septic loosening of the acetabulum

Explanation:

DISCUSSION: The difference in the clinical results combined with the laboratory findings points to infection. While there is a significant risk of false-positive findings with aspiration, the fact that two successive aspirations grew the same organism strongly suggests infection. The radiograph shows that there is more radiolucency around the left acetabular component than the right component.
REFERENCES: White RE: Evaluation of the painful total hip arthroplasty, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998,
vol 2, pp 1377-1385.
Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.

Question 96:

Options:

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

Correct Answer: Ankle-brachial index (ABI)

Explanation:

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

Question 97:

Options:

observation.
a rigid collar for 6 weeks.
halo vest application.
open reduction and posterior stabilization.
open reduction, diskectomy, grafting, and anterior plate stabilization.

Correct Answer: a rigid collar for 6 weeks.

Explanation:

Question 98:

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

Options:

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

Correct Answer: Right L3 nerve root

Explanation:

DISCUSSION: The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.
REFERENCE: An H: Diagnostic imaging of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 102-125.

Question 99:

Recurrence of this deformity after initial treatment should be treated with

Options:

recasting.
anterior tibialis tendon transfer.
extensive posteromedial-lateral release.
tibial osteotomy.

Correct Answer: recasting.

Explanation:

DISCUSSION
Single nuclear polymorphism (SNP) on chromosome 12q24.31, an intergenic SNP, is the PITX1-TBX4 transcriptional pathway that codes for hindfoot formation and is associated with clubfoot. The COLIA-1 gene is related to osteoporosis. Mutations in EXT genes that control formation of tumors cause multiple hereditary exostosis. Mutations in the COL5A or COL3A genes are associated with Ehlers-Danlos syndrome. All idiopathic clubfeet involve abnormalities of or around the talus.
The classic Ponseti technique is associated with a low recurrence rate when followed precisely. The most common reason for recurrence is noncompliance with postsurgical bracing. The initial treatment for recurrence after Ponseti casting is recasting.
NCOA2 fusion transcripts has been noted in mesenchymal chondrosarcoma. Ring chromosomes with CDK4 and MDM2 amplification may be identified with low-grade central osteosarcoma or parosteal osteosarcoma. Fusion transcripts of CDH11-USP6 have been observed in aneurysmal bone cysts.
Video 85
CLINICAL SITUATION FOR QUESTIONS 82 THROUGH 85
Figures 82a and 82b are the radiographs of a 10-year-old girl who was an unrestrained back seat passenger in a motor vehicle collision. Her sole injury is to her left leg. She has a deformed valgus knee with lateral swelling and bruising, and no wound is visible. Upon examination, she has symmetric pulses to her right leg but diminished sensation on the dorsum of the foot and in the first web space. She cannot dorsiflex her left foot or toes but can plantar flex and invert them. Weak ankle eversion is present. Sensation to the plantar foot, medial ankle, and lateral ankle is intact. She likely will reach skeletal maturity at age 14.

Question 100:

What effect does deep freezing have on allograft tissue?

Options:

Causes no deleterious clinical effect on ligamentous grafts
Causes a less deleterious effect on cartilage than on ligamentous grafts
Causes degradation of the extracellular matrix
Allows for preservation of cells with tissue
Eliminates the chance of human immunodeficiency virus (HIV) transmission

Correct Answer: Causes no deleterious clinical effect on ligamentous grafts

Explanation:

DISCUSSION: Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue.
REFERENCES: Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in
knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.
Caspari RB, Botherfield S, Horwitz RL, et al: HIV transmission via allograft organs and tissues. Sports Med Arthroscopy Rev 1993;1:42-46.

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

Orthopedic Board Review MCQs: Spine, Fracture & Ligament | Part 257

Key Takeaway

Orthopedic Board Review MCQs: Spine, Fracture & Ligament | Part 257

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