Orthopedic MCQ Mock Exam: OITE & AAOS | Part 261

About This Board Review Set

This is Part 261 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
Exam Mode — All feedback is hidden until you click Submit & See Results. A live timer tracks elapsed time. A percentage score and detailed breakdown are displayed upon submission.

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

Topics Covered in Part 261

This module focuses heavily on: Cartilage, Fracture, Hip, Shoulder, Tumor, Wrist.

Sample Questions from This Set

Sample Question 1: Studies have shown that the parents and grandparents of people with developmental dysplasia of the hip (DDH)...

Sample Question 2: A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?...

Sample Question 3: When compared with reamed intramedullary nailing for an unstable diaphyseal tibia fracture, unreamed nailing is associated with which of the following?...

Sample Question 4: What is the most common primary malignant bone or cartilage tumor in children?...

Sample Question 5: A 38-year-old man sustained a complete thoracic spinal cord injury at age 14. An MRI scan of his shoulder, when compared with studies from uninjured controls, is more likely to show which of the following? Review Topic...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

Studies have shown that the parents and grandparents of people with developmental dysplasia of the hip (DDH)

Explanation

DISCUSSION
The hip arthritis RR is significantly increased in patients with DDH (RR = 82.4; P < 2e-16), their parents (RR = 2.22; P = 0.0003), and their grandparents (RR = 1.33; P = 0.011). The THA RR also is significantly increased for patients with DDH (RR = 1168; P < 3e-08) and their grandparents (RR = 2.06; P = 0.01). First-degree and second-degree relatives were not at higher risk for knee arthritis or knee arthroplasty. The RR for DDH was significantly increased for first-degree relatives (RR = 12.1; P < 0.000001) and siblings (RR = 11.9; P < 0.000001).

Question 2

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser’s disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock’s disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.
REFERENCE: Perlik PC, Guilford WB: Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:479-484.

Question 3

When compared with reamed intramedullary nailing for an unstable diaphyseal tibia fracture, unreamed nailing is associated with which of the following?

Explanation

The Investigators Randomized Trial of Reamed versus Non-Reamed Intramedullary Nailing of Tibial Shaft Fractures (SPRINT) study, a large, randomized, controlled trial, has shown a benefit of reamed intramedullary (IM) nailing versus unreamed IM nailing for closed tibial shaft fractures with regard to reoperation rates. No such association exists for open tibial fractures; ie, union rates are the same for open fractures. The infection rates are the same, as is functional outcome, and surgical time is potentially shorter for unreamed nails. The potential pulmonary benefits from unreamed nailing have never been clinically proven.

Question 4

What is the most common primary malignant bone or cartilage tumor in children?

Explanation

DISCUSSION: Osteosarcoma is the most common primary malignant bone tumor (5.6 per

1 million children younger than age 15 years), and Ewing’s sarcoma is second (2.1 per

1 million children). Giant cell tumor and chondrosarcoma are rare in children. Osteochondroma is more common than any of the above tumors in children, but it is not malignant.
REFERENCES: Himelstein BP, Dormans JP: Malignant bone tumors of childhood. Pediatr Clin North Am 1996;43:967-984.
Pierz KA, Womer RB, Dormans JP: Pediatric bone tumors: Osteosarcoma, Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis. J Pediatr Orthop 2001;21:412-418.
Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence.

N Engl J Med 1999;341:342-352.

Question 5

A 38-year-old man sustained a complete thoracic spinal cord injury at age 14. An MRI scan of his shoulder, when compared with studies from uninjured controls, is more likely to show which of the following? Review Topic

Explanation

Children that sustain a spinal cord injury or otherwise use a wheelchair for mobility, and thus often have more pain and a higher incidence of structural and functional changes of the shoulder joint as an adult. MRI studies have shown a four-fold risk of rotator cuff tears in people with long-term paraplegia when compared with age-matched controls. An MRI scan would not show bone density changes. The other answer choices have not been demonstrated in higher numbers on MRI in paraplegics.

Question 6

To adequately expose the volar plate of the proximal interphalangeal joint of the finger, which of following pulleys is typically incised?

Explanation

DISCUSSION: Full exposure of the volar plate of the proximal interphalangeal joint of the finger is best accomplished by incision of the distal C1, A3, and proximal C2 pulleys; followed by gentle retraction of the flexor digitorum superficialis and profundus tendons. Sacrifice of the A3 pulley, although associated with some biomechanic disadvantage, can be tolerated without causing functionally limiting bowstringing of the flexor tendon. Sacrifice of even a portion of the A2 or A4 pulleys can decrease the biomechanic leverage provided by the flexor tendon sheath, leading to bowstringing of the flexor tendons.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 176-186.
Strickland J: Flexor tendon-acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2,

pp 1853-1855.
Lin GT, Amadio PC, An KN, et al: Functional anatomy of the human digital flexor pulley system. J Hand Surg Am 1989;14:949-956.

Question 7

A 40-year-old woman has local back pain and intense burning pain in her perianal region after being shot twice in the back. Motor and sensory examination of her lower extremities reveals no apparent deficit. She has present but decreased sensation in her perianal region, an intact anal wink, good rectal tone, and an intact bulbocavernosus reflex. Radiographs and CT scans are shown in Figures 3a through 3d. What is the next most appropriate step in management?

Explanation

DISCUSSION: Because the patient has an apparent compressive neuropathy secondary to the metallic fragments, removal of the fragments in this incomplete lesion at the cauda equina level can be expected to improve her sensory dysesthesias and pain. Steroids are not indicated in a root lesion secondary to a penetrating injury. MRI will have significant artifact effect and will not provide much additional information. The posterior bony elements are not significantly injured; therefore, stabilization is not indicated.
REFERENCES: Bracken MB, Shepard MJ, Holford TR: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. JAMA 1997;277:1597-1604.
Waters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal: A collaborative study by the National Spinal Cord Injury Model Systems. Spine

1991;16:934-939.
Stauffer ES, Wood RW, Kelly EG: Gunshot wounds of the spine: The effects of laminectomy.

J Bone Joint Surg Am 1979;61:389-392.

Question 8

Radiographs of an 80-year-old woman with back pain reveal a compression fracture. Which of the following imaging studies best evaluates the acuity of the fracture?

Explanation

DISCUSSION: The best method of evaluating the acuity of osteoporotic compression fractures is to look for edema in the vertebral body. This is best accomplished with a STIR-weighted MRI scan. Bone scans can show increased uptake at the site of fracture for many months after the fracture. T₁-weighted MRI scans show loss of normal marrow fat that may not necessarily correspond with acuity of the fracture. CT scans and radiographs show fracture deformity but cannot be used to judge acuity.
REFERENCES: Phillips FM: Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine 2003;28:S45-S53.
Rao RD, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 9

A 21-year-old basketball player reports increased left shoulder pain with all lifting and overhead activities. He denies any history of dislocations. Axial MRI arthrogram images are seen in Figures 34a and 34b. An expected finding on physical examination of the shoulder would be positive findings for which of the following tests? Review Topic

Explanation

An MRI arthrogram is a sensitive imaging study used to identify intra-articular shoulder pathology, especially abnormalities of the labrum. Posterior labral tears, although generally less common than anterior tears, can cause significant morbidity, especially in the athlete. Pain, grinding, or gross subluxation often can be elicited with a "jerk" test of the involved shoulder. This test consists of placing an axial load through the humerus, with the shoulder forward flexed to 90 degrees. The shoulder is
then abducted, while maintaining the axial load, and the patient's subjective and objective response is observed. Comparison to the contralateral shoulder is important, especially if painless subluxation is noted, to determine potential evidence of generalized joint laxity.

Question 10

A 51-year-old woman who underwent a total knee arthroplasty 14 months ago for severe degenerative arthritis now reports progressive pain, swelling, and buckling of the knee. She must use crutches and is unable to negotiate stairs. Laboratory testing reveals a normal erythrocyte sedimentation rate and C-reactive protein. Radiographs of the patient are shown in Figures 17a through 17c. What is the most important test to further evaluate this problem?

Explanation

DISCUSSION: The cause of subluxation in this patient is multifactorial, and includes a laterally positioned patellar component, a tibial tray that is internally rotated and translated to the medial side of the proximal tibial surface, and a femoral component that is markedly internally rotated about 10 degrees. All of these findings will be apparent on a CT scan. The long standing radiograph may be helpful but does not show the particular rotational abnormalities of both implants that are causing this problem. Fluoroscopic review may show how unstable the patella is, but the initial Merchant’s view shows the basic problem. A bone scan does not provide information about component malposition. An MRI scan is inferior to a CT scan because of image artifact.
REFERENCES: Stiehl JB: Patellar instability in total knee arthroplasty. J Knee Surg 2003;16:229-235. Berger RA, Crossett LS, Jacobs JJ, et al: Malrotation causing patellofemoral complications after total knee arthroplasty. Clin Orthop Relat Res 1998;356:144-153.

Question 11

Figures 59a and 59b are the radiographs of a 7-year-old boy who was seen 1 week after he underwent a closed reduction and casting in the emergency department after a fall on an outstretched arm. What is the most appropriate next step for this patient? Review Topic

Explanation

This child's radiograph shows an acceptably reduced fracture of both the radius and ulna. Generally accepted limits of shaft angulation for cast treatment for girls 8 years of age or younger and boys age 10 or younger are 20 degrees for distal-third, 15 degrees for middle-third, and 10 degrees for proximal-third fractures. Remodeling decreases as one goes from distal to proximal in the forearm. Unless the child's fracture deviates from these criteria, surgical treatment is not necessary. Because of the risk of displacement, however, close follow-up is recommended.

Question 12

A patient reports hyperesthesia over the base of the thenar eminence following volar locked plating of a distal radius fracture. A standard volar approach of Henry was used. What is the most likely cause of the hyperesthesia?

Explanation

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 13

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

Explanation

DISCUSSION
Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Question 14

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

Explanation

DISCUSSION: Acute posterior dislocations occur rarely, accounting for less than 5% of acute dislocations. They are most often the result of falls on an outstretched hand. Reduction can be accomplished with flexion of the arm to 90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is then externally rotated until the head has cleared the glenoid rim. Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks.
REFERENCES: Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1986;68:724-731.
Pollock RG, Bigliani LU: Recurrent posterior shoulder instability: Diagnosis and treatment.

Clin Orthop 1993;291:85-96.

Question 15

A 12-year-old girl with foot pain who has been diagnosed with hereditary motor sensory neuropathy is seen for the foot deformity shown in Figure 59a. A “block test” is performed and shown in Figure 59b. What is the most appropriate management for this patient?

Explanation

DISCUSSION: The hindfoot varus in this individual with a cavovarus deformity is nonstructural as shown by the “block test”. Therefore, surgical procedures directed at correcting the hindfoot deformity are not necessary. Observation is not in order and shoe modifications have not been shown to be effective in managing this problem. The patient is symptomatic; therefore, the treatment of choice is plantar release with first metatarsal osteotomy and possible tendon transfers.
REFERENCES: Paulos L, Coleman SS, Samuelson KM: Pes cavovarus: Review of a surgical approach
using selective soft-tissue procedures. J Bone Joint Surg Am 1980;62:942-953.
McCluskey WP, Lovell WW, Cummings RJ: The cavovarus foot deformity: Etiology and management. Clin Orthop Relat Res 1989;247:27-37.
Ward CM, Dolan LA, Bennett DL, et al: Long-term results of reconstruction for treatment of a flexible
cavovarus foot in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 2008;90:2631-2642.

Figure 60a Figure 60b Figure 60c

Question 16

Within the menisci, the majority of the large collagen fiber bundles are oriented in what configuration?

Explanation

DISCUSSION: The majority of large collagen fibers within the menisci are oriented circumferentially. It is these fibers that develop the hoop stress with compressive loading of the menisci. Most meniscal tears are longitudinal and occur between these circumferential fibers.
REFERENCES: Mow VC, et al: Structure and function relationships of the menisci of the knee, in Mow VC, Arnoczky SP, Jackson DW (eds): Knee Meniscus: Basic and Clinical Foundations. New York, NY, Raven Press, 1992, pp 37-57.
DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.

Question 17

A 35-year-old man falls off of a roof and sustains an extra-articular supracondylar elbow fracture. He had normal sensation in all fingers after the injury and before undergoing surgery to repair the fracture. The ulnar nerve was not transposed but was inspected prior to wound closure. Ten days after surgery, the patient has numbness in his small finger and is unable to cross his fingers. His elbow range of motion is 40° to 100°. What is the next appropriate step in management?

Explanation

This patient has an early postsurgical ulnar nerve palsy. The causes of this injury are laceration of the nerve during surgery, entrapment of the nerve in the fracture or hardware, or traction injury during surgery. If the orthopaedic surgeon is sure that the nerve was not lacerated at the end of the case or entrapped in the hardware, then the nerve is probably intact and will recover. Observation is the best treatment in this case because the nerve was checked before wound closure. Elbow splinting has not been shown to help with postsurgical nerve recovery. EMG findings may not be accurate this early following the injury.

Question 18

A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 20a and 20b. What is the most appropriate procedure at this time?

Explanation

DISCUSSION: Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 19

An elite football player has sustained a left knee injury during play. A dynamic imaging analysis is performed on the affected knee, which shows anterior shift and internal rotation of the tibia at low flexion angles. There is also some mild medial translation of the tibia at greater flexion angles. What structure(s) have most likely been injury? Review Topic

Explanation

This patient has sustained an anterior cruciate ligament (ACL) rupture.
The ACL is the primary restraint to anterior translation of the tibia relative to the femur. It also acts as secondary restraint to tibial rotation and varus/valgus rotation. ACL-deficient knees have been shown to have abnormal knee kinematics, which has been thought to contribute to the osteoarthritis that develops after injury.
DeFrate et al. examined the knee joint kinematics of 8 patients with unilateral anterior cruciate ligament rupture using in vivo imaging. They found significant anterior shift and internal rotation of the tibia at low flexion angles in ACL-deficient knees. They also noted some medial translation of the tibia between 15° and 90° of flexion.
Illustration A shows the effect of medial tibial translation on tibiofemoral contact in ACL-deficient knees. The medial translation of the tibia causes increased contact between the tibial spine and inner surface of the medial femoral condyle. This might be a contributing factor to the joint degeneration observed in ACL-deficient patients.
Incorrect Answers:

Question 20

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Explanation

DISCUSSION:
Maintenance of the joint line and accurately tensioning the PCL are critical in the proper execution of a PCL-retaining total knee arthroplasty. Appropriate tension helps ensure femoral rollback and avoid stiffness or instability. Raising the joint line to help ensure full extension should be avoided in cruciate- retaining knees, because doing so creates an unfavorable kinematic environment. The three important principles of surgical technique needed to maintain appropriate tensioning of the PCL include 1) choosing the proper femur size to reproduce the native femoral anterior/posterior dimension, 2) reproducing the joint line by resecting as much tibia from the healthy side as will be replaced by the smallest thickness of the tibial component and, 3) ensuring that full extension is achieved by soft-tissue releases and not by taking additional distal femur, as may be done in a posterior stabilized approach. Another important principle is to re-create the natural degree of the patient’s posterior tibial slope to avoid tightness in
flexion.

Question 21

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

Explanation

DISCUSSION: Unlike compression-side stress fractures, tension-side stress fractures on the superior side of the femoral neck are at a very high risk of displacement, even if the patient is not bearing weight. It is highly recommended to treat these fractures like acute fractures and to proceed with internal fixation emergently. Once the fracture has displaced, the prognosis is poor in terms of returning to sports, even when reduced and internally fixed. Nonsurgical management, such as limited weight bearing and low-impact activities, works very well for other lower extremity stress fractures. A training program evaluation (shoes, tracks, schedule) is always indicated for all patients with stress fractures.
REFERENCE: Boden BP, Osbahr DC: High-risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 22

A 30-year-old man has had severe knee pain and swelling for 1 week. He reports he previously had acromioclavicular joint pain that disappeared. He denies any fever. Aspiration of a cloudy fluid from the knee reveals a WBC count of greater than 50,000 with 90% polymorphonucleocytes. While awaiting culture results, what is the most appropriate action?

Explanation

The patient has polyarticular gonococcal arthritis. Acute septic arthritis in adults can be separated into two major patient groups: young (age 15 to 40 years) healthy, sexually active patients with gonococcal pyogenic arthritis and elderly or immunocompromised patients with nongonococcal septic arthritis. In gonococcal septic arthritis, the infecting organism is Neisseria gonorrhea. It is the most common cause of acute joint infection in persons 15 to 40 years of age in the U.S. The clinical presentation is variable, but typically includes migratory polyarthralgias, fever, rash, urethral or vaginal discharge, and tenosynovitis. A patient with disseminated gonococcal infection may report few genital symptoms. More than 50% of these infections are polyarticular. Because patients with gonococcal septic arthritis are healthy, prompt antibiotic treatment results in a generally good prognosis. MRSA septic arthritis would be associated with fever, more rapid onset of symptoms, and is rarely polyarticular.

Question 23

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Explanation

All of the following listed are associated with the female athlete triad except for Low LDL cholesterol levels. In fact, these patients often have elevated levels of LDL due to the hypoestrogenism caused by menstrual dysfunction.
The female athlete triad is an interrelationship of menstrual dysfunction (i.e., amenorrhea or oligomenorrhea), low energy availability (insufficient caloric intake for demand, with or without an eating disorder) and decreased bone mineral density. It is relatively common among young women participating in sports. More recently, it has been suggested that endothelial dysfunction also results, due to an imbalance between vasodilating and vasoconstricting agents triggered from inappropirate levels of nitric oxide on the microscopic level, which predisposes these women to atherosclerotic changes and increases their risk of cardiovascular disease in the future.
Matheson et al. analyzed cases of 320 athletes with bone scan-positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. They found that conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.
Constantini et al. evaluated the prevalence of vitamin D insufficiency and deficiency among young athletes and dancers. They found a higher rate of vitamin D insufficiency among participants who practice indoors, during the winter months, and in the presence of iron depletion.
Nazem et al. reviewed the major components and health consequences of the female athlete triad as well as strategies for diagnosis and treatment of the conditions. They concluded that treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members.
Yagi et al. followed 230 runners participating in high school running teams for a total of 3 years to report occurrence of medial tibial stress syndrome (MTSS) and stress fracture. Predictors of MTSS and stress fracture were investigated. The authors reported a significant relationship between BMI, internal hip rotation angle and MTSS infemales.
Incorrect Answers:

Question 24

Figures 191a and 191b are the radiographs of an 18-year-old man who had an ankle fracture requiring open reduction and internal fixation 2 years ago. He has a progressive symptomatic ankle deformity.Surgical intervention should consist of

Explanation

Question 25

A year old woman undergoes revision total knee arthroplasty for tibial component aseptic loosening. She is concerned about recurrent loosening, and tibial stem fixation options during revision are reviewed. Figure below displays a radiograph of the revision technique used for this patient. What is the incidence of intraoperative tibial shaft fracture that is associated with this type of revision surgery?

Explanation

DISCUSSION:
Using press-fit tibial stems during a hybrid revision total knee arthroplasty is associated with a 3% to 5% incidence of intraoperative tibial shaft fracture. Diaphyseal fixation of press-fit stems has the advantage of setting component alignment, dispersing forces on the proximal tibia, and offers excellent clinical results. The disadvantages include proximal and distal tibia anatomic mismatch and tibial shaft fracture. Cipriano and associates reported a tibial shaft fracture incidence of 4.9% in a series of 420 consecutive
knee revisions. All fractures healed with nonsurgical management, and none led to implant loosening. In this patient, it is important to recognize on the radiograph that this technique is a hybrid method of revision total knee arthroplasty, with cementation along the tibial tray and metaphysis and with press-fit fixation of the diaphyseal engaging stem. Then, it is important to know the risk and management of intraoperative diaphyseal tibial fractures. Cemented tibial stems are associated with a low rate of intraoperative fracture, because the implant is typically undersized to allow for an appropriate cement mantle. Option C is incorrect, because this revision is not cemented. Option A underestimates the incidence of fracture,
whereas D overestimates the rate of fracture.

Question 26

Figures 34a through 34c show the radiographs of a 51-year-old woman who injured her elbow in a fall from standing height. Examination reveals that elbow range of motion is limited by pain only. Management should consist of

Explanation

DISCUSSION: The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore

function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness.
REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364.
Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 27

For this patient, which TKA design is most appropriate?

Explanation

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

Question 28

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

Explanation

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

Question 29

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management?

Explanation

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 30

Smoking has been associated with lower fusion rates in both cervical and lumbar fusion. Which of the following statements best describes an explanation for these findings?

Explanation

Tobacco smoking is now the leading avoidable cause of morbidity and mortality in the United States. The musculoskeletal effects of smoking have been implicated in osteoporosis, low back pain, degenerative disk disease, poor wound healing, and delayed fusion and fracture healing. A number of studies have demonstrated the relationship between smoking and development of pseudarthrosis. Numerous studies
have been performed to offer an explanation of the mechanism mediating this effect. Whereas all of the above have been postulated as explanations, more recent studies have demonstrated that nicotine delivered via a transdermal patch significantly enhanced posterior spinal fusion in rabbits. Thus it appears that the effects of smoking on fracture healing are multifactorial and not yet fully understood.

Question 31

Performing reconstruction of the anterior cruciate ligament by drilling the femoral tunnel via an anteromedial portal, in contrast to transtibial drilling, affords what theoretical benefit? Review Topic

Explanation

Recent trends in anterior cruciate ligament reconstruction include an emphasis on anatomic rather than isometric reconstruction of the ligament. According to some studies, this more effectively restores knee kinematics and with this, rotatory stability. Transtibial drilling affords limited access to the lateral intercondylar wall and has been associated with vertical graft orientation. The anteromedial portal, in contrast, allows independent femoral tunnel drilling and more anatomic positioning of the graft. A more anatomically positioned tunnel established via an anteromedial portal may afford increased tunnel and graft obliquity. This has been suggested to resolve rotatory instability. Knee flexion angle during the course of reaming has been studied to assess favorable and negative tunnel characteristics and hazards to regional anatomic structures. When compared with transtibial drilling, the anteromedial portal is associated with shorter femoral tunnels, posterior tunnel wall integrity compromise, and increased risk to lateral femoral articular cartilage and subchondral bone posteriorly.

Question 32

What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?

Explanation

DISCUSSION
Radiography is the best initial study. Vacuum phenomenon may be found within the disk space. Other possible sources for back pain such as osteoporotic collapse, osteolytic collapse, and deformity also can be evaluated. The other tests may be beneficial and are more appropriate as later imaging options.
RECOMMENDED READINGS
Yu WD, Williams SL. Spinal imaging: Radiographs, computed tomography, and magnetic resonance imaging. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine

Question 33

Figures 1a and 1b are the MR images of a 69-year-old woman with bilateral leg pain that is worse with ambulation. She feels better when she is sitting down or leaning on a grocery cart. Which condition or structure is indicated by the arrows?

Explanation

DISCUSSION
This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable.
A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion.
RECOMMENDED READINGS
Epstein NE, Baisden J. The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration. Surg Neurol Int. 2012;3(Suppl 3):S157-66. doi: 10.4103/2152-7806.98576. Epub 2012 Jul 17. PubMed PMID: 22905322. View Abstract at PubMed
Xu R, McGirt MJ, Parker SL, Bydon M, Olivi A, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine (Phila Pa 1976). 2010 May 1;35(10):1044-53. PubMed PMID: 20173680. View Abstract at PubMed

Question 34

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Explanation

Figure A is an AP radiograph demonstrating a displaced femoral neck fracture. Active older patients who present with a displaced femoral neck fracture should be treated with total hip arthroplasty (THA).
Displaced femoral neck fractures can present a challenge to treat. In younger patients with good bone stock a closed vs. open reduction and internal fixation should be attempted. For active older patients a total hip arthroplasty is the best option, especially if there is pre-existing arthritis in the injured hip. THA provides the best function with the least pain and less need for repeat surgery (compared to hemiarthroplasty). For low-demand or debilitated patients, for patients older than age 80, or for those who can not reliably follow hip precautions a hemiarthroplasty provides the lowest risk of dislocation, and thus would be the treatment of choice.
Macaulay et al. present a prospective randomized trial of patients with femoral neck fractures treated with THA vs hemiarthroplasty. They found that functional outcomes and patient satisfaction were higher in the THA group without significant increased risk of complications. Inclusion criteria required patients to be over age 50, be a community ambulator, and were excluded for presence of dementia.
Abboud et al. retrospectively reviewed patients treated with THA for osteoarthritis and compared them to patients treated with THA for a femoral neck fracture. They found no significant difference between the two groups for outcomes or complications.
Figure A is an AP radiograph demonstrating a displaced femoral neck fracture.
Incorrect Answers:

Question 35

A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?

Explanation

DISCUSSION: The MRI scan shows a ganglion cyst in the region of the spinoglenoid notch. These are difficult to diagnose clinically but are readily apparent on MRI. They usually cause compression of the suprascapular nerve and weakness of the infraspinatus and supraspinatus muscles.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 306-309.
Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 36

A fracture in the following location is most commonly associated with procurvatum and valgus malalignment?

Explanation

Fractures of the proximal tibial shaft are associated with high rates of valgus and apex anterior (procurvatum) malalignment.
Proximal third tibial shaft fractures are often difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. Many different techniques have been devised to overcome the deforming forces. These include (1) Poller blocking screws posterior and lateral to the intramedullary nail (IMN), (2) utilizing a semiextended knee position during IMN of proximal tibia fractures (3) use of a suprapatellar approach for IMN, (4) usage of a slightly more lateral starting point during conventional IMN, and (5) application of unicortical plate.
Ricci et al. describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibia. Post-operatively, all patients in their series had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. At 6 months follow-up, 10/11 patients maintained this alignment.
Illustration A shows intra-operative sagittal radiographs of the proximal tibia. Note the use of Poller blocking screws in the posterior and lateral aspects of the proximal tibia.
Incorrect Answers:

Question 37

Which of the following factors is most likely to contribute to pseudarthrosis in a patient who has undergone a single-level anterior decompression and fusion procedure for the treatment of cervical radiculopathy? Review Topic

Explanation

Various factors affect the pseudarthrosis rate in patients who undergo anterior cervical decompression and fusion. Patient factors, including history of smoking and history of
diabetes mellitus, have been shown to significantly increase pseudarthrosis rates. The literature has been mixed with regard to fusion rates for allograft versus autograft, especially for one-level fusions; in that category, there is minimal, if any, difference. Similarly, several authors have shown higher rates of fusion with uninstrumented single-level rather than instrumented anterior cervical decompressions and fusions. The level (ie, cranial or caudal) of fusion and sagittal alignment have not been correlated with fusion rates.

Question 38

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

Explanation

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

Question 39

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

Explanation

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

Question 40

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Explanation

DISCUSSION: Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although parathesias lasting up to 2 weeks have been reported in up to 3% of patients.
REFERENCES: Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779.
Conn RA, Colfield RH, Byer DE, Lindstromberg JW: Interscalene block anesthesia for shoulder surgery. Clin Orthop 1987;216:94-98.

Question 41

Initial management should consist of Review Topic

Explanation

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

Question 42

Which of the following is a recognized predictor of mortality after hip fracture?

Explanation

DISCUSSION: The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.
The study by Richmond et al looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality amongst patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.

Question 43

A patient wakes up with a foot drop following open reduction internal fixation of a posterior wall/posterior column acetabular fracture. What position of the leg causes the highest intraneural pressure in the sciatic nerve?

Explanation

DISCUSSION: Borrelli et al examined the intraneural pressure of the sciatic nerve with the hip and knee in various different positions. They found that the "sciatic nerve appeared to exceed published critical thresholds for alterations of blood flow and neural function only when the hip was flexed to 90 degrees and the knee was fully extended." As a result, the leg is typically position with the hip in extension (or minimal flexion) and the knee in about 90 degrees of flexion when performing acetabular surgery via a posterior approach.

Question 44

A 21-year-old throwing athlete has persistent shoulder pain. Figures 73a and 73b are arthroscopic photographs taken from a posterior viewing portal and an anterior viewing portal. During which phase of the throwing motion did the injury most likely occur? Review Topic

Explanation

Five distinct phases of the throwing motion have been identified, each of which places the static and dynamic stabilizers of the shoulder under different stresses. In the late cocking phase, the throwing arm is abducted and maximally externally rotated.
Rotator cuff tears in throwing athletes may be the result of either tensile or compressive forces. Tensile failure is believed to be the result of repetitive eccentric contractions. Compressive failure is thought to result from direct contact of the articular side of the rotator cuff between the greater tuberosity and posterior glenoid. Compressive failure results in tearing of the posterior supraspinatus and anterior infraspinatus, in contrast to the more common partial tearing of the anterior supraspinatus seen in the general population. In addition to tearing of the articular side of the rotator cuff, compressive forces also contribute to the peel-back mechanism and resultant avulsion of the posterosuperior labrum and biceps anchor. Articular-sided posterior supraspinatus and infraspinatus tears in combination with posterosuperior labral and biceps anchor detachment has been termed internal impingement. It is believed to be the primary result of either posterior capsular contracture (GIRD) or anterior capsular laxity.

Question 45

A 55-year-old woman has slowly increasing pain at the distal end of her little finger that is exacerbated by cold temperatures. She denies any history of trauma to her hands and is employed as a school teacher. The histology of the resected specimen is shown in Figure 71. What is the most likely diagnosis?

Explanation

DISCUSSION: Glomus tumors are rare vascular lesions typically occurring about the nail of the distal phalanx of the hand. The diagnostic “triad” of glomus tumors consists of local pain, sensitivity to cold, and paroxysmal pain. They tend to present with pain as the most typical symptom and this can be exacerbated by changes in temperature that is felt to cause a vascular response within the lesion. The biopsy specimen confirms a glomus tumor showing the typical vascular spaces surrounded by glomus epithelioid glomus cells.
REFERENCES: Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.
McDermott EM, Weiss AP: Glomus tumors. J Hand Surg Am 2006;31:1397-1400.

Question 46

Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Explanation

PHASE V: the crescent sign and articular collapse. The supporting bony architecture may become sufficiently weakened by continued resorption of trabecular bone and subchondral bone plate along the reactive interface that the stress of weight-bearing can result in subchondral bone plate fracture with focal articular cartilage buckling and eventual collapse. This is best seen in the frog-lateral radiograph.

Question 47

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

Explanation

DISCUSSION: The radiographs show displacement of the prosthesis, and there has been large amounts of bone resected to insert the implant. Arthrodesis is indicated with interposition bone graft to stabilize the joint and restore length to the first ray.
REFERENCE: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 265-266.

Question 48

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Explanation

DISCUSSION: The biopsy specimens show a chondromyxoid fibroma with varying amounts of cartilage, benign fibrous tissue, giant cells, and loose myxoid areas. Chondromyxoid fibroma is a benign active bone lesion that is best treated with aggressive curettage and bone grafting. Although recurrences are common, more aggressive treatment is not warranted initially.
REFERENCES: Wilson AJ, Kyriakos M, Ackerman LV: Chondromyxoid fibroma: Radiographic appearance in 38 cases and in a review of the literature. Radiology 1991;179:513-518.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 167-189.

Question 49

A 12-year-old girl has had lower back pain for the past 6 months that interferes with her ability to participate in sports. She denies any history of radicular symptoms, sensory changes, or bowel or bladder dysfunction. Examination reveals a shuffling gait, restriction of forward bending, and tight hamstrings. Radiographs show a grade III spondylolisthesis of L5 on S1, with a slip angle of 20°. Management should consist of

Explanation

DISCUSSION: Indications for surgical treatment of spondylolisthesis include pain and/or progression of deformity. Specifically, surgery is necessary when there is persistent pain or a neurologic deficit that fails to respond to nonsurgical therapy, there is significant slip progression, or the slip is greater than 50%. For patients with mild spondylolisthesis, in situ posterolateral L5-S1 fusion is adequate. In patients with more severe slips (greater than 50%), extension of the fusion to L4 offers better mechanical advantage. Postoperative immobilization may be achieved with instrumentation, casting, or both. In patients with a slip angle of greater than 45°, reduction of the lumbosacral kyphosis with instrumentation or casting is desirable to prevent slip progression. Laminectomy alone is contraindicated in a child. Nerve root decompression is indicated if radiculopathy is present clinically.
REFERENCES: Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Newton PO, Johnston CE II: Analysis and treatment of poor outcomes following in situ arthrodesis in adolescent spondylolisthesis. J Pediatr Orthop 1997;17:754-761.

Question 50

Which of the following cardiac conditions is considered an absolute contraindication to vigorous exercise?

Explanation

DISCUSSION: Hypertrophic cardiomyopathy (HCM) accounts for up to 50% of cases of
sudden death in young athletes. HCM phenotype becomes evident by age 13 to 14 years. Those at higher risk include individuals with cardiac symptoms, a family history of inherited cardiac disease, and those with a family history of premature sudden death. Echocardiography is useful for detecting structural heart disease, including the cardiomyopathies and valvular abnormalities. Trained adolescent athletes demonstrated greater absolute left ventricular wall thickness (LVWT) compared to controls. HCM should be considered in any trained adolescent male athlete with a LVWT of more than 12 mm (female of more than 11 mm) and a nondilated ventricle. Adolescent and adult athletes differ with respect to the range of LVWT measurements, as a manifestation of left ventricular hypertrophy (LVH). Differentiating LVH (“athlete’s heart”) from HCM involves looking at additional echocardiographic features. Sharma and associates reported that adolescents with HCM had a small or normal-sized left ventricle (less than 48 mm) chamber size, while those with LVH had a chamber size at the upper limits of normal (52 mm to 60 mm).
REFERENCES: Sharma S, Maron BJ, Whyte G, et al: Physiologic limits of left ventricular hypertrophy in elite junior athletes: Relevance to differential diagnosis of athlete’s heart and hypertrophic cardiomyopathy. J Am College Cardiol 2002;40:1431-1436.
Maron BJ, Spirito P, Wesley Y, et al: Development and progression of left ventricular hypertrophy in children with hypertrophic cardiomyopathy. N Engl J Med 1986;315:610-614.
Pelliccia A, Culasso F, Di Paolo FM, et al: Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999;130:23-31.

Question 51

Figure 44 shows the AP radiograph of the hip of a patient who underwent screw fixation of the acetabulum. Which of the following structures is at least risk for injury during screw placement in the acetabular component?

Explanation

DISCUSSION: Acetabular screws are inserted to supplement fixation. The acetabular component can be divided into four quadrants. Anatomic studies have shown that screws placed in the anterior superior and anterior inferior quadrants of the cup may injure the external iliac vein and obturator artery, respectively. Posterior superior and posterior inferior placement (in screws greater than 25 mm) may injure the sciatic nerve or the superior gluteal artery. The common iliac artery is proximal to the acetabulum and is at least risk for injury from acetabular screw placement.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 207-215.

Question 52

A 28-year-old man sustained a fracture-dislocation of T8 in a motor vehicle accident 1 week ago. The injury resulted in complete paraplegia. Management should consist of

Explanation

DISCUSSION: With a complete injury in the thoracic spinal cord, the likelihood of neurologic recovery is small. If possible, treatment should be planned to allow rapid mobilization and rehabilitation without the use of braces and their associated skin problems. The use of long segment fixation provides for rapid mobilization without having to use braces postoperatively. The use of steroid protocol is controversial and should be considered only if it can be started within 8 hours of the injury. Laminectomy is contraindicated because it will increase instability.
REFERENCE: Tasdemiroglu E, Tibbs PA: Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine 1995;20:1704-1708.

Question 53

Which 2 tendons are identified in the dissection shown in Video 92?

Explanation

The demonstration in Video 92 shows the tendons of the semitendinosus and gracilis muscles. They insert on the tibia deep to the sartorial fascia. The semimembranosus inserts more proximal and posterior on the tibia.
RECOMMENDED READINGS
Babb JR, Detterline AJ, Noyes FR. AAOS Orthopaedic Video Theater. The Key to the Knee: A Layer-by-Layer Video Demonstration of Medial and Anterior Anatomy. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:493-568.

Question 54

A 60-year-old man reports increasing pain in his right foot with limited ankle dorsiflexion and anterior ankle pain after sustaining a fracture of the calcaneus in a fall several years ago. Bracing, nonsteroidal anti-inflammatory drugs, and cortisone injections have failed to provide significant relief. Radiographs are shown in Figures 19a and 19b. What is the next most appropriate step in management?

Explanation

DISCUSSION: Following a calcaneal fracture, the patient has severe subtalar arthritis with loss of talar declination and shortening of the heel; therefore, the treatment of choice is subtalar distraction arthrodesis. Orthotics will not provide significant relief as bracing has failed. Ankle arthrodesis will not be beneficial because the arthritis is in the subtalar joint. Subtalar arthroscopy would only be helpful for a small area of arthrosis, and calcaneal osteotomy would not be beneficial given the extent of the arthritis of the subtalar joint.
REFERENCE: Robinson TF, Murphy GA: Arthrodesis as salvage for calcaneal avulsions. Foot Ankle Clin 2002;7:107-120.

Question 55

Kinematic analysis of the medial and lateral menisci has demonstrated that the lateral meniscus has which of the following characteristics compared with the medial meniscus?

Explanation

DISCUSSION: Kinematic analysis of both menisci demonstrates anterior movement with extension and posterior movement with flexion. The lateral meniscus has more mobility than the medial meniscus because of less soft-tissue attachments.
REFERENCES: Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. New York, NY, Churchill Livingstone, 2001, vol 1, p 474.
Thompson WO, Thaete FL, Fu FH, et al: Tibial meniscal dynamics using 3D reconstructions
of MR images, in Proceedings of the Orthopaedic Research Society 1990;389.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy
of Orthopaedic Surgeons, 2005, pp 15-28.

Question 56

What muscle attaches to the site shown by the arrow in Figure 2?

Explanation

DISCUSSION: The latissimus dorsi inserts on the humerus metaphysis between the pectoralis major (posterior) and teres major (anterior). Teres minor inserts on the base of the greater tuberosity. Pectoralis minor does not insert on the humerus.
REFERENCES: Williams PL, Warwick R, Dyson M, Bannister LH: Neurology, in Gray’s Anatomy, ed 37. Edinburgh, Scotland, Churchill Livingstone, 1989, pp 1131-1132.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 131-132.

Question 57

In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?

Explanation

DISCUSSION:
When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

Question 58

An 11-year-old basketball player reports that he felt a painful pop in the left knee when he stumbled while running. He is unable to bear weight on the extremity and cannot actively extend the knee against gravity. Examination reveals a large knee effusion. A lateral radiograph is shown in Figure 7. Management should consist of

Explanation

DISCUSSION: The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.
REFERENCES: Maguire JK, Canale ST: Fractures of the patella in children and adolescents.

J Pediatr Orthop 1993;13:567-571.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990;10:721-730.

Question 59

Patients with rheumatoid arthritis may exhibit an increase in viral load for which of the following viruses?

Explanation

DISCUSSION: Rheumatoid arthritis (RA) is a complex multisystem disorder. It has been suggested that patients with RA have an impaired capacity to control infection with Epstein-Barr virus. Epstein-Barr virus has oncogenic potential and is implicated in the development of some lymphomas. Recent publications provide evidence for an altered Epstein-Barr virus-host balance in patients with RA who have a relatively high Epstein-Barr virus load. Large epidemiologic studies confirm that lymphoma is more likely to develop in patients with RA than in the general population. The overall risk of development of lymphoma has not risen with the increased use of methotrexate or biologic agents. Histologic analysis reveals that most lymphomas in patients with RA are diffuse large B cell lymphomas, a form of non-Hodgkin lymphoma. Epstein-Barr virus is detected in a proportion of these. Patients with RA do not have prevalence for infection with any of the other mentioned viruses.
REFERENCES: Callan MF: Epstein-Barr virus, arthritis, and the development of lymphoma in arthritis patients. Curr Opin Rheumatol 2004;16:399-405.
Baecklund E, Sundstrom C, Ekbom A, et al: Lymphoma subtypes in patients with rheumatoid arthritis: Increased proportion of diffuse large B cell lymphoma. Arthritis Rheum

2003;48:1543-1550.

Question 60

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

Explanation

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

Question 61

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management? Review Topic

Explanation

New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.

Question 62

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Explanation

DISCUSSION: Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Bell MJ, Beachamp CG, Kellam JK, McMurtry RY: The results of plating humeral shaft fractures in patients with multiple injuries: The Sunnybrook experience. J Bone Joint Surg Br 1985;67:293-296.

Question 63

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Explanation

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

Question 64

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. Unicompartmental knee arthroplasty (UKA) is discussed with the patient. The most appropriate next radiographic evaluation should be

Explanation

DISCUSSION:
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact anterior cruciate ligament (ACL). The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph aids the orthopaedic surgeon in determining the correction of the varus deformity and assessing the lateral compartment. An inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared with other age groups, but survivorship is lower for UKA than for TKA. No studies to date have shown any differences in survivorship between fixed-bearing and mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, which occurs in less than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA are low. Arthritis may progress faster in patients with mobile-bearing UKAs than in those with fixed-bearing UKAs.

Question 65

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

Explanation

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

Question 66

A 32-year-old man has posttraumatic arthritis after undergoing open reduction and internal fixation of a left acetabular fracture. A total hip arthroplasty is performed, and the radiograph is shown in Figure 18. What is the most common mode of failure leading to revision in this group of patients?

Explanation

DISCUSSION: Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation.
REFERENCES: Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.
Romness DW, Lewallen DG: Total hip arthroplasty after fracture of the acetabulum: Long-term results. J Bone Joint Surg Br 1990;72:761-764.

Question 67

A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?

Explanation

DISCUSSION: Because the radiographs demonstrate severe arthritis, hallux metatarsophalangeal arthrodesis is the treatment of choice. Cheilectomy alone will not relieve pain because the entire joint is degenerative. Joint replacement has not been shown to be a long-term solution. Keller resection arthroplasty is not indicated in younger active patients. Hallux valgus correction will not address arthritis of the joint and could stiffen the joint further.
REFERENCES: Smith RW, Joanis TL, Maxwell PD: Great toe metatarsophalangeal joint arthrodesis: A user-friendly technique. Foot Ankle 1992;13:367-377.
Mann RA: Hallux rigidus. Instr Course Lect 1990;39:15-21.

Question 68

A 13-year-old girl has had right groin pain for the past 3 weeks. She denies any history of trauma. Examination of the hip reveals no palpable soft-tissue mass or lymphadenopathy, and there is full range of motion. A plain radiograph and MRI scan are shown in Figures 15a and 15b. Biopsy specimens are shown in Figures 15c and 15d. What is the most likely diagnosis?

Explanation

DISCUSSION: Fibrous dysplasia frequently occurs in the proximal femur. Microfractures and remodeling can lead to the classic “Shepherd’s crook deformity.” The lesion has a ground-glass appearance on plain radiographs. The histologic appearance shows proliferating fibroblasts in a loose spindle cell background. Dysplastic metaplastic trabeculae are arranged in an irregular or “Chinese letter” appearance.
REFERENCES: Enneking WF, Gearen PF: Fibrous dysplasia of the femoral neck: Treatment by cortical bone grafting. J Bone Joint Surg Am 1986;68:1415-1422.
Simon MA, Springfield DS, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-200.

Question 69

What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

Explanation

DISCUSSION: Achilles tendon tension is not affected by knee position when the ankle is in 20° to 25° of plantar flexion. Skin perfusion overlying the Achilles tendon is maximal in 20° of plantar flexion and is reduced beyond 20° of plantar flexion. Neutral flexion or any amount of dorsiflexion compromises the repair.
REFERENCE: Poynton AR, O’Rourke K: An analysis of skin perfusion over the Achilles tendon in varying degrees of plantar flexion. Foot Ankle Int 2001;22:572-574.

Question 70

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no

Explanation

The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.

Question 71

Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury? Review Topic

Explanation

Treatment should consist of relative protection for 10 to 14 days followed by early range of motion and gentle closed-chain quadriceps strengthening. Isolated grade 1 and grade 2 posterior cruciate ligament injuries can be successfully managed nonsurgically. Progression to global knee strengthening can begin 4 to 6 weeks after the injury, with return to functional activity when full range of motion and strength is established. Plyometric exercises involve rapid alteration of contraction and loading of a muscle and should not be used in the early rehabilitation of a ligament injury of the knee because it risks further injury to the ligament. Hamstring strengthening should be avoided until the ligament has healed (4 to 6 weeks) because the posterior force on the tibia will stress the injured posterior cruciate ligament. Immobilization may be used for a short time to allow swelling and pain to subside, but early range of motion is preferred to avoid unnecessary stiffness following the stable injury.

Question 72

An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain but no obvious neurologic deficits. Radiographs reveal a nondisplaced type II odontoid fracture. What is the most appropriate treatment? Review Topic

Explanation

The treatment options for a type II odontoid fracture include halo immobilization, odontoid screw fixation, and posterior atlantoaxial arthrodesis. However, surgical care at this time without attempting nonsurgical management is not warranted; therefore, the most appropriate management at this time is immobilization in a rigid cervical orthosis for 6 to 8 weeks. Halo vest fixation can lead to high healing rates but is generally contraindicated in elderly patients, especially one with COPD and dementia. Posterior surgical fusion techniques provide high fusion rates, but do so at the expense of loss of cervical rotation and surgical complications. Resection of a nondisplaced odontoid fracture without cord compression via a transoral approach is not necessary.

Question 73

The swelling pressure in cartilage is predominantly due to the association of exchangeable water with which of the following substances? Review Topic

Explanation

Biglycan and versican are two of the small proteoglycans in cartilage. Biglycan plays a role in molecular association between cartilage and other molecules. Versican is more associated with the cell surface and plays multiple roles. Aggrecan has a longer core protein with multiple keratin sulfate and chondroitin sulfate chains. The molecular weight is around 1,000,000. Aggrecan aggregates on hyaluronic acid with link proteins. Aggrecan can associate with 50 times its weight in water. The resulting swelling pressure is retained by 20% by type II collagen. This results in the physiologic properties of articular cartilage. Type IX collage plays a role in matrix molecule association with type II collagen.

Question 74

A sedentary 60-year-old woman has had good elbow function and pain relief after undergoing an ulnohumeral interposition arthroplasty 10 years ago. However, she currently reports pain and stiffness for the past 6 months, and nonsurgical management has failed to provide relief. Examination reveals range of motion of 40 to 110 degrees of flexion with pain during the entire range. Radiographs are shown in Figures 43a and 43b. What is the next most appropriate step in management? Review Topic

Explanation

The patient had a good outcome after interposition arthroplasty but has now progressed to end-stage arthritis with loss of joint space and instability. A conversion to semiconstrained total elbow arthroplasty is most reliable for pain relief and improved function. In the setting of ligamentous instability, an unconstrained prosthesis will fail. Revision interposition ulnohumeral arthroplasty and arthroscopic debridement or open debridement, as in the Outerbridge-Kashiwagi procedure, are not reliable in this age group with this amount of joint space loss.

Question 75

A healthy 2-year-old boy falls from a swing and sustains a displaced midshaft femoral fracture with 1 cm of shortening. What is the most appropriate treatment?

Explanation

AL-Madena Copy
DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.

Figure 29a Figure 29b

Question 76

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 77

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Explanation

Open chain exercises of the lower extremity are defined as "The foot is mobile, and motion at the knee joint occurs independent of motion at the hip and ankle joints, as opposed to closed chain exercises in which the foot is fixed and motion at the knee joint is accompanied by motion at the hip and ankle joints in a predictable manner.

Question 78

What is the most common short-term complication following femoral impaction grafting for revision total hip arthroplasty?

Explanation

DISCUSSION: Impaction grafting is an alternative for severe femoral bone deficiency; however, stem subsidence is commonly observed during the first few months. Slight subsidence is felt to be integral to the success of the procedure. Predictable bone graft incorporation and stable stem fixation have been reported in the medium-term. The incidence of periprosthetic fractures has been reported as high as 24%.
REFERENCES: Mikhail MWE, Weidenhielm L, Jazrawi LM, et al: Collarless, polished, tapered stem failure. J Bone Joint Surg Am 2000;82:1513-1514.
Leopold SS, Rosenberg AG: Current status of impaction allografting for revision of a femoral component. Instr Course Lect 2000;49:111-118.

Question 79

Figures 11a and 11b show the T 2 -weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?

Explanation

DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T₂-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option.
REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972.
Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.

Question 80

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

Explanation

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

Question 81

A 20-year-old athlete sustains a 2- x 3-cm grade IV chondral injury to the right knee. After failure of nonsurgical management, which of the following procedures would ensure the highest percentage of hyaline-like cartilage?

Explanation

DISCUSSION: Autologous chondrocyte implantation was first reported by Brittberg in 1994 and has resulted in predominantly type II collagen (hyaline-like articular cartilage) in the repair tissue. The extracellular matrix in articular cartilage is made up primarily of type II collagen, proteoglycans, and water. Arthroscopic chondroplasty, microfracture, drilling, and abrasion arthroplasty all result eventually in fibrocartilage fill of the defect (predominantly type I collagen).
REFERENCES: Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895.
Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 787-804.

Question 82

Arthritic change in cartilage is characterized by which of the following findings?

Explanation

Experimental models of late-stage arthritis in animals demonstrated lower compressive modulus, higher permeability, and higher water content. There is proteoglycan loss within the matrix. A significant and progressive decrease in the tensile and shear modulus has been observed.

Question 83

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

Explanation

Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Question 84

What is the most common site of nerve compression in radial tunnel syndrome?

Explanation

A 25-year-old man has an isolated flexor digitorum profundus laceration just proximal to the distal interphalangeal (DIP) flexion crease of his ring finger. The tendon ends are trimmed, removing 10 mm from each end (secondary to fraying) and the tendon repaired. Four months later, he reports limited finger motion of the long, ring, and small fingers. He cannot fully extend his wrist and all joints of the 3 fingers simultaneously. He has full passive flexion but cannot actively completely close his fingers into a fist. What is the most likely cause?
A. Quadrigia
B. Intrinsic tightness
C. Lumbrical plus deformity
D. Disruption of the tendon repai

Question 85

Figures 2a and 2b show the radiograph and MRI scan of a 56-year-old woman who has low back pain and right leg pain. She has grade 3/5 toe and ankle dorsiflexion strength on the right side. Nonsurgical management has failed to provide relief; therefore, surgery should include Review Topic

Explanation

The lateral radiograph and MRI scan demonstrate a grade 2 isthmic spondylolisthesis of L5 on S1. The radiograph shows a pars defect of L5. Isthmic spondylolistheses are most common at L5-S1. Degenerative spondylolistheses rarely progress beyond a grade 1 slip. The patient has frank neurologic weakness on the right side and nonsurgical management has failed to provide relief. In patients with significant motor weakness, neurologic decompression is indicated. An L5 pars repair is not recommended in patients with more than a grade 1 slip. Laminectomy alone can destabilize the spine and lead to further slippage and thus it is recommended to fuse the segment. A stand-alone anterior lumbar interbody fusion has a high failure rate with isthmic spondylolisthesis. Isthmic spondylolisthesis is a contraindication for lumbar total disk replacement. While there is some literature that supports fusion without laminectomy or decompression for patients with isthmic slips and radicular pain without neurologic deficit, this patient does not fulfill these criteria.

Question 86

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Explanation

DISCUSSION
Complications are numerous in adult spinal deformity surgery. Many complications are related to the patient's sagittal balance following surgery and recognition of the potential to develop sagittal imbalance or flat-back syndrome following spinal fusion. The quality of bone density is important in spinal instrumented fusions, especially among older patients. Patients with osteopenia or osteoporosis have a higher incidence of proximal-level screw cut-out through the vertebral body into the cephalad disk space.
Proximal junctional kyphosis is common in longer instrumented fusions, especially when instrumented to the sacrum/pelvis; when the spine is fixed in a "flat" or hypolordotic position; when the thoracic spine is hyperkyphotic (ie, Scheuermann kyphosis); when the end instrumented vertebrae is kyphotic; or when the sagittal plumb line (measured from C7) is more than 4 cm forward of the posterior corner of the sacrum.
Sagittal imbalance is a common complication when the spine is instrumented in a hypolordotic position. This can occur with degenerative conditions that necessitate multilevel fusions or fusions to sacrum without recognition of the degree of lordosis the patient should have. Pelvic incidence (PI) is a spinopelvic measurement that is a constant that measures an angle from the hips to the midpoint of the sacral end plate. PI correlates to the amount of lumbar lordosis that a patient would typically have in an upright position (+/-10 degrees). If a patient has significant sagittal imbalance, he or she will have a forward lean and lack the ability to extend the spine to stand upright. In an attempt to stand upright, the patient may bend his or her knees or hips in a crouched position. When extending their knees, they again lean forward.
Pseudarthrosis is common with noninstrumented fusions. Deep surgical-site infections are uncommon but can be major complications that are difficult to treat, necessitating formal irrigation and debridement and long-term antibiotics. Patients with diabetes have a higher incidence of infection.
RECOMMENDED READINGS
Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-

Question 87

The patient decides to pursue surgical intervention. Which compartments should be released?

Explanation

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible for the patient's symptoms and falls below current thresholds for diagnosis.

Question 88

Figures below show the radiographs obtained from an 86-year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 89

Passive glycation of articular cartilage results in

Explanation

DISCUSSION: Passive glycation of articular cartilage occurs over decades. One of the consequences of this glycation appears to be the stiffening of collagen. This phenomenon appears to be associated with an increased collagen degradation and development of osteoarthrosis. Passive glycation also results in a relatively yellow appearance. Passive glycation does not directly influence chondrocyte proliferation.
REFERENCES: DeGroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis. Arthritis Rheum 2004;50:1207-1215.
Chen AC, Temple MM, Ng DM, et al: Induction of advanced glycation end products and alterations of the tensile properties of articular cartilage. Arthritis Rheum 2002;46:3212-3217.

Question 90

A 19-year-old running back lands directly on his anterior knee after being tackled. He has mild anterior knee pain, a trace effusion, a 2+ posterior drawer, a grade 1+ stable Lachman, no valgus laxity, and negative dial tests at 30 degrees and 90 degrees. What is the best treatment strategy at this time? Review Topic

Explanation

This patient has likely sustained an isolated PCL injury. The examination is consistent with a grade II injury to the PCL. In this scenario, the best initial option is nonsurgical treatment and return to play as symptoms subside and strength improves. Physical therapy with a focus on quadriceps strengthening and delayed PCL reconstruction is not the answer because this patient can likely be treated without surgery. The absence of valgus laxity and negative dial testing findings suggest that an injury to the posteromedial and posterolateral corners has not occurred. Initial nonsurgical treatment is indicated for this patient. If he completes rehabilitation and experiences persistent disability with anterior and/or medial knee discomfort or senses the knee is "loose," PCL reconstruction should be considered at that time.

Question 91

A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

Explanation

DISCUSSION: A delta P (diastolic blood pressure minus compartment pressure measurement)of < 30 mmHg is an indication for fasciotomies with the caveat that the diastolic pressure is measured either pre- or postoperatively.
Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. Determining if a patient needs fasciotomies in the operating room while a patient is under anesthesia is complicated by the fact that obtaining a clinical exam is impossible, and that the diastolic blood pressure may be falsely decreased compared to normal pre- or postoperative measurements. Currently, it is recommended that intraoperative compartment pressures be compared to preoperative diastolic blood pressures, with delta p < 30 indicating the need for fasciotomies.
Kakar et al. review the preoperative, intraoperative, and postoperative diastolic blood pressure (DBP) in 242 patients with a tibia fracture treated operatively. They found the mean DBP was 18 points lower in the operating room compared to the preoperative measurement. In addition, they found the difference between preoperative and postoperative diastolic blood pressures to be within 2 points, indicating the decrease seen intraoperatively is likely a spurious value induced by anesthetic.
McQueen and Court-Brown prospectively review 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of
30 mmHg is a more reliable indicator of compartment syndrome.
Incorrect Answers:

Question 92

An 11-year-old boy has right shoulder pain and has been unwilling to use the arm after throwing a baseball in a Little League game 3 weeks ago. Examination reveals upper arm and shoulder tenderness with swelling. A radiograph and MRI scan are shown in Figures 27a and 27b. Management should consist of

Explanation

DISCUSSION: The radiograph is consistent with a unicameral (simple) bone cyst. The MRI scan reveals that the cyst is juxtaposed to the physis and therefore can be classified as active (latent cysts are more than 1 cm away from the physis). Active cysts are treated with aspiration and steroid injection, although repeated injections may be necessary. Curettage and bone grafting results in more reliable healing but may lead to growth arrest in active cysts.
REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 945-946.
Malawer MM: Tumors of the shoulder girdle: Techniques of resection and description of surgical classification. Orthop Clin North Am 1991;22:7-35.

Question 93

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future? Review Topic

Explanation

For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.

Question 94

Examination of a 13-year-old boy with asymptomatic poor posture reveals increased thoracic kyphosis that is fairly rigid and accentuates during forward bending. The neurologic examination is normal. Spinal radiographs show 10 degrees of scoliosis at Risser stage 2, and there is no evidence of spondylolisthesis. A standing lateral view of the thoracic spine is shown in Figure 41. The kyphosis corrects to 50 degrees. Management should consist of

Explanation

DISCUSSION: The radiograph shows excessive thoracic kyphosis (normal 20 degrees to

50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.
REFERENCES: Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75:236-248.
Wenger DR, Frick SL: Scheuermann kyphosis. Spine 1999;24:2630-2639.
Tribus CB: Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management.

J Am Acad Orthop Surg 1998;6:36-43.

Question 95

A 16-year-old girl injured her hip in a fall. Radiographs are shown in Figures 14a and 14b. She denies any history of pain prior to the fall and is currently asymptomatic. A bone scan, MRI scan, and biopsy specimens are shown in Figures 14c through 14f. What is the most likely diagnosis?

Explanation

DISCUSSION: Although the classic radiographic appearance of fibrous dysplasia is one of a central metaphyseal lesion with ground glass matrix, it is not unusual to see either a more radiodense-appearing lesion or a more peripheral location. The histologic finding of spicules of woven bone without osteoblastic rimming in a bland fibrous background is diagnostic of fibrous dysplasia. The imaging studies could be consistent with low-grade osteosarcoma, osteoblastoma, or osteomyelitis, but all have a very different histologic picture. Observation is indicated in the absence of symptoms, impending fracture, or deformity. Fibrous dysplasia most commonly occurs in the proximal femur.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 30-43.
DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation, and treatment.

J Bone Joint Surg Am 2005;87:1848-1864.

Question 96

A workers' compensation carrier for a local manufacturing company requests a second opinion on a 59-year-old man who sustained a crush injury to his foot and leg at work 6 months ago. His leg and foot were pinned between a forklift and a wall when an employee he was supervising lost control of the forklift. The employer suspects that the injured worker is malingering because the treating physician released him to work, but he has not returned to work. Which of the following elements of your history will best help you determine that the injured worker does not want to return to work out of fear of a confrontation with the employee he was supervising?

Explanation

Empathy during the interview demonstrates compassion and earns the patient's trust; which, in turn, enables the patient to discuss any agenda or concerns he or she may otherwise feel uncomfortable revealing. It is also important to engage the patient to establish a trusting relationship and thus understand all the factors impacting the patient. A formal attitude toward the patient makes it difficult to engage the patient to be "drawn in." An engaged patient is more comfortable, reliable, and thorough when providing a history. Closed-end, yes-no questions do not allow the patient to detail all of the subtle nuances of their condition and its effect on their life. Taking copious notes likewise prevents engagement of the patient and the distraction of taking notes may cause the physician to miss an important detail. It is better to lean forward in a chair when interviewing a patient because this suggests the physician is genuinely interested, whereas leaning back in a chair suggests the physician is simply waiting for the patient to finish talking. Avoid interrupting the patient when talking.

Question 97

Figure 24 shows the radiograph of an otherwise healthy 56-year-old patient who reports hip pain after undergoing a primary cementless hip replacement 4 months ago. The next most appropriate step should consist of

Explanation

DISCUSSION: Periosteal new bone formation is a warning sign of prosthetic infection. Indomethacin may prevent heterotopic ossification if given early enough; however, it is irrelevant in this patient. A C-reactive protein and a sed rate are useful screening studies that add to the predictive value of the radiographs and may be performed routinely if sepsis is suspected. A bone scan obtained 4 months after surgery would show increased uptake in all cases. If results of a sed rate and C-reactive protein are normal, then a biopsy should be considered to rule out a neoplasm.
REFERENCE: Fitzgerald RH Jr: Infected total hip arthroplasty: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:249-262.

Question 98

A 61-year-old man with a body mass index of 31 had a 6-month gradual onset of right medial knee pain. Examination revealed a small effusion, stable ligaments, a normally tracking patella, and mild medial joint line tenderness. Standing radiographs show mild medial joint space narrowing. Effective treatment at this stage of early medial compartmental osteoarthritis includes

Explanation

DISCUSSION:
According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee (Nonarthroplasty), level 1 evidence confirms that weight loss and exercise benefit patients with knee osteoarthritis. The other responses have either inclusive evidence (a valgus-directing brace) or no evidence to support their use (glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day as well as arthroscopic debridement and lavage).

Question 99

A 10-year-old boy with an L1 myelomeningocele has a low-grade fever and a swollen thigh that is warm to touch and erythematous. AP and lateral radiographs are shown in Figures 24a and 24b. Management should consist of

Explanation

DISCUSSION: Fractures of the long bones are common in patients with myelodysplasia, and the frequency of fracture increases with higher level defects. Fractures also occur following surgery and immobilization secondary to disuse osteoporosis. The response to the fracture (swelling, fever, warmth, erythema) is often confused with infection, osteomyelitis, or cellulitis. Management should consist of a short period of immobilization in a well-padded splint. Long-term casting results in further osteopenia and repeated fractures.
REFERENCES: Lock TR, Aronson DD: Fractures in patients who have myelomeningocele. J Bone Joint Surg Am 1989;71:1153-1157.
Kumar SJ, Cowell HR, Townsend P: Physeal, metaphyseal, and diaphyseal injuries of the lower extremities in children with myelomeningocele. J Pediatr Orthop 1984;4:25-27.

Question 100

Which of the following is considered the best method to measure limb-length discrepancy in a patient with a knee flexion contracture?

Explanation

DISCUSSION: The most effective way to measure a limb-length discrepancy in a patient with a knee flexion contracture is a lateral CT scanogram. All the other methods listed provide inaccurate results with a knee flexion contracture because the measurements are made in the coronal plane.
REFERENCES: Aaron A, Weinstein D, Thickman D, et al: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.
Tachdjian MO: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management. Stamford, CT, Appleton and Lange, 1997, pp 237-240.

Full Question & Answer Text (for Search Engines)

Question 1:

Studies have shown that the parents and grandparents of people with developmental dysplasia of the hip (DDH)

Options:

were more likely to receive a hip arthritis diagnosis and undergo total hip arthroplasty (THA) than the general population.
were less likely to receive a hip arthritis diagnosis and undergo THA than the general population.
had a higher incidence of hip and knee arthritis than the general population.
had a DDH relative risk (RR) of 1.4.

Correct Answer: were more likely to receive a hip arthritis diagnosis and undergo total hip arthroplasty (THA) than the general population.

Explanation:

Question 2:

A 21-year-old man who was injured in a snowboarding accident 18 months ago now reports wrist pain. An MRI scan is shown in Figure 37. Based on the image findings, what is the most likely diagnosis?

Options:

Preiser’s disease
Scaphoid nonunion and osteonecrosis
Kienbock’s disease
Intraosseous ganglion
Scapholunate dissociation

Correct Answer: Scaphoid nonunion and osteonecrosis

Explanation:

DISCUSSION: The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser’s disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock’s disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.
REFERENCE: Perlik PC, Guilford WB: Magnetic resonance imaging to assess vascularity of scaphoid nonunions. J Hand Surg Am 1991;16:479-484.

Question 3:

When compared with reamed intramedullary nailing for an unstable diaphyseal tibia fracture, unreamed nailing is associated with which of the following?

Options:

Longer surgical times
Higher infection rates
Lower functional outcome scores
Similar union rates in open fractures
Higher incidence of pulmonary complications

Correct Answer: Similar union rates in open fractures

Explanation:

Question 4:

What is the most common primary malignant bone or cartilage tumor in children?

Options:

Ewing’s sarcoma
Giant cell tumor
Osteosarcoma
Chondrosarcoma
Osteochondroma

Correct Answer: Osteosarcoma

Explanation:

DISCUSSION: Osteosarcoma is the most common primary malignant bone tumor (5.6 per
1 million children younger than age 15 years), and Ewing’s sarcoma is second (2.1 per
1 million children). Giant cell tumor and chondrosarcoma are rare in children. Osteochondroma is more common than any of the above tumors in children, but it is not malignant.
REFERENCES: Himelstein BP, Dormans JP: Malignant bone tumors of childhood. Pediatr Clin North Am 1996;43:967-984.
Pierz KA, Womer RB, Dormans JP: Pediatric bone tumors: Osteosarcoma, Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis. J Pediatr Orthop 2001;21:412-418.
Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence.
N Engl J Med 1999;341:342-352.

Question 5:

Options:

Hypertrophied subscapular muscle
Rotator cuff tear
Posterior glenohumeral subluxation
Increased bone density
Supraspinatus nerve compression

Correct Answer: Rotator cuff tear

Explanation:

Question 6:

To adequately expose the volar plate of the proximal interphalangeal joint of the finger, which of following pulleys is typically incised?

Options:

Entire A3, entire C2, and the proximal portion of A4
Entire C1 only
Entire C2 only
Distal portion of A2, entire C1, and entire A3
Distal portion of C1, entire A3, and the proximal portion of C2

Correct Answer: Distal portion of C1, entire A3, and the proximal portion of C2

Explanation:

DISCUSSION: Full exposure of the volar plate of the proximal interphalangeal joint of the finger is best accomplished by incision of the distal C1, A3, and proximal C2 pulleys; followed by gentle retraction of the flexor digitorum superficialis and profundus tendons. Sacrifice of the A3 pulley, although associated with some biomechanic disadvantage, can be tolerated without causing functionally limiting bowstringing of the flexor tendon. Sacrifice of even a portion of the A2 or A4 pulleys can decrease the biomechanic leverage provided by the flexor tendon sheath, leading to bowstringing of the flexor tendons.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 176-186.
Strickland J: Flexor tendon-acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2,
pp 1853-1855.
Lin GT, Amadio PC, An KN, et al: Functional anatomy of the human digital flexor pulley system. J Hand Surg Am 1989;14:949-956.

Question 7:

Options:

Initiation of spinal cord injury steroid protocol
MRI of the lumbar spine
Immobilization in a thoracolumbosacral orthosis
Removal of the metallic fragments via laminectomy
Removal of the metallic fragments and posterior fusion with instrumentation

Correct Answer: Removal of the metallic fragments via laminectomy

Explanation:

DISCUSSION: Because the patient has an apparent compressive neuropathy secondary to the metallic fragments, removal of the fragments in this incomplete lesion at the cauda equina level can be expected to improve her sensory dysesthesias and pain. Steroids are not indicated in a root lesion secondary to a penetrating injury. MRI will have significant artifact effect and will not provide much additional information. The posterior bony elements are not significantly injured; therefore, stabilization is not indicated.
REFERENCES: Bracken MB, Shepard MJ, Holford TR: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. JAMA 1997;277:1597-1604.
Waters RL, Adkins RH: The effects of removal of bullet fragments retained in the spinal canal: A collaborative study by the National Spinal Cord Injury Model Systems. Spine
1991;16:934-939.
Stauffer ES, Wood RW, Kelly EG: Gunshot wounds of the spine: The effects of laminectomy.
J Bone Joint Surg Am 1979;61:389-392.

Question 8:

Radiographs of an 80-year-old woman with back pain reveal a compression fracture. Which of the following imaging studies best evaluates the acuity of the fracture?

Options:

Triple phase bone scan
T 1 -weighted MRI scan
Short tau inversion recovery (STIR)-weighted MRI scan
CT
Standing lateral radiograph

Correct Answer: Short tau inversion recovery (STIR)-weighted MRI scan

Explanation:

DISCUSSION: The best method of evaluating the acuity of osteoporotic compression fractures is to look for edema in the vertebral body. This is best accomplished with a STIR-weighted MRI scan. Bone scans can show increased uptake at the site of fracture for many months after the fracture. T
1
-weighted MRI scans show loss of normal marrow fat that may not necessarily correspond with acuity of the fracture. CT scans and radiographs show fracture deformity but cannot be used to judge acuity.
REFERENCES: Phillips FM: Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine 2003;28:S45-S53.
Rao RD
, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 9:

Options:

O'Brien's test
Speed's test
Jerk test
Neer impingement test
Apprehension test

Correct Answer: Jerk test

Explanation:

Question 10:

Options:

Long standing anterior-posterior radiograph of the hip-knee-ankle
Axial CT views from the supracondylar distal femur to the proximal tibia below the tibial tubercle
Fluoroscopic stress views to demonstrate the position of subluxation
Bone scan
MRI scan

Correct Answer: Axial CT views from the supracondylar distal femur to the proximal tibia below the tibial tubercle

Explanation:

Question 11:

Options:

Observation
Repeat closed reduction and casting
Open reduction and plate fixation
Closed reduction and intramedullary nail fixation

Correct Answer: Observation

Explanation:

Question 12:

Options:

Complex regional pain syndrome
Wartenberg’s syndrome
Carpal tunnel syndrome
Palmar cutaneous nerve injury
C7 radiculopathy

Correct Answer: Palmar cutaneous nerve injury

Explanation:

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 13:

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

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
Metal artifact reduction sequence (MARS) MRI
CT scan of pelvis

Correct Answer: Metal artifact reduction sequence (MARS) MRI

Explanation:

Question 14:

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

Options:

Abduction
External rotation
Internal rotation
Extension
Elevation

Correct Answer: Internal rotation

Explanation:

Question 15:

Options:

Observation
Corrective shoes
Plantar release with first metatarsal osteotomy and possible tendon transfers
Calcaneal osteotomy
Triple arthrodesis

Correct Answer: Plantar release with first metatarsal osteotomy and possible tendon transfers

Explanation:

Question 16:

Within the menisci, the majority of the large collagen fiber bundles are oriented in what configuration?

Options:

Radially
Circumferentially
Vertically
Obliquely
Randomly

Correct Answer: Circumferentially

Explanation:

Question 17:

Options:

Elbow splint at 40° for 6 weeks
Electromyography (EMG)
Exploration of ulnar nerve and transposition
Continued observation

Correct Answer: Continued observation

Explanation:

Question 18:

Options:

Semitendinosis figure-of-eight graft
Subclavius tendon transfer
Medial clavicular osteotomy
Medial clavicular resection
Sternoclavicular arthrodesis

Correct Answer: Semitendinosis figure-of-eight graft

Explanation:

DISCUSSION: Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 19:

Options:

Anterior cruciate ligament
Posterior cruciate ligament
Posterior cruciate ligament and medial collateral ligament
Medial collateral ligament
Lateral collateral ligament, popliteal tendon and arcuate ligament

Correct Answer: Medial collateral ligament

Explanation:

Question 20:

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Options:

accurately tension the PCL.
use bony resection to adjust the joint line.
maintain a small amount of residual deformity.
use intraoperative fluoroscopy to ensure femoral roll back.

Correct Answer: accurately tension the PCL.

Explanation:

Question 21:

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

Options:

limited weight bearing for 6 weeks, followed by a progressive return to activity.
no weight bearing for 6 weeks, followed by no running for 6 months.
no weight bearing for 2 weeks, followed by internal fixation if symptoms persist.
internal fixation at the time of diagnosis.
cessation of running for 6 weeks.

Correct Answer: internal fixation at the time of diagnosis.

Explanation:

Question 22:

Options:

Cortisone injection
Open surgical debridement
Immediate arthroscopic lavage
Intravenous vancomycin for presumptive MRSA infection
Obtain sexual activity history and select appropriate antibiotic

Correct Answer: Obtain sexual activity history and select appropriate antibiotic

Explanation:

Question 23:

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Options:

Amenorrhea
Osteoporosis
Low LDL levels
Decreased immune function
Insufficient caloric intake

Correct Answer: Amenorrhea

Explanation:

Question 24:

Options:

ankle arthrodesis.
total ankle arthroplasty.
supramalleolar tibial osteotomy.
valgus-producing calcaneal osteotomy.
epiphyseodesis of the distal tibial physis.

Correct Answer: supramalleolar tibial osteotomy.

Question 25:

Options:

0% to 1% with press-fit tibial stems B. 3% to 5% with press-fit tibial stems C. 3% to 5% with cemented tibial stems
More than 5% with press-fit tibial stems

Correct Answer: More than 5% with press-fit tibial stems

Explanation:

Question 26:

Options:

open reduction and internal fixation.
excision of the radial head.
excision of the radial head and prosthetic arthroplasty.
a long arm cast.
a sling and early range-of-motion exercises.

Correct Answer: a sling and early range-of-motion exercises.

Explanation:

DISCUSSION: The radiographs show a small minimally displaced radial head fracture that is amenable to nonsurgical management. Early range-of-motion exercises will best restore
function and minimize stiffness. A long arm cast for any length of time will result in severe elbow stiffness.
REFERENCES: Morrey BF: Radial head fracture, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 341-364.
Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.

Question 27:

For this patient, which TKA design is most appropriate?

Options:

Bicruciate-retaining TKA
Unicompartmental arthroplasty
Hinged TKA
Posterior substitution TKA

Correct Answer: Posterior substitution TKA

Explanation:

Question 28:

Options:

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

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

Explanation:

Question 29:

Options:

MRI-arthrogram to evaluate the rotator cuff
Rotator cuff strengthening program
Posterior capsular stretching program
Shoulder arthroscopy with SLAP repair
Shoulder arthroscopy with posterior capsular release

Correct Answer: Posterior capsular stretching program

Explanation:

DISCUSSION: Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Myers JB, Laudner KG, Pasquale MR, et al: Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med 2006;34:385-391.

Question 30:

Smoking has been associated with lower fusion rates in both cervical and lumbar fusion. Which of the following statements best describes an explanation for these findings?

Options:

Nicotine impairs osteoblast activity, thus interfering with bone remodeling.
The effects of smoking on bone healing are multifactorial and not yet fully understood.
The vasoconstrictive and platelet-activating properties of nicotine inhibit fracture healing.
Nicotine inhibits the function of fibroblasts, red blood cells, and macrophages.
Hydrogen cyanide inhibits oxidative metabolism at the cellular level.

Correct Answer: The effects of smoking on bone healing are multifactorial and not yet fully understood.

Explanation:

Question 31:

Options:

Longer femoral tunnel
More anatomic graft placement
A more vertically oriented graft
Diminished risk of posterior tunnel wall violation ("blowout")
Diminished risk to lateral femoral articular cartilage and subchondral bone posteriorly

Correct Answer: More anatomic graft placement

Explanation:

Question 32:

What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?

Options:

MRI
Discography
CT discography
Radiography

Correct Answer: Radiography

Explanation:

Question 33:

Options:

Disk herniation
Synovial cyst
Arachnoid cyst
Epidural lipomatosis

Correct Answer: Synovial cyst

Explanation:

DISCUSSION
This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable.
A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion.
RECOMMENDED READINGS
Epstein NE, Baisden J. The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration. Surg Neurol Int. 2012;3(Suppl 3):S157-66. doi: 10.4103/2152-7806.98576. Epub 2012 Jul 17. PubMed PMID: 22905322.
View Abstract at PubMed
Xu R, McGirt MJ, Parker SL, Bydon M, Olivi A, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine (Phila Pa 1976). 2010 May 1;35(10):1044-53. PubMed PMID: 20173680.
View Abstract at PubMed

Question 34:

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Options:

year-old female golf instructor
year-old female with Parkinsons dementia
year-old male household ambulator
year-old male alcoholic with hepatic encephalopathy
year-old male laborer

Correct Answer: year-old female with Parkinsons dementia

Explanation:

Question 35:

A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?

Options:

Subscapular
Suprascapular
Axillary
Musculocutaneous
Medial pectoral

Correct Answer: Suprascapular

Explanation:

Question 36:

A fracture in the following location is most commonly associated with procurvatum and valgus malalignment?

Options:

Humeral shaft
Distal femur
Proximal tibia
Distal third tibia shaft with intact fibula
Subtrochanteric proximal femur

Correct Answer: Humeral shaft

Explanation:

Question 37:

Options:

Sagittal alignment
History of diabetes mellitus and tobacco use
Performance of an uninstrumented fusion (ie, no plate and screws)
Use of allograft (instead of autograft)
Fusion at the C3-C4 level

Correct Answer: History of diabetes mellitus and tobacco use

Explanation:

Question 38:

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

Options:

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

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

Explanation:

Question 39:

Options:

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

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

Question 40:

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Options:

Cardiovascular collapse
Block failure
Seizure secondary to intravascular injection
Phrenic nerve injury
Laryngeal nerve injury

Correct Answer: Block failure

Explanation:

Question 41:

Initial management should consist of Review Topic

Options:

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

Correct Answer: cessation of throwing activities.

Explanation:

Question 42:

Which of the following is a recognized predictor of mortality after hip fracture?

Options:

American Society of Anesthesiologist (ASA) classification
Post-operative weight bearing status
Fracture comminution
Fixation device used
Hip fracture type

Correct Answer: American Society of Anesthesiologist (ASA) classification

Explanation:

Question 43:

Options:

hip and knee extension
hip flexion to 90, knee extension
hip internal rotation, knee flexion to 90
hip and knee flexion to 90
hip extension, knee flexion to 90

Correct Answer: hip and knee extension

Explanation:

Question 44:

Options:

Wind-up
Early cocking
Late cocking
Acceleration
Deceleration

Correct Answer: Late cocking

Explanation:

Question 45:

Options:

Inclusion cyst
Schwannoma
Scleroderma
Paranychia
Glomus tumor

Correct Answer: Glomus tumor

Explanation:

DISCUSSION: Glomus tumors are rare vascular lesions typically occurring about the nail of the distal phalanx of the hand. The diagnostic “triad” of glomus tumors consists of local pain, sensitivity to cold, and paroxysmal pain. They tend to present with pain as the most typical symptom and this can be exacerbated by changes in temperature that is felt to cause a vascular response within the lesion. The biopsy specimen confirms a glomus tumor showing the typical vascular spaces surrounded by glomus epithelioid glomus cells.
REFERENCES: Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.
McDermott EM, Weiss AP: Glomus tumors. J Hand Surg Am 2006;31:1397-1400.

Question 46:

- Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Options:

traumatic femoral head fracture
osteonecrosis
osteoarthritis
neuropathic joint
rheumatoid arthritis

Correct Answer: osteonecrosis

Explanation:

Question 47:

Options:

Removal of the implant alone
Amputation of the hallux
Revision of the implant with a Silastic joint replacement
Arthrodesis of the hallux metatarsophalangeal joint with interposition bone graft
Rocker bottom steel shank shoe with orthosis

Correct Answer: Arthrodesis of the hallux metatarsophalangeal joint with interposition bone graft

Explanation:

Question 48:

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Options:

wide resection and salvage of the physis.
resection and hemicondylar osteoarticular allograft.
cryosurgery.
radiation therapy.
curettage and bone grafting.

Correct Answer: curettage and bone grafting.

Explanation:

Question 49:

Options:

brace treatment.
laminectomy, nerve root decompression, and in situ fusion of L4 to the sacrum.
in situ fusion of L4 to the sacrum.
excision of the L5 lamina.
physical therapy.

Correct Answer: in situ fusion of L4 to the sacrum.

Explanation:

Question 50:

Which of the following cardiac conditions is considered an absolute contraindication to vigorous exercise?

Options:

Hypertrophic cardiomyopathy (HCM)
Sclerosis of the aortic valve without stenosis
Mild mitral valve regurgitation
Left ventricular hypertrophy (LVH)
Functional murmurs

Correct Answer: Hypertrophic cardiomyopathy (HCM)

Explanation:

Question 51:

Options:

Common iliac artery
Superior gluteal artery
Obturator artery
Sciatic nerve
External iliac vein

Correct Answer: Common iliac artery

Explanation:

Question 52:

A 28-year-old man sustained a fracture-dislocation of T8 in a motor vehicle accident 1 week ago. The injury resulted in complete paraplegia. Management should consist of

Options:

mobilization in a kinetic therapy bed for 8 weeks.
initiation of a steroid protocol.
immediate laminectomy of T7, T8, and T9.
application of a total contact orthosis.
open reduction and posterior segmental stabilization and grafting.

Correct Answer: open reduction and posterior segmental stabilization and grafting.

Explanation:

Question 53:

Which 2 tendons are identified in the dissection shown in Video 92?

Options:

Semitendinosus and gracilis
Semitendinosus and semimembranosus
Semimembranosus and gracilis
Semimembranosus and sartorius

Correct Answer: Semitendinosus and gracilis

Explanation:

Question 54:

Options:

Subtalar distraction arthrodesis
Subtalar arthroscopy with debridement
Custom orthotics
Ankle arthrodesis
Calcaneal osteotomy

Correct Answer: Subtalar distraction arthrodesis

Explanation:

Question 55:

Kinematic analysis of the medial and lateral menisci has demonstrated that the lateral meniscus has which of the following characteristics compared with the medial meniscus?

Options:

More soft-tissue attachments/restraints
More mobility
Less mobility
No posterior movement with flexion
No anterior movement with extension

Correct Answer: More mobility

Explanation:

Question 56:

What muscle attaches to the site shown by the arrow in Figure 2?

Options:

Teres minor
Teres major
Latissimus dorsi
Pectoralis major
Pectoralis minor

Correct Answer: Latissimus dorsi

Explanation:

Question 57:

Options:

Subtrochanteric osteotomy with femoral shortening
An offset femoral component
A lateralized liner
Extended trochanteric osteotomy

Correct Answer: Subtrochanteric osteotomy with femoral shortening

Explanation:

Question 58:

Options:

physical therapy for quadriceps strengthening exercises.
a long leg cast with the knee fully extended.
excision of the fragment.
suture reattachment of the patellar tendon to the tibial tuberosity.
open reduction and tension band fixation.

Correct Answer: open reduction and tension band fixation.

Explanation:

DISCUSSION: The radiograph shows an avulsion fracture, or “sleeve fracture,” of the distal pole of the patella. The distal fragment is much larger than it appears on the radiograph because it largely consists of cartilage; therefore, excision of the fragment is contraindicated. The treatment of choice is open reduction and tension band fixation to correct patella alta and restore the extensor mechanism.
REFERENCES: Maguire JK, Canale ST: Fractures of the patella in children and adolescents.
J Pediatr Orthop 1993;13:567-571.
Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990;10:721-730.

Question 59:

Patients with rheumatoid arthritis may exhibit an increase in viral load for which of the following viruses?

Options:

Human immunodeficiency virus (HIV)
Papilloma virus
Epstein-Barr virus (EBV)
Hepatitis C virus (HCV)
Hepatitis B virus( HBV)

Correct Answer: Epstein-Barr virus (EBV)

Explanation:

Question 60:

Options:

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

Correct Answer: incidence of complications.

Explanation:

Question 61:

Options:

Total shoulder arthroplasty
Hemiarthroplasty with glenoid interposition
Surface replacement hemiarthroplasty
Arthroscopic debridement
Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer: Anti-inflammatory drugs and a range-of-motion stretching program

Explanation:

Question 62:

Options:

external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
external fixation of both fractures.
open reduction and internal fixation of both fractures.
open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
application of a long arm cast.

Correct Answer: open reduction and internal fixation of both fractures.

Explanation:

Question 63:

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Options:

Effectiveness of chemotherapy
Effect of local adjuvant
Open physes
Presence of giant cells
Effectiveness of embolization

Correct Answer: Open physes

Explanation:

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

Question 64:

Options:

MRI of the left knee to evaluate the lateral compartment.
a CT arthrogram to evaluate the status of the medial and lateral meniscus.
a stress radiograph to evaluate correction of the varus deformity.
a sunrise view to determine the status of the patellofemoral joint.

Correct Answer: a stress radiograph to evaluate correction of the varus deformity.

Explanation:

Question 65:

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

Options:

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

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

Explanation:

Question 66:

Options:

Infection
Heterotopic ossification
Dislocation
Periprosthetic fracture
Acetabular component loosening

Correct Answer: Acetabular component loosening

Explanation:

Question 67:

Options:

Dorsal cheilectomy
Keller resection arthroplasty
Silastic joint replacement
Hallux metatarsophalangeal arthrodesis
Hallux valgus correction

Correct Answer: Hallux metatarsophalangeal arthrodesis

Explanation:

Question 68:

Options:

Fibrous dysplasia
Osteosarcoma
Ewing’s sarcoma
Periosteal chondroma
Aneurysmal bone cyst

Correct Answer: Fibrous dysplasia

Explanation:

Question 69:

What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?

Options:

Ten degrees of dorsiflexion
Ten degrees of plantar flexion
Twenty degrees of plantar flexion
Neutral
Resting equinus

Correct Answer: Twenty degrees of plantar flexion

Explanation:

Question 70:

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no

Options:

continued rapid fluid infusion.
administration of broad-spectrum antibiotics.
administration of 30/mg/kg methylprednisolone over 1 hour.
administration of pressors.
cardioversion and implantation of a pacemaker.

Correct Answer: administration of pressors.

Explanation:

Question 71:

Which of the following rehabilitation techniques is appropriate for initial nonsurgical management of an isolated grade 2 posterior cruciate ligament injury? Review Topic

Options:

Immobilization in full extension for 4 weeks
Immobilization in 30 degrees of flexion for 4 weeks
Relative protection for 10 to 14 days, then range of motion with progressive plyometric exercises
Relative protection for 10 to 14 days, then range of motion with gentle open-chain hamstring strengthening
Relative protection for 10 to 14 days, then range of motion with gentle closed-chain quadriceps strengthening

Correct Answer: Relative protection for 10 to 14 days, then range of motion with gentle closed-chain quadriceps strengthening

Explanation:

Question 72:

Options:

Immobilization in a rigid cervical orthosis for 6 to 8 weeks
Posterior occipital-cervical fusion with iliac crest bone graft
Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
Resection of the odontoid process through a transoral approach
Halo skeletal fixation

Correct Answer: Immobilization in a rigid cervical orthosis for 6 to 8 weeks

Explanation:

Question 73:

The swelling pressure in cartilage is predominantly due to the association of exchangeable water with which of the following substances? Review Topic

Options:

Biglycan
Type II collagen
Type IX collagen
Aggrecan
Versican

Correct Answer: Aggrecan

Explanation:

Question 74:

Options:

Unconstrained total elbow arthroplasty
Revision interposition ulnohumeral arthroplasty with allograft
Arthroscopic osteocapsular arthroplasty
Outerbridge-Kashiwagi procedure
Semiconstrained total elbow arthroplasty

Correct Answer: Semiconstrained total elbow arthroplasty

Explanation:

Question 75:

A healthy 2-year-old boy falls from a swing and sustains a displaced midshaft femoral fracture with 1 cm of shortening. What is the most appropriate treatment?

Options:

Pavlik harness
Skeletal traction for 3 weeks followed by a spica cast
Skin traction for 3 weeks followed by a spica cast
Closed reduction and spica casting
Closed reduction and an intramedullary pin

Correct Answer: Closed reduction and spica casting

Explanation:

AL-Madena Copy
DISCUSSION: For children between the ages of 1 and 6 years, closed reduction and early spica casting is recommended. In some instances, associated injuries or body habitus may preclude cast treatment. Pavlik harness treatment of femoral fractures is for infants younger than 1 year of age. Rarely is there an indication for traction. Internal fixation is reserved in general for children older than age 6 years or with confounding factors.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 271-280.
Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.
Figure 29a Figure 29b

Question 76:

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 77:

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Options:

Isotonic
Isokinetic
Isometric
Open kinetic chain
Dynamic variable resistance

Correct Answer: Open kinetic chain

Explanation:

Question 78:

What is the most common short-term complication following femoral impaction grafting for revision total hip arthroplasty?

Options:

Periprosthetic fracture
Infection
Loosening
Osteolysis
Dislocation

Correct Answer: Periprosthetic fracture

Explanation:

Question 79:

Figures 11a and 11b show the T 2 -weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?

Options:

Ligamentum flavum
Lumbar synovial cyst
Tarlov cyst
Pseudomeningocele
Herniated nucleus pulposus

Correct Answer: Lumbar synovial cyst

Explanation:

DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T
2
-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option.
REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972.
Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.

Question 80:

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

Options:

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

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

Explanation:

Question 81:

Options:

Arthroscopic chondroplasty
Autologous chondrocyte implantation
Microfracture
Arthroscopic drilling
Abrasion arthroplasty

Correct Answer: Autologous chondrocyte implantation

Explanation:

Question 82:

Arthritic change in cartilage is characterized by which of the following findings?

Options:

Proteoglycan loss in the cartilage matrix
Increased compressive modulus compared to normal cartilage
Increased tensile modulus
Decreased water content
Increase in the shear modulus

Correct Answer: Proteoglycan loss in the cartilage matrix

Explanation:

Question 83:

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
MRI with metal artifact reduction sequence (MARS)
CT of pelvis

Correct Answer: MRI with metal artifact reduction sequence (MARS)

Explanation:

Question 84:

What is the most common site of nerve compression in radial tunnel syndrome?

Options:

Fibrous bands anterior to the radiocapitellar joint
Recurrent radial vessels
Medial edge of the extensor carpi radialis brevis (ECRB)
Proximal aponeurotic edge of the supinator (arcade of Frohse) Radial tunnel syndrome occurs as the result of radial nerve compression at 5 potential sites. These are the fibrous bands anterior to the radiocapitellar joint, the radial recurrent vessels (known as the leash of Henry), the medial edge of the ECRB, the proximal aponeurotic edge of the supinator (arcade of Frohse), and the distal edge of the supinator. The arcade of Frohse is the most common site of compression. The chief discomfort is deep, aching pain in the dorsoradial proximal forearm. Motor and sensory symptoms usually are absent. This condition often is seen when pain persists after surgery for lateral epicondylitis. Lateral epicondylitis and radial tunnel syndrome coexist 5% of the time. Examination findings are tenderness 4 cm distal to the lateral epicondyle, pain with resisted supination, and pain with resisted long finger extension. Electromyogram/nerve conduction study and MRI results usually are normal. A steroid injection can be diagnostic and also may provide temporary relief of symptoms. Surgery involves decompression of all potential areas of compression and allows good to excellent results in only 50% to 90% of cases. Symptoms may take 9 to 18 months to resolve after surgery.

Correct Answer: Proximal aponeurotic edge of the supinator (arcade of Frohse) Radial tunnel syndrome occurs as the result of radial nerve compression at 5 potential sites. These are the fibrous bands anterior to the radiocapitellar joint, the radial recurrent vessels (known as the leash of Henry), the medial edge of the ECRB, the proximal aponeurotic edge of the supinator (arcade of Frohse), and the distal edge of the supinator. The arcade of Frohse is the most common site of compression. The chief discomfort is deep, aching pain in the dorsoradial proximal forearm. Motor and sensory symptoms usually are absent. This condition often is seen when pain persists after surgery for lateral epicondylitis. Lateral epicondylitis and radial tunnel syndrome coexist 5% of the time. Examination findings are tenderness 4 cm distal to the lateral epicondyle, pain with resisted supination, and pain with resisted long finger extension. Electromyogram/nerve conduction study and MRI results usually are normal. A steroid injection can be diagnostic and also may provide temporary relief of symptoms. Surgery involves decompression of all potential areas of compression and allows good to excellent results in only 50% to 90% of cases. Symptoms may take 9 to 18 months to resolve after surgery.

Explanation:

Question 85:

Options:

L5 pars repair.
L5 laminectomy alone.
L5 laminectomy and fusion.
stand-alone anterior lumbar interbody fusion.
L5-S1 total disk replacement.

Correct Answer: L5 laminectomy and fusion.

Explanation:

Question 86:

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Options:

Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance

Correct Answer: Pseudarthrosis

Explanation:

Question 87:

The patient decides to pursue surgical intervention. Which compartments should be released?

Options:

Anterior and lateral
Anterior, lateral, and deep posterior
Anterior, lateral and superficial posterior
Lateral and superficial posterior

Correct Answer: Anterior and lateral

Explanation:

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible
for the patient's symptoms and falls below current thresholds for diagnosis.

Question 88:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 89:

Passive glycation of articular cartilage results in

Options:

protection of collagen from degradation.
increased collagen stiffness and degradation.
increased chondrocyte proliferation.
increased proteoglycan association with type II collagen.
decreased synthesis of new collagen.

Correct Answer: increased collagen stiffness and degradation.

Explanation:

Question 90:

Options:

Physical therapy with a focus on quadriceps strengthening
Physical therapy and delayed posterior cruciate ligament (PCL) reconstruction
PCL reconstruction
PCL and posterolateral corner reconstruction

Correct Answer: Physical therapy with a focus on quadriceps strengthening

Explanation:

Question 91:

A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome?

Options:

Preoperative anterior compartment measurement of 29, with diastolic pressure 58
Preoperative anterior compartment measurement of 25, with diastolic pressure of 60
Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54
Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72
Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

Correct Answer: Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72

Explanation:

Question 92:

Options:

irrigation, debridement, and IV antibiotics.
curettage and bone grafting.
preoperative chemotherapy followed by wide excision.
observation.
aspiration and injection with methylprednisolone.

Correct Answer: aspiration and injection with methylprednisolone.

Explanation:

Question 93:

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future? Review Topic

Options:

Asymmetric tonic neck reflex
Moro reflex
Extensor thrust
Positive parachute reaction
Absent foot placement

Correct Answer: Positive parachute reaction

Explanation:

Question 94:

Options:

electrical stimulation.
a Charleston bending brace at night.
an extension-type spinal orthosis.
posterior spinal fusion with instrumentation.
anterior spinal release and posterior spinal instrumentation.

Correct Answer: an extension-type spinal orthosis.

Explanation:

DISCUSSION: The radiograph shows excessive thoracic kyphosis (normal 20 degrees to
50 degrees) with multiple contiguous vertebral wedging and end plate irregularity, all consistent with the diagnosis of Scheuermann’s kyphosis. The patient is skeletally immature; therefore, there is the potential for progression of the kyphotic deformity. Extension bracing has shown efficacy in the treatment of Scheuermann’s kyphosis that measures 50 degrees to 74 degrees, and has actually reduced the curvature permanently in some patients. A thoracolumbosacral orthosis may be used if the apex of kyphosis is at T7 or lower. Indications for surgical treatment are controversial, but spinal fusion most likely should not be considered for a painless kyphosis measuring less than 75 degrees.
REFERENCES: Murray PM, Weinstein SL, Spratt KF: The natural history and long-term follow-up of Scheuermann kyphosis. J Bone Joint Surg Am 1993;75:236-248.
Wenger DR, Frick SL: Scheuermann kyphosis. Spine 1999;24:2630-2639.
Tribus CB: Scheuermann’s kyphosis in adolescents and adults: Diagnosis and management.
J Am Acad Orthop Surg 1998;6:36-43.

Question 95:

Options:

Osteosarcoma
Fibrous dysplasia
Osteoblastoma
Ossifying fibroma
Osteomyelitis

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: Although the classic radiographic appearance of fibrous dysplasia is one of a central metaphyseal lesion with ground glass matrix, it is not unusual to see either a more radiodense-appearing lesion or a more peripheral location. The histologic finding of spicules of woven bone without osteoblastic rimming in a bland fibrous background is diagnostic of fibrous dysplasia. The imaging studies could be consistent with low-grade osteosarcoma, osteoblastoma, or osteomyelitis, but all have a very different histologic picture. Observation is indicated in the absence of symptoms, impending fracture, or deformity. Fibrous dysplasia most commonly occurs in the proximal femur.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 30-43.
DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation, and treatment.
J Bone Joint Surg Am 2005;87:1848-1864.

Question 96:

Options:

Formality
Empathy
Yes-no questions
Taking copious notes
Sitting leaning back in a chair

Correct Answer: Empathy

Explanation:

Question 97:

Options:

indomethacin for 3 months.
C-reactive protein and a sed rate.
MRI scan.
bone scan.
follow-up radiograph in 3 months.

Correct Answer: C-reactive protein and a sed rate.

Explanation:

Question 98:

Options:

glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day.
weight loss through dietary management and low-impact aerobic exercises.
arthroscopic debridement and lavage.
a valgus-directing brace.

Correct Answer: weight loss through dietary management and low-impact aerobic exercises.

Explanation:

Question 99:

Options:

aspiration of the femoral metaphysis.
IV antibiotics.
a biopsy.
immobilization in a well-padded splint for 2 to 3 weeks.
immobilization in a spica cast for 6 weeks.

Correct Answer: immobilization in a well-padded splint for 2 to 3 weeks.

Explanation:

Question 100:

Which of the following is considered the best method to measure limb-length discrepancy in a patient with a knee flexion contracture?

Options:

Obtain a standard scanogram
Obtain a lateral CT scanogram
Measure the distance from the anterior superior iliac spine to the medial malleolus
Measure the distance from the umbilicus to the medial malleolus
Stand the patient on blocks to measure the difference in the heights of the iliac wings

Correct Answer: Obtain a lateral CT scanogram

Explanation:

DISCUSSION: The most effective way to measure a limb-length discrepancy in a patient with a knee flexion contracture is a lateral CT scanogram. All the other methods listed provide inaccurate results with a knee flexion contracture because the measurements are made in the coronal plane.
REFERENCES: Aaron A, Weinstein D, Thickman D, et al: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.
Tachdjian MO: Clinical Pediatric Orthopaedics: The Art of Diagnosis and Principles of Management. Stamford, CT, Appleton and Lange, 1997, pp 237-240.

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

Orthopedic MCQ Mock Exam: Trauma, Oncology & Joint Surgery | Part 261

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 261

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index