OITE & AAOS Orthopedic Board Review MCQs: Part 263

About This Board Review Set

This is Part 263 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 263

This module focuses heavily on: Arthroplasty, Elbow, Foot, Fracture, Hip.

Sample Questions from This Set

Sample Question 1: 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 surgica...

Sample Question 2: A 5-year-old boy has had pain in the right foot for the past month. Examination reveals tenderness and mild swelling in the region of the tarsal navicular. Radiographs are shown in Figure 30. Management should consist of...

Sample Question 3: Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic...

Sample Question 4: A 23-year-old man is injured in a motorcycle accident and has a Glasgow Coma Scale (GCS) score of 10. His fiance arrives shortly after he does. He has an open, IIIc tibial fracture. The patient's parents are on the way but are not expected ...

Sample Question 5: A 72-year-old patient fell 3 weeks after undergoing a total hip arthroplasty using cementless fixation ofthe femoral component. She sustained a comminuted Vancouver type B-2 fracture with displacement of the calcar fragment. What is the bes...

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

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 2

A 5-year-old boy has had pain in the right foot for the past month. Examination reveals tenderness and mild swelling in the region of the tarsal navicular. Radiographs are shown in Figure 30. Management should consist of

Explanation

DISCUSSION: The child has the classic findings of Kohler’s disease or osteochondrosis of the tarsal navicular. The cause of this condition is not known, but osteonecrosis and mechanical compression have been proposed. Children generally report midfoot pain over the tarsal navicular and limping. Physical findings include tenderness, swelling, and occasionally redness in the region of the tarsal navicular. Radiographs show sclerosis and narrowing of the tarsal navicular. The natural history of the condition is spontaneous resolution and reconstitution of the navicular. Symptomatic treatment with restriction of weight bearing or casting is recommended.
REFERENCES: Karp M: Kohler’s disease of the tarsal scaphoid. J Bone Joint Surg

1937;19:84-96.
Borges JL, Guille JT, Bowen JR: Kohler’s bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.

Question 3

Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic

Explanation

The moving valgus stress test is used in the diagnosis of medial collateral ligament instability of the elbow. The other tests apply a varus force to the elbow and are used to diagnose lateral ulnar collateral insufficiency.

Question 4

A 23-year-old man is injured in a motorcycle accident and has a Glasgow Coma Scale (GCS) score of 10. His fiance arrives shortly after he does. He has an open, IIIc tibial fracture. The patient's parents are on the way but are not expected to arrive for some time. Who should be asked to provide informed consent?

Explanation

With a GCS of 10, the patient is not capable of providing consent nor does the fiancTe have legal standing to do so. This is an emergency and waiting for the parents is not acceptable. Two surgeons of similar knowledge and experience may confirm the necessity of the procedure.

Question 5

A 72-year-old patient fell 3 weeks after undergoing a total hip arthroplasty using cementless fixation of the femoral component. She sustained a comminuted Vancouver type B-2 fracture with displacement of the calcar fragment. What is the best treatment option?

Explanation

DISCUSSION:
The patient has an acute postoperative fracture of the proximal femur with subsidence. It is also common that the stem retroverts relative to the femur. It is most often seen in proximally porous coated stems within 90 days of surgery, one paper found it to occur 0.7% of the time in modern implants. There is always a debate whether this is a missed intraoperative fracture, or a new fracture that has resulted from an event of increased hoop stresses. Removal of the primary stem, placement of a diaphyseal engaging
stem (most frequently a tapered-fluted stem), and cabling of the fracture is the most successful treatment.

Question 6

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Explanation

DISCUSSION: It is generally accepted that reconstructions of the proximal tibia are associated with the highest incidence of failure, probably because of poor soft-tissue coverage, the need for extensor mechanism reconstruction, and other anatomic issues. It also may be related to the fact that patients with tumors of the proximal tibia, in general, have a better prognosis and better survival rates than patients with tumors located elsewhere in the body. Reconstructions of the proximal humerus may be more durable because they are not involved in weight-bearing activities.
REFERENCE: Horowitz SM, Glasser DB, Lane JM, Healey JH: Prosthetic and extremity survivorship after limb salvage for sarcoma: How long do the reconstructions last? Clin Orthop 1993;293:280-286.

Question 7

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Explanation

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,

pp 110-121.

Question 8

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 9

The patient undergoes hip arthroscopy and the image of the right hip is shown in Figure 39. Repair of the injured structure would be expected to improve

Explanation

DISCUSSION
The radiographic studies reveal both acetabular dysplasia and cam-type femoroacetabular impingement. The MR image shows an acetabular labral tear. Structural abnormalities of the hip, including femoroacetabular impingement, have commonly been identified in association with labral tears. Disruption of the ligamentum teres is not associated with impingement conditions in the absence of trauma.
The patient has acetabular dysplasia with a decreased lateral center-edge angle and also has visible cam-type femoroacetabular impingement. The common pathway for joint degeneration in hips with cam-type femoral head anatomy includes the development of cartilage damage in the anterior or superolateral aspects of the acetabular cartilage. Paralabral cysts may be seen more commonly in association with acetabular dysplasia, although the patient’s radiographs did not demonstrate substantial cystic changes. Osteochondral loose bodies and ligamentum teres ruptures can be seen at arthroscopy in a small number of cases.
There are several proposed roles of the acetabular labrum. It can increase the depth of the acetabular socket by as much as 21% to 28%. Roles of the acetabular labrum include joint lubrication, shock absorption, and pressure distribution. Recent studies assessing the effects of loading on joint stability for both normal and dysplastic hips did not demonstrate a substantial role of the labrum in differences in loading. Although joint stability might be improved following surgical repair, acetabular dysplasia is not likely to be resolved with acetabular labral repair alone.
RECOMMENDED READINGS
Tibor LM, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular impingement. Bone Joint Res. 2012 Oct 1;1(10):245-57. doi: 10.1302/2046-3758.110.2000105.PubMed: 23610655. View Abstract at PubMed
Peelle MW, Della Rocca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clin Orthop Relat Res. 2005 Dec;441:327-33. PubMed PMID: 16331022. View Abstract at PubMed
Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011 Jul;39 Suppl:72S-8S. doi: 10.1177/0363546511412320.
PubMed PMID: 21709035. View Abstract at PubMed
James SL, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of 37
femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec;187(6):1412-9. PubMed PMID: 17114529. View Abstract at PubMed
Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun;2(2):105-17. doi: 10.1007/s12178-009-9052-9. Epub 2009 Apr 7. PubMed PMID: 19468871. View Abstract at PubMed
Henak CR, Ellis BJ, Harris MD, Anderson AE, Peters CL, Weiss JA. Role of the acetabular labrum in load support across the hip joint. J Biomech. 2011 Aug 11;44(12):2201-6. doi: 10.1016/j.jbiomech.2011.06.011. Epub 2011 Jul 14. PubMed PMID: 21757198. View Abstract at PubMed

Question 10

A 33-year-old man had his foot run over by a forklift 1 hour ago. Examination reveals that the head of the fifth metatarsal is extruded through the plantar aspect of the foot. The foot is severely swollen and pale, there is no sensation in the toes, and the pulses are not palpable. Radiographs are shown in Figures 42a and 42b. Emergent management should consist of

Explanation

DISCUSSION: Following a severe crush injury, the patient has an acute compartment syndrome. Even though there is an open fracture, this is not sufficient to decompress the compartment syndrome. Therefore, splinting and observation are not appropriate. The surgical treatment of choice is fasciotomy with fixation of the multiple fractures. A primary amputation is not indicated because there is potential for salvage of this devastating injury.
REFERENCES: Fakhouri AJ, Manoli A II: Acute foot compartment syndromes. J Orthop Trauma 1992;6:223-228.
Myerson MS: Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248.
Ziv I, Mosheiff R, Zeligowski A, Liebergal M, Lowe J, Segal D: Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle 1989;9:185-189.

Question 11

A 24-year-old professional basketball player reports the gradual onset of pain that is poorly localized to the left midfoot for the past 2 months. Examination reveals diffuse tenderness to palpation, full range of motion of the ankle and subtalar joint, and a normal neurovascular examination to the foot. An AP radiograph is shown in Figure 10. Definitive treatment should include

Explanation

DISCUSSION: The imaging studies reveal a navicular stress fracture. This condition is secondary to chronic overuse (often running on hard surfaces) and results in vague, ill-defined pain in the midfoot. These fractures can be missed on radiographs but are well-defined on CT or MRI. Tarsal navicular fractures are typically oriented in the sagittal plane. Surgery is typically indicated for the high-level athlete because of the high risk for nonunion and persistent symptoms following nonsurgical management. Internal fixation is the treatment of choice.
REFERENCES: Torg JS, Pavlov H, Cooley JH, et al: Stress fractures of the tarsal navicular.
J Bone Joint Surg Am 1982;64:700-712.
Brodsky JW, Krause JO: Stress fractures of the foot and ankle, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2391-2409.

Question 12

Second-impact syndrome following a concussion

Explanation

RESPONSES FOR QUESTIONS 2 THROUGH 6
Curettage and/or grafting
Radiofrequency ablation
Intravenous (IV) antibiotics
Incision, drainage, and IV antibiotics
Neoadjuvant chemotherapy followed by surgical reconstruction
Observation alone
For each clinical vignette seen in the figures, select the best initial treatment from the list above.

Question 13

During a transperitoneal approach to the L5-S1 interspace, care must be taken to protect the superior hypogastric plexus from injury. Which of the following techniques reduces the risk of neurologic injury?

Explanation

DISCUSSION: Retrograde ejaculation is the sequela of superior hypogastric plexus injury. This structure needs protection, especially during anterior exposure of the L5-S1 disk space. Only blunt dissection should be used, and use of monopolar electrocautery should be avoided. If possible, preserve and retract the middle sacral artery. Once the iliac veins are isolated, blunt dissection is begun along the course of the medial edge of the left iliac vein, reflecting the prevertebral tissues toward the patient’s right side. The dissection goes from left to right because the parasympathetic plexus is more adherent on the right side.
REFERENCE: Transperitoneal midline approach to L4-S1, in Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer Verlag, 1983, pp 123-129.

Question 14

A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

Explanation

This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the medial collateral ligament [MCL] is intact and the lateral collateral ligament [LCL] is disrupted, or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction,
application of a hinged external fixator may be considered.

Question 15

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management? Review Topic

Explanation

In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step
in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography.

Question 16

Figures A and B show routine postoperative radiographs obtained 2 weeks after anterior cruciate ligament (ACL) reconstruction with autologous patellar tendon graft. Based on these findings, what is the next most appropriate action? Review Topic

Explanation

The radiographs reveal an intra-articular position of the femoral bone plug; therefore, revision ACL surgery is indicated. Recognized early, this graft may be suitable to use for the revision, but an alternate should be available.

Question 17

The best definitive treatment for this patient’s left knee is

Explanation

DISCUSSION
This patient now has a major fixed flexion contracture and severe varus alignment and instability. Infection of the knee joint has to be ruled out. The radiograph shows all the hallmarks of Charcot arthropathy, including disintegration and fragmentation of the joint with major deformity. Infection of the knee joint and contiguous osteomyelitis still have to be ruled out. The clinical and radiographic findings are highly suggestive of a Charcot neurogenic arthropathy associated with uncontrolled diabetes. This patient is an unsuitable candidate for total knee arthroplasty (TKA) because he is noncompliant regarding his diabetes and has had a previously infected native joint that now is associated with Charcot arthropathy. He is nonambulatory. The failure rate of TKA or knee arthrodesis is extremely high in this setting. He will best be served with observation or amputation depending upon his symptom severity.

Question 18

A 15-year-old boy has had pain in the right shoulder for the past 3 months. He denies any history of trauma and has no constitutional symptoms. Examination reveals a large firm mass in the proximal arm. A radiograph and MRI scan are shown in Figures 27a and 27b. Biopsy specimens are shown in Figures 27c and 27d. Management should consist of

Explanation

DISCUSSION: The patient has an aneurysmal bone cyst. The fluid-fluid levels seen on the MRI scan are typical for aneurysmal bone cyst, and the histology is consistent with a cystic lining. Vascular lakes, multinucleated giant cells, reactive bone, fibrovascular tissue, and an absence of atypical cells or numerous mitoses are seen histologically. Aneurysmal bone cysts will typically continue to grow and cause further bone destruction; therefore, observation is not recommended. Steroid injections are not effective. A thorough curettage of the cyst lining and bone grafting are required. Wide resection and chemotherapy are reserved for more aggressive tumors. There is no evidence of infection radiographically or histologically. Telangiectatic osteosarcoma should also be considered in the differential diagnosis; therefore, biopsy is an important part of the work-up.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 232-233.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-196.

Question 19

A 13-year-old girl was riding on an all-terrain vehicle when the driver struck a tree. She sustained the injury shown in Figures 45a through 45d. This injury is best described as what type of acetabular fracture pattern?

Explanation

DISCUSSION: The fracture is a both-column fracture in the Judet/Letournel classification and a C3 in the AO classification. There is extension into the sacroiliac joint along the pelvic brim and comminution along the posterior column above the sciatic notch. Both the anterior and posterior columns are separately broken and displaced. However, the defining feature of a both-column pattern, as seen in this patient, is that all articular fragments are on fracture fragments and no joint surface is left intact to the axial skeleton above. The use of three-dimensional images makes it easier to view the location of the fracture fragments and the amount and direction

of displacement.
REFERENCES: Helfet DL, Beck M, Gautier E, et al: Surgical techniques for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 533-603.
Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

Question 20

A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option? Review Topic

Explanation

This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.
Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles (Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poor-quality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsi
transfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.
Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.
Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.
Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI < 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.
Incorrect Answers:

Question 21

A 70-year-old man is experiencing neck pain, progressive weakness, and numbness in his arms and legs without bowel or bladder dysfunction or dysphagia. Upon examination, he has atrophy of his upper extremities but normal muscle bulk in his legs. Strength is diffusely 4/5 throughout. Cervical spine radiographs show spondylosis. Electromyography (EMG) reveals fibrillations with increased amplitude in the extensor carpi radialis and pronator teres. Nerve conduction studies demonstrate slowing conduction diffusely in the sural, peroneal, and ulnar nerves, and severe slowing in the median nerve. Testing of the tongue and thoracic paraspinal muscles does not show fibrillations or positive short waves. What is the most likely diagnosis? Review Topic

Explanation

Physical examination and presentation is consistent with possible cervical radiculopathy vs motor neuron disease. EMG findings are most consistent with cervical radiculopathy. There is denervation (fasciculations and positive short waves) of the C6 innervated muscles consistent with radiculopathy. However, evaluation of other body regions does not show evidence of denervation (tongue, thoracic paraspinal muscles). Fasciculations in the hand muscles were not widespread. Nerve conduction suggests the presence of a peripheral polyneuropathy with possible superimposed median neuropathy. Amyotrophic lateral sclerosis is a motor neuron disease that affects both upper and lower neurons. Presentation includes rapid progression of weakness, muscle atrophy, fasciculations, spasticity, dysarthria, dysphagia, and respiratory compromise.

Question 22

Which of the following advantages does the use of a vascularized fibula graft have over a nonvascularized fibula graft?

Explanation

A vascularized fibula graft, because its osteogenic potential remains unhampered by loss of vascularity it will begin to remodel and hypertrophy more quickly. Both types of grafts would act equivocably as scaffolding for osteoconduction. Early risk of fracture is increased if the nonvascularized fibula graft is over 12 centimeters in length as compared to a vascularized graft.
And a vascularized graft requires greater technical skills and a larger dissection to isolate the vascular pedicle with associated increased donor site morbidity.

Question 23

A 45-year-old woman with grade II adult-acquired flatfoot deformity has pain on the lateral side of her foot just distal to the tip of the fibula. Which component of a comprehensive flatfoot reconstruction most likely will address the deformity responsible for this pain?

Explanation

DISCUSSION
Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide.
RECOMMENDED READINGS
Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May;31(5):361-71. doi: 10.3113/FAI.2010.0361. PubMed PMID:

Question 24

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Explanation

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed . 26

Question 25

Figures 65a and 65b show the MRI scans of a 33-year-old man with severe left leg pain. He has had symptoms for 3 months with progressive worsening pain and function. Examination reveals ankle plantar-flexor weakness and diminished light touch sensation on the plantar surface of the foot. What treatment provides the best outcome? Review Topic

Explanation

The patient's signs and symptoms are consistent with lumbar radiculopathy. Surgical treatment for this condition has been shown to yield significantly improved outcomes when compared with nonsurgical management. Surgical management is best performed with a laminotomy and removal of the sequestered disk herniation ("limited diskectomy"). A complete (ie, subtotal) diskectomy may reduce the rate of recurrence for disk herniation but has been shown to worsen back pain postoperatively. A laminectomy may be necessary for larger herniations with severe central stenosis; the patient does not meet those criteria and, as noted, a total diskectomy is not indicated. Arthrodesis in the setting of primary lumbar disk herniation is not indicated and is considered overly aggressive treatment.

Question 26

A 52-year-old man has had groin and deep buttock pain for the past 2 months. Examination reveals that hip range of motion is mildly restricted, and he has pain with both weight bearing and at rest. An MRI scan is shown in Figure 28. Management should consist of

Explanation

DISCUSSION: The MRI findings show highly increased signal through the entire femoral head and neck that is diagnostic of transient osteoporosis of the femoral head. This recently described entity is often seen in middle-aged men and should be treated nonsurgically with protected weight bearing and anti-inflammatory drugs. The natural history is that of self-resolution.
REFERENCES: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.
Urbanski SR, de Lange EE, Eschenroeder HC Jr: Magnetic resonance imaging of transient osteoporosis of the hip:. A case report. J Bone Joint Surg Am 1991;73:451-455.

Question 27

A 10-year-old girl with a monoarticular pattern of juvenile rheumatoid arthritis (JRA) has had a 3-cm limb-length discrepancy since age 8 years when inflammation in the right knee came under good medical control. Because her right leg is longer, the patient states that she would like her legs to be close to equal in length in the future. A growth-remaining chart is shown in Figure 14. Management should consist of

Explanation

DISCUSSION: In a subgroup of patients with monoarticular JRA and a limb-length discrepancy that developed before the age of 9 years, Simon and associates showed that a subsequent growth deceleration on the affected side may correct a large part of the difference in length. This possibility would make surgery unnecessary and should prompt further observation.
REFERENCES: Simon S, Whiffen J, Shapiro F: Leg-length discrepancies in monoarticular and pauciarticular juvenile rheumatoid arthritis. J Bone Joint Surg Am 1981;63:209-215.
Ansell BM, Bywaters EGL: Growth in Still’s disease. Ann Rheum Dis 1956;15:295-319.

Question 28

A 45-year-old man who has had recurrent pain and swelling of the left Achilles tendon insertion for the past 10 years reports that physical therapy and activity modification have provided relief in the past. He now has continued pain despite these efforts. He also reports occasional bouts of dysuria that he attributes to a history of prostatitis. He also notes recent eye irritation that he attributes to allergies. A lateral heel radiograph is shown in Figure 33. Which of the following laboratory studies would best aid in diagnosis?

Explanation

DISCUSSION: Reiter’s syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis. Tendon ensethopathies can also be present. It is most often seen in men and is associated with a positive HLA-B27 marker. Rheumatoid arthritis does not usually present with these features; more commonly it causes forefoot pain and synovitis of the metatarsophalangeal joints. A CBC count with differential would be helpful in a situation of possible infection. The urethral swab would help to diagnose a gonococcal infection which can cause a monoarticular septic arthritis. Antiphospholipid antibody is associated with a hypercoaguable state and increased risk of deep venous thrombosis.
REFERENCE: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 560-650.

Question 29

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

Explanation

DISCUSSION: The authors of several studies conducted in Europe have reported promising results in the short- and medium-term with use of a reversed or inverted shoulder implant. The most recent investigation, a multicenter study in Europe in which 77 patients (80 shoulders) with glenohumeral osteoarthritis and a massive rupture of the rotator cuff were treated with the Delta III prosthesis, described an improvement in the mean constant score of 42 points, an increase of 65 degrees in forward elevation, and minimal or no pain in 96% of the patients. Hemiarthroplasty, the “nonconstrained” option, has long been the standard of care for rotator cuff tear arthropathy. However, careful examination of the literature reveals that the results have not been uniform.
REFERENCES: Favard L, Lautmann S, Sirveaux F, et al: Hemiarthroplasty versus reverse arthroplasty in the treatment of osteoarthritis with massive rotator cuff tear, in Walch G, Boileau P, Mole D (eds): 2000 Shoulder Prosthesis Two to Ten Year Follow-Up. Montpellier, France, Sauramps Medical, 2001, pp 261-268.
Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.
Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 30

Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

Explanation

DISCUSSION: Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace. Contraindications to use of the functional brace include:

1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Sarmiento A. Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486.

Question 31

A 75-year-old man presents with worsening low back and bilateral leg pain. The pain worsens with ambulation and improves with sitting. On exam, he has strong DP and PT pulses. Straight leg raise is negative. A MRI of the lumbar spine is performed and is pictured in Figure A. On further questioning, which of the following is the patient also likely to report? Review Topic

Explanation

The patient has lumbar spinal stenosis with neurogenic claudication and therefore is likely to experience worsening pain with activities that result in lumbar extension, such as walking down stairs.
Lumbar spinal stenosis often results from degenerative changes of the intervertebral disc and facet joints which ultimately narrows the space available for the thecal sac and exiting nerve roots. Patients can present with neurogenic claudication, reported as worsening leg and/or back pain with ambulation and diminished walking capacity. MRI may demonstrate disc degeneration/bulging, hypertrophy of the ligamentum flavum and facet capsule, and narrowing of the central canal. Nonoperative management includes NSAIDs, PT and epidural steroid injections (ESI). Surgery is reserved for patients who have failed nonoperative measures and includes decompressive laminectomy with or without fusion depending on presence of instability.
Issack et al reviewed degenerative lumbar spinal stenosis. Unlike patients with vascular claudication, patients with neurogenic claudication are able to improve walking tolerance with postural changes, specifically with flexed-forward posture (such as leaning forward on a shopping cart). They are unable to improve their symptoms simply by cessation of walking. Patients with neurogenic claudication tend to lack the trophic changes of the skin on the legs/feet as well as diminished pulses characteristic of vascular disease.
Young et al reviewed the utilization of lumbar ESI for low back and leg pain. The authors concluded that lumbar ESI are a reasonable nonsurgical option to provide temporary symptomatic relief. Fluoroscopic guidance facilitates accurate placement of the injection into the epidural space, while its nonuse may lead to higher percentage of technical failures. Lastly, the transforaminal approach is more selective
than the interlaminar approach and can provide diagnostic information as well as symptom relief.
Figures A and B are T1 sagittal and T2 axial MR images, respectively, of the lumbar spine demonstrating significant central canal stenosis most notable at L4-L5 with broad disc protrusion, facet degeneration and infolding of the ligamentum flavum.
Incorrect
Responses:

Question 32

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

Explanation

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

Question 33

During total hip arthroplasty, what characteristic of irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene should provide a more wear-resistant construct than traditional gamma-irradiated (2.5-4 Mrad)-in-air polyethylene mated with the same head?

Explanation

DISCUSSION:
Highly cross-linked polyethylene makes material resistant to adhesive wear. Abrasive wear from third bodies does not decrease wear. The fatigue strength of such material is inferior to that of traditional polyethylene, and its resistance to creep is the same, if not lower, than that of traditional polyethylene.

Question 34

The Lisfranc ligament connects the base of the

Explanation

DISCUSSION: The Lisfranc ligament arises from the lateral surface of the first (medial) cuneiform and is directed obliquely outward and slightly downward to insert on the medial surface of the second metatarsal base. It is the strongest of the tarsometatarsal interosseous ligaments.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.
Solan MC, Moorman CT III, Miyamoto RG, et al: Ligamentous restraints of the second tarsometatarsal joint: A biomechanical evaluation. Foot Ankle Int 2001;22:637-641.

Question 35

A 54-year-old man undergoes total shoulder arthroplasty for osteoarthritis. Despite compliance with an early passive range-of-motion exercise program, he does not regain more than 90 degrees of elevation, 10 degrees of external rotation, and has internal rotation to the fifth lumbar vertebra. At 6 months, his motion fails to improve. Radiographs are shown in Figures 18a and 18b. What is the best course of action?

Explanation

DISCUSSION: The patient has a global loss of motion that has failed to improve with 6 months of nonsurgical treatment; because he has reached a plateau, further nonsurgical management will likely be ineffective. Revision in the form of an open release is indicated to lyse intra- and extra-articular adhesions; subscapularis lengthening may be done concurrently as needed. Revising to a smaller head can be considered if adequate motion is not achieved. The radiographs reveal an adequate neck cut with appropriate seating of the component. Removing the glenoid component will decrease capsular tension but will probably increase pain because of the lack of glenoid resurfacing. Increasing humeral retroversion will not improve motion.
REFERENCES: Cuomo F, Checroun A: Avoiding pitfalls and complication in total shoulder arthroplasty. Orthop Clin North Am 1998;29:507-518.
Wirth MA, Rockwood CA Jr: Complications of shoulder arthroplasty. Clin Orthop 1994;307:47-69.

Question 36

Figure 62 shows the radiograph of a 46-year-old man who has had increasing shoulder pain and diminishing motion over the last 10 years. Because his difficulties are severely impacting his quality of life, he is seeking advice and treatment options. Twenty five years ago, he underwent a shoulder stabilization procedure for recurrent shoulder dislocations. Examination reveals he can only elevate his arm to less than shoulder level and his external rotation is no more than 10 degrees. Management consisting of nonsteroidal anti-inflammatory drugs and intra-articular steroid injections has failed to provide relief. What is the most appropriate treatment recommendation? Review Topic

Explanation

The patient has classic "arthritis of dislocation." Procedures done years ago were designed to enhance shoulder stability by limiting external rotation. However, it is now understood that limiting external rotation results in significant alteration of joint mechanics and kinematics, thus leading to the development of osteoarthritis. The average age of patients who develop arthritis of dislocation is 45 years old. Despite the young age of these patients, total shoulder arthroplasty offers the most predictable improvement in pain and function. However, the patient must be made aware of the need to protect the arm from excessive loads to protect the glenoid implant. Because there is complete loss of articular cartilage and incongruent joint surfaces, there is no role for arthroscopic debridement and capsular release. Injections offer little, if any, chance of improvement with the prior history of nonresponse. Physical therapy predictably makes patients worse because loading the arthritic joint generates more pain. Reverse shoulder arthroplasty is reserved for elderly patients with severe rotator cuff deficiency. A humeral head arthroplasty, while potentially more ideal than a total shoulder arthroplasty because of glenoid concerns, would likely not offer pain relief in the face of the significant glenoid involvement and incongruity.

Question 37

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 38

Which of the following types of sarcoma of the bone is most sensitive to external beam radiation?

Explanation

Parosteal osteosarcoma occurs on the surface of the metaphyseal regions of the distal femur or the proximal humerus most commonly. The treatment is wide surgical resection versus limb salvage. Dedifferentiated chondrosarcoma has a moth eaten appearance and may occur as a transformation of chondrosarcoma. Treatment is resection and prognosis is poor. Low-grade intramedullary chondrosarcoma is also treated with surgical resection. High-grade intramedullary osteosarcoma is usually treated with pre-op chemo and resection. The only tumor listed where radiation is an option is Ewings tumor.

Question 39

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

Explanation

The 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

Question 40

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 41

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

Explanation

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

Question 42

A 38-year-old man reports a 6-week history of shoulder pain and stiffness after falling on the stairs and landing onto the affected side. Radiographs are shown in Figures 54a and 54b. What is the most appropriate treatment? Review Topic

Explanation

The patient has a chronic posterior shoulder dislocation of 6-weeks duration. A CT scan will provide preoperative information regarding the size of the McLaughlin or reverse Hill-Sachs lesion. Open glenohumeral reduction with transfer of the lesser tuberosity and attached subscapularis has been shown to be successful in stabilizing a posterior dislocation. Closed reduction is highly unlikely to achieve a reduction and may cause displacement of an unrecognized humeral surgical neck fracture. Hemiarthroplasty would be considered for lesions involving more than 50% of the humeral head or when the joint has been dislocated for several months and late collapse of the head postreduction is likely. Rotator cuff tears are not commonly associated with posterior shoulder dislocation.

Question 43

A 52-year-old man underwent arthroscopic repair of a 1-cm supraspinatus tendon tear 3 weeks ago. He was doing well until he fell down three stairs. One week after the fall he continues to report pain similar to his preoperative pain. An MRI scan reveals a minimally retracted 1-cm supraspinatus tendon tear in the same location as his original tear. Management should now consist of Review Topic

Explanation

The patient has retorn his rotator cuff repair. This traumatic retear is different from a chronic tear and should be treated similar to an acute rotator cuff tear. Because the patient is younger than age 65 and has a small, single tendon tear, a revision rotation cuff repair is indicated with an expected tendon healing rate of greater than 95%. A physical therapy program is not indicated, and further delay in repair compromises his functional recovery. A cortisone injection is not indicated for this repairable tendon tear. Immobilization will not allow the tendon to heal once it has retorn. A debridement procedure is not indicated on this repairable tendon tear; this procedure is indicated in painful, chronic, irreparable tendon tears.

Question 44

-Figures 56a and 56b are the MRI scans of a 2-year-old girl who has a fever of 39°C and inability to move her left arm. She has not had any recent injury and is otherwise healthy. Radiograph findings of her left upper extremity are normal. What is the most appropriate treatment?

Explanation

Question 45

A 12-year-old girl who plays softball has chronic lateral hindfoot aching pain that is aggravated by weight-bearing activity. She reports that the pain has recurred after initial improvement with cast immobilization, and it continues to limit her overall level of activity. Radiographs are seen in Figures 40a through 40c. What is the most appropriate surgical treatment? Review Topic

Explanation

Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following? Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury? Review Topic

Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 46

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50? Review Topic

Explanation

The image shows a view of the radiocapitellar joint from an anterior medial portal. The radial nerve lies on the elbow capsule at the midportion of the capitellum. It is at risk for injury when capsular excision is performed in this region.

Question 47

A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity?

Explanation

DISCUSSION: Contracture of the intrinsic flexor muscles of the foot can be the result of unrecognized foot compartment syndrome. Foot compartment syndrome is a known complication of calcaneus fractures.
Myerson reported 3/43 patients in his series below had chronic foot compartment syndrome. There are 9 compartments in the foot: (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The plantar fascia limits the space available for hematoma and swelling, causing damage to the intrinsic flexors of the foot (particularly the lumbricals and interossei), resulting in clawtoes.

Question 48

Cortical bone demonstrates viscoelastic behavior as its mechanical properties are sensitive to strain rate and duration of applied load. Regarding longitudinal strain in cortical bone, which of the following statements regarding this characteristic is true?

Explanation

As strain rate increases, both elastic modulus and ultimate strength increase.
For LOW strain rates typical of normal activity (physiological strain rates of <0.1/s), bone is ELASTIC and DUCTILE (increasing ultimate strain with increasing strain rate). There is a ductile-to-brittle transition with increasing strain rate from normal to
supranormal rates. For EXTREMELY HIGH supranormal strain rates (>0.1/s, high impact trauma), bone is VISCOELASTIC and BRITTLE (low ultimate strain with increasing strain rate). Bone also becomes stronger and stiffer (higher modulus, steeper slope of stress-strain plot) as strain rate increases. This viscoelastic property helps in damping muscle contracture.
Natali and Meroi reviewed studies examining mechanical properties of bone. Mechanical properties are correlated with moisture, deformation rate, density and region of bone. Mechanical adaptation of bone is affected by strain rate (rate at which bone is deformed), strain mode (tension, compression, shear), strain direction (direction of strain relative to bone surface), strain frequency (cycles/second), stimulus duration (period over which deformation cycles are applied), strain distribution (pattern of strain magnitude across bone section) and strain energy (energy stored during deformation).
Illustration A shows the mechanical properties of bone with increasing strain rates. Incorrect Answers:
increase. During normal activity, as strain rate increases, bone is more ductile. With high impact trauma, bone is more brittle.

Question 49

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

Explanation

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

Question 50

A 34-year-old woman has had painful snapping and popping in the elbow since falling while in-line skating 6 months ago. The popping also occurs when she pushes off with her hands to rise from a seated position. Initial radiographs were normal, and she was told that she had sprained her elbow. Examination reveals few findings except that she is very apprehensive when the forearm is forcefully supinated with the elbow extended or partially flexed. A radiograph taken in that position is shown in Figure 24. Treatment should consist of

Explanation

DISCUSSION: The radiograph reveals posterolateral rotatory subluxation of the radiohumeral and ulnohumeral joints. The space between the ulna and trochlea is enlarged, particularly posteriorly at the olecranon. These findings are diagnostic of posterolateral rotatory instability, which causes recurrent subluxation and reduction as the elbow is flexed from an extended and supinated position with valgus load. The posterolateral rotatory instability apprehension test was performed on this patient and the result was positive. The lateral pivot-shift test causes a clunk as the elbow reduces but is more difficult to perform, even under general anesthesia. The patient does not have isolated subluxation of the radial head, although these findings can be mistakenly diagnosed as such. The radial head is normally shaped and does not represent a congenital dislocation. There are no findings here to suggest osteochondritis dissecans or loose bodies.
REFERENCES: O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.
Burgess RC, Sprague HH: Post-traumatic posterior radial head subluxation: Two case reports. Clin Orthop 1984;186:192-194.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 51

Figures 25a and 25b show the radiograph and MRI scan of a 7 1/2-year-old boy who has been limping for 1 year. His pain has worsened over the past 2 weeks, and his parents note swelling over the dorsum of the foot for the past 4 days. Examination reveals no fever, and laboratory studies show a WBC of 6,700/mm 3 , an erythrocyte sedimentation rate of 26 mm/h, and a normal C-reactive protein level. What is the most likely diagnosis?

Explanation

DISCUSSION: The diagnosis of tuberculous osteomyelitis in children is often delayed. In one series of 23 children, the average interval between the onset of symptoms and definite diagnosis was 4.3 months. In these patients, the presenting signs and symptoms were found to be mild, with the most common signs being localized swelling (69.6%) and a painful disability of the involved limbs (65.2%). A mild elevation of the erythrocyte sedimentation rate may be present, but the C-reactive protein level is usually normal. In patients who have osteoarticular tuberculosis, an MRI scan generally shows large intra-articular effusions, periarticular osteoporosis, and gross thickening of the synovial membrane. Differential diagnosis between tuberculosis and pyogenic arthritis is difficult, and an accurate diagnosis usually requires biopsy of synovial tissue. Aspiration of synovial fluid often results in insufficient information to make a diagnosis. Treatment generally consists of surgical debridement and combined antituberculous chemotherapy with isoniazid, ethambutol, and rifampin.
REFERENCES: Wang MN, Chen WM, Lee KS, Chin LS, Lo WH: Tuberculous osteomyelitis in young children. J Pediatr Orthop 1999;19:151-155.
Watts HG, Lifeso RM: Tuberculosis of the bones and joints. J Bone Joint Surg Am 1996;78:288-298.

Question 52

An otherwise healthy 33-year-old man who works in construction reports a 3-month history of knee pain. Radiographs are shown in Figures 9a and 9b. An axial T 1 -weighted MRI scan with contrast, an angiogram, and histologies are shown in Figures 9c through 9f. What is the most likely diagnosis?

Explanation

DISCUSSION: Dedifferentiated parosteal osteosarcoma designates high-grade transformation of conventional low-grade parosteal osteosarcoma. Unlike conventional parosteal osteosarcoma, where wide surgical excision alone is considered adequate treatment, patients with dedifferentiated osteosarcoma are treated with neoadjuvant chemotherapy and wide local resection. Recognition of dedifferentiated areas with angiography can localize the area that should be biopsied and thus render an accurate diagnosis. Percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome.
REFERENCES: Sheth DS, Yasko AW, Raymond AK, et al: Conventional and dedifferentiated parosteal osteosarcoma: Diagnosis, treatment, and outcome. Cancer 1996;78:2136-2145.
Lewis VO, Gebhardt MC, Springfield DS: Parosteal osteosarcoma of the posterior aspect of the distal part of the femur: Oncological and functional results following a new resection technique. J Bone Joint Surg Am 2000;82:1083-1088.

Question 53

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

Explanation

Incomplete cord syndromes include anterior cord syndrome, Brown-Sequard syndrome, central cord syndrome, and posterior cord syndrome. The anterior cord syndrome involves a variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception as seen in this patient. The Brown-Sequard syndrome involves an ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. The posterior cord syndrome is a rare injury and is characterized by preservation of motor function, sense of pain and light touch, with loss of proprioception and temperature sensation below the level of the lesion. The central cord syndrome is characterized with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Spinal shock is the period of time, usually 24 hours, after a spinal injury characterized by absent reflexes, flaccidity, and loss of sensation below the level of the injury.

Question 54

below show the radiographs, and the MRIs obtained from a year-old man with worsening left knee pain. A foot hip-to-ankle radiograph shows a degree varus knee deformity. The patient sustained a major left knee injury 5 years ago and a confirmed complete anterior cruciate ligament (ACL) tear. He managed this injury nonsurgically with a functional brace but experienced worsening pain. He was seen by an orthopaedic surgeon 18 months ago, and a medial meniscus tear was diagnosed; the tear was treated with an arthroscopic partial medial meniscectomy. Since then, his knee has been giving way more often, and he no longer feels safe working on a pitched roof. The patient received 6 months of formal physical therapy and was fitted for a new functional ACL brace, but he still has pain and instability. He believes he has exhausted his nonsurgical options and would like to undergo surgery. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Proximal tibial osteotomy is the most appropriate intervention to correct varus malalignment and to reduce stress on the ACL. In some cases, proximal tibial osteotomy alone may address both pain and instability, but if instability persists, particularly in the setting in which instability can be dangerous, subsequent ACL reconstruction can further stabilize the knee with less stress on the graft after the correction of malalignment. Varus alignment places increased stress on the native or reconstructed ACL. ACL reconstruction should be performed only at the same time as or following proximal tibial osteotomy to correct alignment in the setting of varus malalignment. It is not appropriate to perform ACL reconstruction prior to proximal tibial osteotomy in this setting. Distal femoral osteotomy is not indicated to correct varus malalignment. Varus alignment places increased stress on the native or reconstructed ACL, and ACL
reconstruction alone is not indicated for this patient.

Question 55

What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint? Review Topic

Explanation

Concavity compression is a stabilizing mechanism by which muscular compression of the humeral head into the glenoid fossa stabilizes the glenohumeral joint against shear forces. This is dependent on the depth of the concavity and the magnitude of the compressive force.

Question 56

Figure 16 shows the radiograph of a 56-year-old man who has neck pain after a rollover accident on his lawnmower. The injury appears to be isolated, and he is neurologically intact. Management of the fracture should consist of

Explanation

DISCUSSION: The radiograph shows a type IIa Hangman’s fracture, and the classic treatment is halo vest immobilization. Traction should be avoided in type IIa injuries because of the risk of overdistraction. A lesser form of immobilization such as a hard collar or a Minerva jacket can be used for nondisplaced (type I) fractures. Surgery generally is reserved for type III fractures (includes C2-3 facet dislocation), or extenuating circumstances such as multiple trauma or other fractures of the cervical spine that require surgical stabilization.
REFERENCES: Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.
Jackson RS, Banit DM, Rhyne AL III, et al: Upper cervical spine injuries. J Am Acad Orthop Surg 2002;10:271-280.

Question 57

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

Explanation

DISCUSSION: The MRI scans show a mesoacromion with tendonopathy of the supraspinatus. The history and physical findings indicate that the patient has a symptomatic os acromiale. Simple excision of the unstable os acromiale has not yielded consistently good results. Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem.
REFERENCES: Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 1993;9:28-32.
Warner JJ, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

Question 58

Receptor activator of nuclear factor kappa b (RANKL) and macrophage colony stimulating factor (MCSF) signaling pathways are necessary for the formation of multinucleated osteoclasts that resorb bone. Which of the following cells are known to produce RANKL?

Explanation

Osteoclast differentiation and function depend on the establishment of specific patterns of gene expression achieved through networks of transcription factors activated by osteoclastogenic cytokines such as RANKL and MCSF. RANKL and MCSF are produced by osteoblasts and T cells. Key transcriptional factors responsible for osteoclatogenesis require activation of transcriptional factors such as PU.1, NF-kappaB, AP-1, NFATc1, Mitf, Myc, and Src in osteoclast precursors that are of monocyte/macrophage origin.

Question 59

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

Explanation

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

Figure 59a Figure 59b

Question 60

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion? Review Topic

Explanation

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening.

Question 61

--The patient is offered a VPHTO. What aspect of his history will determine the most appropriate VPHTO technique?

Explanation

DISCUSSION FOR QUESTIONS 13 THROUGH 16
This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. An ultrasound can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario.
Because the patient has a correctable deformity (gaps 3 mm with valgus stress) and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgicalplanning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient.A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation,examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result,current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 is an indication for HTO but does not influence technique.

Question 62

What is the most likely type of pathology seen in Figure 16?

Explanation

DISCUSSION: The figure shows the missing pedicle or “winking owl” sign that is characteristic of tumor involvement of the cortical bone of the pedicle. None of the other pathologic processes commonly gives this radiographic picture. Thinned, but not missing pedicles, have been described as a normal variant.
REFERENCES: McLain R, Weinstein J: Tumors of the spine, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1173.
Charlton OP, Martinez S, Gehweiler JA Jr: Pedicle thinning at the thoracolumbar junction: A normal variant. Am J Roentgenol 1980;134:825-826.

Question 63

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 64

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Explanation

RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 65

A 63-year-old woman is seen 10 weeks after sustaining a closed minimally displaced distal radius fracture. She has been in a short-arm cast and reports minimal pain but notes that she is having difficulty using her thumb. An extensor pollicis longus (EPL) tendon rupture is suspected. Which examination finding would confirm lack of EPL function?

Explanation

EXPLANATION:
As many as to 5% of patients with a nondisplaced distal radius fracture experience EPL rupture. The extensor pollicis brevis (EPB) tendon often attaches to the extensor hood and sometimes continues more distally, providing weak metacarpophalangeal extension even in the setting of EPL disruption. However, because of the vector of its pull, the EPB cannot extend the thumb dorsal to the plane of the palm. A positive Froment sign is noted when flexion of the thumb interphalangeal joint with an attempted key pinch is caused by adductor pollicis weakness from ulnar nerve dysfunction. Compression of the median nerve in the carpal tunnel affects the recurrent motor branch of the abductor pollicis brevis, leading to thenar atrophy. The flexor pollicis longus tendon (FPL) is intact so the patient would not have difficulty flexing the thumb with the palm flat.

Question 66

Which of the following is considered the most common complication of the impaction grafting technique for femoral revision surgery?

Explanation

DISCUSSION: Impaction grafting technique for femoral revision surgery has become increasingly popular over the past decade. This technique is designed to address cavitary deficiencies of the femur. The femoral stem is inserted with cement fixation. Its clinical efficacy has not been shown to be superior to extensively porous-coated stems. Early subsidence of the stem has been reported in more than 50% of the patients. However, loss of fixation has occurred infrequently (5%) in reported series conducted by experienced surgeons. It has not been shown to have a higher infection rate.
REFERENCES: Gie GA, Linder L, Ling RS, Simon JP, Slooff TH, Timperley AJ: Impacted cancellous allografts and cement for revision total hip arthroplasty. J Bone Joint Surg Br 1993;75:14-21.
Meding JB, Ritter MA, Keating ME, Faris PM: Impaction bone-grafting before insertion of a femoral stem with cement in revision total hip arthroplasty: A minimum two-year follow-up study. J Bone Joint Surg Am 1998;79:1834-1841.

Question 67

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Explanation

DISCUSSION: A positive jaw jerk reflex suggests that the problem is above the level of the pons. All of the other physical signs are exhibited in patients with cervical myelopathy. Although these signs also may be present in conditions affecting the brain, they do not help differentiate between a brain etiology and a cervical spine etiology. A jaw jerk reflex, however, is not present in patients with cervical myelopathy alone.
REFERENCES: Montgomery DM, Brower RS: Cervical spondylotic myelopathy: Clinical syndrome and natural history. Orthop Clin North Am 1992;23:487-493.
Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K: Myelopathy hand: New clinical signs of cervical cord damage. J Bone Joint Surg Br 1987;69:215-219.
An HS, Simpson JM: Surgery of the Cervical Spine. Baltimore, MD, Williams and

Wilkins, 1994.

Question 68

A 32 yr old man with oxalosis is scheduled for a surgical treatment of spinal stenosis. Which of the following organs is most likely to show signs of systemic oxalosis during a preoperative assessment?

Explanation

“Oxalosis is a genetic transmitted, autosomal recessive disorder of glyoxalate metabolism...Nephrolithiasis and nephrocalcinosis, secondary to calcium oxalate hypersaturation in the patient’s kidney, usually cause an initial presentation of renal colic and/or asymptomatic gross hematuria...[and later] chronic renal failure” This finding would be detected on either UA or BUN/Cr labs.

Question 69

A patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the site of the tenderness, about 7 cm above the lateral heel, provided temporary relief of the pain. What is the recommended course of management for the persistent burning pain?

Explanation

The patient has a sural nerve neuroma, which is a known complication of the extensile lateral approach. Of the available choices, excision and burial of the sural nerve in muscle or vein is the best choice because it gives better pain relief due to the better blood supply in muscle than bone. Recent authors advocate burying the nerve in vein as the best option. Neuroplasty is a possibility (but not of the superficial peroneal nerve), but the sural nerve is usually very sensitive and often pain relief with a release is incomplete. Additionally, implant removal is not indicated because of the patient's complaints; also, the implants should not be removed at 6 months. A subtalar fusion is the choice for posttraumatic arthritis from the calcaneus fracture. Electromyography/nerve conduction velocity studies are reasonable choices if there was an indication the pain could be coming from the back or there was no clear evidence of a sural nerve neuroma.

Question 70

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Explanation

The reverse total shoulder arthroplasty depends on a functional deltoid muscle which is innervated by the axillary nerve to restore elevation for the patient. Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty has not been correlated with poor results with a reverse shoulder arthroplasty. As long as the patient does not have an active infection, prior infections are not a contraindication. Patients can still have pain and pseudoparalysis from a chronic rotator cuff tear, despite having normal cartilage, and they will still benefit from a reverse total shoulder arthroplasty if other treatments have failed.

Question 71

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

Explanation

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

Question 72

A 59-year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Question 73

A 65-year-old woman has had chronic aching discomfort involving her elbow for the past 6 months. Radiographs and a biopsy specimen are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The histologic features of multiple myeloma are distinctive for this lesion. The plasma cells are round or oval and have an eccentric nucleus and prominent nucleolus. These characteristics and a clear area next to the eccentric nucleus representing the prominent Golgi center are pathognomonic for plasma cells. Lymphoma is in the differential diagnosis; the most frequent types that occur in bone are large cell or mixed small and large cell types. The histologic appearance of the specimen is not consistent with the other choices.
REFERENCE: Dorfman HD, Bodgan C: Immunohematopoietic tumors, in Dorfman HD, Bogdan C (eds): Bone Tumors. St Louis, MO, Mosby, 1998, Chapter 12.

Question 74

Figures below depict the radiographs obtained from a 60-year-old man with instability and pain 1 year after primary right total knee arthroplasty. He states that he had surgery on two occasions for a tendon rupture that was repaired with sutures but that his knee popped again, and now the leg is unable to hold his weight. On examination, he is in no acute distress. His height is 6'3", and he weighs 240 pounds. He is ambulatory with crutches. Range of motion of the right knee is 50° to 120° actively and 0° to 120° passively. More than 10° of varus/valgus laxity and more than 5 mm of anteroposterior drawer are present. A palpable defect is observed in the tissue just proximal to the patella. The incision is well healed. The erythrocyte sedimentation rate is 46 mm/h (reference range 0 to 20 mm/h) and the C-reactive protein level is 2.04 mg/L (reference range 0.08 to 3.1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Explanation

DISCUSSION:
This patient has a chronic quadriceps tendon rupture after total knee arthroplasty. Two previous primary repair attempts have failed, which is not surprising based on the poor results of primary repair reported in the literature. The patient also has an unstable knee and will require revision of some or all of the prosthesis to achieve a stable knee. Revision total knee arthroplasty with extensor mechanism allograft allows an allograft reconstruction of the ruptured quadriceps tendon. The other option is to utilize a synthetic mesh extensor mechanism reconstruction. These are likely to have the best result in this situation. Revision total knee arthroplasty with liner change and primary quadriceps repair is not the best form of management, because it involves a third attempt at primary tendon repair, which will likely fail again. Resection knee arthroplasty and arthrodesis with antegrade nail is a possible option but is not the best, because it would likely make driving and other daily activities difficult. Two-stage revision total
knee arthroplasty with extensor mechanism allograft is not the best option because the laboratory results show no signs of infection, so a single-stage procedure is preferred.

Question 75

Atraumatic suprascapular nerve compression usually occurs at which of the following anatomic locations if it develops atraumatically? Review Topic

Explanation

The suprascapular nerve has the potential to be compressed as it passes through the suprascapular and spinoglenoid notches. If the site of compression occurs at the suprascapular notch, both the supraspinatus and infraspinatus muscles will be affected. If the site of compression occurs at the spinoglenoid notch, only the infraspinatus muscle will be affected. Fascial bands and ganglion cysts often compress the nerve in these areas. The other anatomic areas are not associated with suprascapular nerve compression.

Question 76

A 27-year-old man has had pain in the right index finger for the past 9 months. The pain is completely relieved with ibuprofen. An AP radiograph and CT scan are shown in Figures 80a and 80b. What is the most likely diagnosis?

Explanation

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a

radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic

features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 77

A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of

Explanation

DISCUSSION: The major obstacle to overcome in the surgical treatment of this cock-up deformity is recurrence. Dorsal releases can be performed; however, chronic dislocation of the fifth MTP joint usually needs to be addressed with plantar release as well. Chronic dorsal soft-tissue contractures may be overcome with translation of the toe into a plantar-based incision, as described originally by Cockin and accredited to Butler. This is the treatment of choice. Resection of the proximal phalanx improves symptoms but induces a secondary deformity; this procedure is usually reserved for skeletally mature individuals.
REFERENCES: Black GB, Grogan DP, Bobechko WP: Butler arthroplasty for correction of adducted fifth toe: A retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441.
Paton RW: V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249.
Coughlin MJ, Mann RA: Lesser toe deformities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 5. St Louis, MO, Mosby, 1986, pp 132-157.

Question 78

The most appropriate next surgical procedure is

Explanation

DISCUSSION
This patient’s arthritis likely has progressed to the lateral compartment. The location and degree of local pain and tenderness are the most important physical findings. History and physical findings indicate arthritis progression to the lateral and anterior compartments. This scenario suggests the need for conversion of the unicompartmental arthroplasty to TKA.

Question 79

Which of the following abnormalities has been observed in a higher than expected frequency in patients with metal-on-metal hip bearings?

Explanation

DISCUSSION: Metal-on-metal hip bearings have been associated with very low rates of wear and are commonly used in North America and Europe. Patients with these bearings have higher levels of metal ions (particularly cobalt and chromium) in the bloodstream than patients with bearings made of other materials. Although many researchers have been concerned that these ions may predispose to cancer, there has been no evidence that patients with metal-on-metal bearings are developing sarcomas or carcinomas with higher frequency than the general population. However, there has been mixed data as to whether hematopoietic malignancies are slightly more prevalent in patients with metal-on-metal bearings. Two recent reports have found chromosomal abnormalities, such as translocations and aneuploidy, to be increased in patients with metal-on-metal hip bearings. The clinical consequences of these changes, if any, remain unknown.
REFERENCES: Dunstan E, Ladon D, Whittingham-Jones P, et al: Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings. J Bone Joint Surg Am 2008;90:517-522. Ladon D, Doherty A, Newson R, et al: Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metal-on-metal hip arthroplasty. J Arthroplasty 2004:19:78-83.
Visuri T, Pukkala E, Paavolainen P, et al: Cancer risk after metal on metal and polyethylene on metal total hip
arthroplasty. Clin Orthop Relat Res 1996:329:S280-S289. Question 61
A 73-year-old woman with a history of type II diabetes mellitus undergoes a total hip arthroplasty for osteoarthritis. She continues to have serosanguinous wound drainage from the midportion of the incision 12 days after surgery. What is the most appropriate treatment at this time?
Return to the operating room for debridement and irrigation with removal of all implants and immediate reimplantation
Return to the operating room for open debridement and irrigation, exchange of the polyethylene
insert, followed by appropriate antibiotics based on intraoperative culture results
Hip spica pressure dressing and a 2-week course of oral antibiotics
Hip aspiration for culture, followed by a 2-week course of appropriate IV antibiotics based on
culture results
Hip aspiration for culture, followed by a 6-week course of appropriate IV antibiotics based on culture results
DISCUSSION: This patient has an acute postoperative deep infection, with prolonged drainage at 12 days postoperatively. Even without other signs or symptoms of infection, the prolonged drainage this far out after surgery is concerning for an acute postoperative infection. The most appropriate treatment at this point is open debridement with retention of the implants. Modular parts, if present, are exchanged. Oral or IV antibiotics alone are generally inadequate to treat the infection, and this form of management alone would result in a missed opportunity to potentially cure the infection. Removal of all implants at this point is not required because early aggressive debridement within the first 2 weeks after surgery offers a reasonable outcome. After 4 to 6 weeks of symptoms, results of debridement are less favorable and removal of the implants is usually required.
REFERENCES: Crockarell JR, Hanssen AD, Osmon DR, et al: Treatment of infection with debridement and retention of the components following hip arthroplasty. J Bone Joint Surg Am 1998;80:1306-1313. Hanssen AD, Osmon DR: Assessment of patient selection criteria for treatment of the infected hip arthroplasty. Clin Orthop Relat Res 2000;381:91 -100.

Question 80

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Explanation

Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 81

A 12-month-old boy has right congenital fibular intercalary hemimelia with a normal contralateral limb. A radiograph of the lower extremities shows a limb-length discrepancy of 2 cm. All of the shortening is in the right tibia. Assuming that no treatment is rendered prior to skeletal maturity, the limb-length discrepancy will most likely

Explanation

DISCUSSION: Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a “multiplier method,” as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements.
REFERENCES: Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting

limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446.
Moseley CF: A straight-line graph for leg length discrepancies. Clin Orthop 1978;136:33-40.

Question 82

The knee arthroplasty type associated with the highest 5-year revision rate is

Explanation

CLINICAL SITUATION QUESTIONS 167 THROUGH 169
Figures 167a and 167b are the radiographs of a middle-age man. He is a noncompliant patient who has severe insulin-dependent diabetes and a below-knee amputation on the right side. He is usually in a wheelchair, does not use a prosthesis, transfers using a walker, and resides in an institution. He had an infection in the left leg years ago, which was treated successfully with intravenous antibiotics (the details are unknown). His left knee is mildly painful, swollen but not warm, has limited range of motion (40-140 degrees), and is grossly unstable.

Question 83

An otherwise healthy 25-year-old man with an isolated closed mid-diaphyseal femoral fracture undergoes intramedullary nailing. Compared with nonreamed nailing, reamed femoral nailing is associated with a higher rate of Review Topic

Explanation

Bhandari and associates, in a meta-analysis, concluded that sufficient evidence exists to suggest that reamed intramedullary nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing. Tornetta and Tiburzi, in a prospective randomized study, determined that reamed canal preparation led to faster healing of distal fractures treated with statically locked intramedullary nails. Blood loss was greater in the reamed group, but this did not translate into increased transfusion requirements. In this series, there was no advantage to nail insertion without reaming. In a prospective randomized multicenter study, the overall incidence of acute respiratory distress syndrome (ARDS) was found to be low with primary stabilization of femoral shaft fractures with intramedullary nailing. There was no difference in the incidence of ARDS between the reamed and unreamed groups. In a retrospective study performed by Handolin and associates, intramedullary nailing of long bone fractures in patients with multiple injuries and with a coexisting pulmonary contusion did not impair pulmonary function or outcome. No study has convincingly demonstrated an increased trend toward infection with reamed femoral intramedullary nailing.

Question 84

Figures 34a and 34b show the axial and sagittal MRI scans of a 36-year-old man who reports the insidious onset of pain in the right shoulder. What is the most appropriate description of the acromial morphology?

Explanation

DISCUSSION: The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.
REFERENCES: Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, p 23.
Sammarco VJ: Os acromiale: Frequency, anatomy, and clinical implications. J Bone Joint Surg Am 2000;82:394-400.

Question 85

After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office with continued pain 2 years after surgery. He describes instability, particularly when descending stairs. Upon examination, there is range of motion from 0 to 120 degrees with no extensor lag. The knee is stable to varus and valgus stress in extension, but there is flexion instability in both the anterior-posterior direction and in the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection workup is negative. What is the most appropriate surgical intervention at this time?

Explanation

DISCUSSION

Video 99 for reference
This patient has valgus knee alignment, and, after undergoing appropriate bone resections and soft-tissue balancing, has demonstrated a tight PCL on trial reduction as evidenced by lift-off of the trial insert as described by Scott and Chmell. The appropriate maneuver is PCL recession with partial release of tight (usually anterolateral) PCL fibers. However, for this patient, instability resulted in increased anterior translation. At this stage, the options are to convert to either a deeper-dish insert with increased sagittal conformity or a posterior stabilized insert. The only appropriate choice among the responses is use of an insert with increased sagittal conformity to prevent excessive anterior translation. Increasing the polyethylene could improve stability in flexion, but, considering there is good stability in extension, this likely would lead to an inability to achieve full extension. The patient’s valgus deformity, flexion contracture, correction with release of the iliotibial band, and posterolateral capsule predispose him to increased risk for peroneal nerve palsy. His symptoms at follow-up suggest knee flexion
instability with pain, swelling, and difficulty descending stairs. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant depending on the condition of the ligaments likely is needed to address his symptoms. The difference in extension vs flexion stability makes polyethylene exchange a poor option. There is no reason to believe a constrained rotating hinge design is necessary. Repeat use of a PCL-retaining insert is not recommended.

Question 86

A 20-year-old man has activity-related deep-seated shoulder pain in his dominant right shoulder. He has taken 3 months off training as a college javelin thrower, and management consisting of physical therapy has failed to provide relief. Shoulder arthroscopic views are shown in Figures 16a through 16c. What is the underlying association with this condition? Review Topic

Explanation

The patient is involved in overhead athletics and reports deep-seated pain. The arthroscopic views show a SLAP tear with posterior extension that is typical of internal impingement. The history lacks a component of gross instability expected in traumatic anterior dislocations or multidirectional instability associated with a connective tissue disorder, and it also lacks risk factors for osteonecrosis. The images do not show evidence of an unstable humeral cartilage flap or a supraspinatus tear.

Question 87

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

Explanation

The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.

Question 88

Figures 136a through 136c are the weight-bearing anteroposterior and lateral radiographs of a 28-year-old construction worker who has had 6 months of progressive knee pain isolated to the medial aspect of his right knee. The pain has not responded to nonsurgical treatment. His body mass index is 26. He has knee range of motion from 0 to 125 degrees, and his knee is stable to ligament examination. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
Proximal tibial osteotomy is the best option for this young patient who has good range of motion and arthritis isolated to the medial compartment. Distal femoral osteotomy is more appropriate for correction of valgus deformity. In the setting of most varus deformities as shown in this patient’s radiographs, there is varus angulation of the proximal tibial. Correction of alignment at the femur results in obliquity of the joint line and abnormal loading. Medial
unicompartmental knee arthroplasty and TKA are less optimal in this setting because of this patient’s young age and high demands as a laborer. Unicompartmental knee arthroplasty and TKA are not preferred options for this patient because risk for premature failure is high.

Question 89

A 25-year-old woman returns for her first postoperative visit after arthroscopic thermal capsulorrhaphy for recurrent multidirectional instability. Examination reveals that the portals are healed, there is no swelling; and passive range of motion is within the normal range. However, she is unable to actively raise her arm. Shoulder radiographs are normal. What is the most likely cause of these findings? Review Topic

Explanation

Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.

Question 90

A 25-year-old male professional lacrosse player collides with another player, with injury resulting from a knee impacting the athlete’s thigh. He has immediate pain in the mid-thigh area and is unable to return to the game because of difficulty with running. Examination reveals developing swelling in the anterior mid-thigh area. The thigh compartments are soft, and he is able to extend his knee against gravity. Knee flexion at 90° gives him discomfort in the thigh but no knee pain. The knee and hip examinations are otherwise unremarkable. Plain films of the femur are negative. What is the best next step?

Explanation

The lesion seen in the MRI scan in Figure 1 is treated with a marrow stimulation technique. The reparative tissue formed by this technique is predominantly composed of
A. only type 1 collagen.
B. only type 2 collagen.
C. type 1 and type 2 collagen.
D. neither type 1 or type 2 collagen.
The MRI scan shows a full-thickness cartilage defect. When treated with a marrow stimulation technique, such as a microfracture, the reparative tissue is fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen, fibrocartilage is composed of both type 1 and type 2 collagen.
15- Figures 1 and 2 are the radiographs of a 58-year-old retired laborer who has had many years of right shoulder pain. He initially experienced relief with anti-inflammatory medication over the past year, but this no longer provides him pain relief. He has pain with overhead activities and is dissatisfied with his shoulder function. Examination indicates active and passive forward elevation to 130°, full strength with external rotation, and a negative belly press test. MRI demonstrates an intact rotator cuff. What is the best next step in treatment?
A. Anatomic total shoulder arthroplasty (TSA)
B. Hemiarthroplasty
C. Reverse shoulder arthroplasty
D. Arthroscopy with debridement and biceps tenodesis
The patient has glenohumeral osteoarthritis based on the radiograph. His examination demonstrates limited motion and no significant rotator cuff pathology – full strength with external rotation, negative belly press, and no pseudoparalysis. Of all the answer choices, an anatomic TSA would be the most appropriate treatment option. Hemiarthroplasty does not address glenoid pathology and provides inferior pain relief and function, compared with TSA. A reverse shoulder arthroplasty is utilized for patients with degenerative shoulder changes in conjunction with irreparable rotator cuff pathology. Shoulder arthroscopy with debridement and biceps tenodesis is not appropriate for those with severe degenerative changes of the shoulder.
16- According to the MRI scan shown in Figure 1, which pathologic finding is expected to be encountered during arthroscopy?
A. Figure 2
B. Figure 3
C. Figure 4
D. Figure 5
The sagittal MRI scan is a clear example of a double posterior cruciate ligament (PCL) sign. This sign has a high specificity for a displaced bucket handle tear of the medial meniscus as seen in Figure 4. The other arthroscopic
images show a flap tear of the medial meniscus (Figure 2), anterior cruciate ligament tear (Figure 3), and a full thickness articular cartilage defect (Figure 5). Other less likely causes of a double PCL sign include intermeniscal ligament, meniscofemoral ligaments, loose bodies, osteophytes, and fracture fragments. Correct answer : C 13
17- Figures 1 and 2 are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test, trace effusion, and range of motion from 0 to 85° of knee flexion. Which factor is most contributory to his examination findings?
A. Incorrect graft choice
B. Improper tunnel position
C. Tibial graft-tunnel mismatch
D. Femoral fixation at 80° flexion
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

Question 91

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

Explanation

Polylactic acid suture and suture anchors are popular bioabsorbable orthopaedic implants. This material undergoes hydrolysis of the ester background in vivo. Resulting lactic acid enters the tricarboxylic acid (Krebs) cycle and is excreted as carbon dioxide by the lungs. Polyglycolic acid and poly(p-dioxanone) may also be excreted by the kidneys.

Question 92

A 13-year-old patient has foot drop and lateral knee pain. AP and lateral radiographs and an MRI scan are shown in Figures 49a through 49c. A biopsy specimen is shown in Figure 49d. What is the preferred method of treatment?

Explanation

DISCUSSION: The “sunburst” radiographic appearance suggests an osteosarcoma, and the histologic findings confirm the diagnosis with malignant cells surrounded by pink osteoid. MRI scans are not particularly helpful in the diagnosis of osteosarcoma but are mandatory for surgical planning. Osteosarcomas are high-grade sarcomas that are best treated with chemotherapy and wide resection. Even though the peroneal nerve is involved, limb salvage is indicated. Survival after limb salvage is equivalent to amputation, with better function.
REFERENCES: Goorin AM, Abelson HT, Frei E: Osteosarcoma: Fifteen years later. N Engl J Med 1985;313:1637.
Link MP, Goorin AM, Miser AW, et al: The effect of adjuvant chemotherapy on relapse-free survival in patients with osteosarcoma of the extremity. N Engl J Med 1986;314:1600.
Davis AM, Bell RS, Goodwin PJ: Prognostic factors in osteosarcoma: A critical review. J Clin Oncol 1994;12:423.

Question 93

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder?

Explanation

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 94

Which of the following tendons is the primary antagonist of the posterior tibialis tendon?

Explanation

DISCUSSION: The primary action of the posterior tibialis tendon is inversion of the foot; secondarily, it plantar flexes the ankle. The anterior tibialis tendon also inverts the foot and only partially antagonizes the posterior tibialis tendon. The primary action of the peroneus longus is plantar flexion of the first ray. It secondarily everts the posterior tibialis tendon. The action of the flexor digitorum longus tendon is synergistic with the posterior tibialis tendon. The primary action of the peroneus brevis tendon is eversion; therefore, it is the primary antagonist of the posterior tibialis tendon.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993, pp 550-551.
Mann RA: Biomechanics of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 2-36.

Question 95

A 32-year-old volleyball player has dull posterior shoulder pain. An examination reveals moderate external rotation weakness with his arm at his side but normal strength on supraspinatus isolation. Deltoid and supraspinatus bulk appear normal, although there appears to be mild infraspinatus atrophy. Sensation is normal throughout the shoulder and shoulder girdle. What is the most likely diagnosis?

Explanation

This clinical scenario describes a patient with an isolated injury affecting the infraspinatus muscle. The anatomic location of such a lesion would be at the spinoglenoid notch, at which the suprascapular nerve may be compressed distal to its innervation of the supraspinatus but proximal to the infraspinatus innervation. A calcified transverse scapular ligament would also affect the suprascapular nerve but is proximal to the innervation of both muscles. Quadrilateral space syndrome would affect innervation of the deltoid (and teres minor). Parsonage-Turner syndrome is a more diffuse, and often severely painful, brachial plexus neuropathy.

Question 96

Figures 1 and 2 are the most recent radiographs of an 18-year-old high school student who sustains an anterior shoulder dislocation playing recreational football. He has a low Beighton score on physical examination. He was closed reduced and underwent a course of physical therapy but had a second dislocation playing recreational basketball. What is the most appropriate course of treatment, with the lowest complication rate, to prevent further dislocation?

Explanation

The patient has recurrent instability and is at a high rate of further dislocations due to his young age. Therefore, therapy and bracing are unlikely to decrease his dislocation rate. The radiographs are normal, and there is no Hill-Sachs lesion or bony Bankart lesion. His instability severity index score is 3, and; therefore, a bony procedure such as Latarjet is not necessary. Furthermore, the rate of complication following a Latarjet procedure, especially nerve
injury and hardware problems, exceeds that of arthroscopic Bankart repair.

Question 97

In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?

Explanation

This answer was based on studies by Hooten, Engh. They found that the overall failure rate was 44 %. Selections 1, 3, 4, and 5 were incorrect. They also reported an increase failure rate if more than 50% of the cup rested on allograft. When there is no satisfactory alternative to a bulk allograft available, close radiographic monitoring was recommended. [JBJS 1994, 76B pg. 419-422.

Question 98

A 17-year-old high school athlete comes in with a 6-month history of right midfoot pain. She has been treated with cast immobilization, crutches, and physical therapy. She still has significant pain with activities and cannot participate in sports. Her radiograph is shown in Figure 93a, and MR images are shown in Figures 93b and 93c. What is the most appropriate 79 next step? A B C

Explanation

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 99

Figures below demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. A further work-up reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MRI with MARS. Revision THA is recommended. The most common complication following revision of a failed metal-on- metal hip arthroplasty is

Explanation

THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cellcounts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

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 2:

Options:

biopsy of the tarsal navicular.
curettage and bone grafting of the tarsal navicular.
CBC count, C-reactive protein level, erythrocyte sedimentation rate, blood cultures, and IV antibiotics.
symptomatic treatment with restriction of weight bearing or application of short leg cast.
medial column lengthening of the foot through the tarsal navicular.

Correct Answer: symptomatic treatment with restriction of weight bearing or application of short leg cast.

Explanation:

DISCUSSION: The child has the classic findings of Kohler’s disease or osteochondrosis of the tarsal navicular. The cause of this condition is not known, but osteonecrosis and mechanical compression have been proposed. Children generally report midfoot pain over the tarsal navicular and limping. Physical findings include tenderness, swelling, and occasionally redness in the region of the tarsal navicular. Radiographs show sclerosis and narrowing of the tarsal navicular. The natural history of the condition is spontaneous resolution and reconstitution of the navicular. Symptomatic treatment with restriction of weight bearing or casting is recommended.
REFERENCES: Karp M: Kohler’s disease of the tarsal scaphoid. J Bone Joint Surg
1937;19:84-96.
Borges JL, Guille JT, Bowen JR: Kohler’s bone disease of the tarsal navicular. J Pediatr Orthop 1995;15:596-598.

Question 3:

Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic

Options:

Posterolateral rotatory drawer test
Lateral pivot-shift test
Moving valgus stress test
Chair test (apprehension or dislocation on terminal extension of the supinated forearm when rising from a seated position)
Pushup sign

Correct Answer: Moving valgus stress test

Explanation:

Question 4:

Options:

The patient
The fiance
The surgeon performing the procedure along with another physician with similar experience and knowledge
The surgeon performing the procedure and a nurse taking care of the patient
Wait for the patient's parents to arrive and have them provide informed consent

Correct Answer: The surgeon performing the procedure along with another physician with similar experience and knowledge

Explanation:

Question 5:

Options:

Revision using a proximal femoral replacement prosthesis
Revision using a diaphyseal engaging femoral prosthesis along with cerclage fixation
Open reduction internal fixation using a locking plate with strut graft
Protected weight bearing with abduction bracing

Correct Answer: Revision using a diaphyseal engaging femoral prosthesis along with cerclage fixation

Explanation:

Question 6:

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Options:

Proximal femur
Proximal humerus
Proximal tibia
Distal femur
Distal humerus

Correct Answer: Proximal tibia

Explanation:

Question 7:

What is the heaviest weight that can be safely applied to the adult cervical spine via Gardner-Wells tong traction?

Options:

40 pounds
50 pounds
75 pounds
100 pounds
Greater than 100 pounds

Correct Answer: Greater than 100 pounds

Explanation:

DISCUSSION: Cotler and associates reported on the use of awake skeletal traction to reduce facet fracture-dislocations in 24 patients. Seventeen patients required more than 50 pounds of traction (the “traditional” limit) to achieve reduction. More than 100 pounds of traction was safely used in one-third of the patients in this study. A cadaver study has supported the safe use of traction with weights in excess of 100 pounds.
REFERENCES: Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. Spine 1993;18:386-390.
Anderson DG, Vacccaro AR, Gavin K: Cervical orthoses and cranioskeletal traction, in Clark CR (ed): The Cervical Spine, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 2005,
pp 110-121.

Question 8:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 9:

The patient undergoes hip arthroscopy and the image of the right hip is shown in Figure 39. Repair of the injured structure would be expected to improve

Options:

hip joint survival.
hip joint lubrication.
hip joint motion. 36
hip joint stability.

Correct Answer: hip joint lubrication.

Explanation:

DISCUSSION
The radiographic studies reveal both acetabular dysplasia and cam-type femoroacetabular impingement. The MR image shows an acetabular labral tear. Structural abnormalities of the hip, including femoroacetabular impingement, have commonly been identified in association with labral tears. Disruption of the ligamentum teres is not associated with impingement conditions in the absence of trauma.
The patient has acetabular dysplasia with a decreased lateral center-edge angle and also has visible cam-type femoroacetabular impingement. The common pathway for joint degeneration in hips with cam-type femoral head anatomy includes the development of cartilage damage in the anterior or superolateral aspects of the acetabular cartilage. Paralabral cysts may be seen more commonly in association with acetabular dysplasia, although the patient’s radiographs did not demonstrate substantial cystic changes. Osteochondral loose bodies and ligamentum teres ruptures can be seen at arthroscopy in a small number of cases.
There are several proposed roles of the acetabular labrum. It can increase the depth of the acetabular socket by as much as 21% to 28%. Roles of the acetabular labrum include joint lubrication, shock absorption, and pressure distribution. Recent studies assessing the effects of loading on joint stability for both normal and dysplastic hips did not demonstrate a substantial role of the labrum in differences in loading. Although joint stability might be improved following surgical repair, acetabular dysplasia is not likely to be resolved with acetabular labral repair alone.
RECOMMENDED READINGS
Tibor LM, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular impingement. Bone Joint Res. 2012 Oct 1;1(10):245-57. doi: 10.1302/2046-3758.110.2000105.PubMed: 23610655.
View Abstract at PubMed
Peelle MW, Della Rocca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clin Orthop Relat Res. 2005 Dec;441:327-33. PubMed PMID: 16331022.
View Abstract at PubMed
Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011 Jul;39 Suppl:72S-8S. doi: 10.1177/0363546511412320.
PubMed PMID: 21709035.
View Abstract at PubMed
James SL, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of
37
femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec;187(6):1412-9. PubMed PMID: 17114529.
View Abstract at PubMed
Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun;2(2):105-17. doi: 10.1007/s12178-009-9052-9. Epub 2009 Apr 7. PubMed PMID: 19468871.
View Abstract at PubMed
Henak CR, Ellis BJ, Harris MD, Anderson AE, Peters CL, Weiss JA. Role of the acetabular labrum in load support across the hip joint. J Biomech. 2011 Aug 11;44(12):2201-6. doi: 10.1016/j.jbiomech.2011.06.011. Epub 2011 Jul 14. PubMed PMID: 21757198.
View Abstract at PubMed

Question 10:

Options:

immediate transmetatarsal amputation.
immediate below-knee amputation.
application of a splint and observation.
fasciotomy and fracture fixation.
fasciotomy without fracture fixation.

Correct Answer: fasciotomy and fracture fixation.

Explanation:

Question 11:

Options:

a custom-molded orthotic and anti-inflammatory drugs.
partial weight-bearing ambulation with crutches.
weight bearing as tolerated with a walking boot.
casting for 6 weeks with bone stimulation.
internal fixation.

Correct Answer: internal fixation.

Explanation:

Question 12:

Second-impact syndrome following a concussion

Options:

poses minimal concern for morbidity or mortality.
is less common in adolescents than in adults.
is related to a disruption of cerebral autoregulation.
refers to a second head injury after the athlete has been medically cleared to return to play.

Correct Answer: is related to a disruption of cerebral autoregulation.

Explanation:

DISCUSSION
According to several consensus statements, no child or adolescent athlete with a concussion should be allowed to return to play on the same day, regardless of severity. Second-impact syndrome refers to a second traumatic head injury that occurs while an athlete is still experiencing symptoms from the first injury. Young athletes are particularly vulnerable to second-impact syndrome. The mechanism by which this syndrome occurs likely is disruption of cerebral autoregulation, which may result in cerebral vascular congestion, diffuse brain swelling, and death.
RESPONSES FOR QUESTIONS 2 THROUGH 6
Curettage and/or grafting
Radiofrequency ablation
Intravenous (IV) antibiotics
Incision, drainage, and IV antibiotics
Neoadjuvant chemotherapy followed by surgical reconstruction
Observation alone
For each clinical vignette seen in the figures, select the best initial treatment from the list above.

Question 13:

Options:

Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the sacral promontory
Transverse incision across the posterior peritoneum and disk space, reflecting the tissues toward the confluence of the iliac veins
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the right iliac vein extending toward the left iliac vein
Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues bilaterally away from the midline

Correct Answer: Vertical midline incision of the posterior peritoneum, reflecting the prevertebral tissues beginning at the margin of the left iliac vein and extending toward the right iliac vein

Explanation:

Question 14:

A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

Options:

early mobilization only.
surgical reconstruction of medial and lateral collateral ligaments.
active motion in a hinged brace from 30° to 120°.
application of hinged external fixator with early mobilization.

Correct Answer: early mobilization only.

Explanation:

Question 15:

Options:

MRI
Electromyography
Open repair of the supraspinatus
Arthrography
Arthroscopic labral repair

Correct Answer: MRI

Explanation:

Question 16:

Options:

CT
Routine ACL rehabilitation
Modified ACL rehabilitation to limit weight bearing
Modified ACL rehabilitation to limit flexion
Revision ACL surgery

Correct Answer: Revision ACL surgery

Explanation:

Question 17:

The best definitive treatment for this patient’s left knee is

Options:

total knee replacement.
knee arthrodesis using an anterior plate and screws.
knee arthrodesis using an external fixator.
observation.

Correct Answer: observation.

Explanation:

Question 18:

Options:

observation.
steroid injection.
curettage and bone grafting.
wide resection with neoadjuvant chemotherapy.
debridement, irrigation, and intravenous antibiotics.

Correct Answer: curettage and bone grafting.

Explanation:

Question 19:

Options:

T-type
Anterior column
Both-column
Anterior column posterior hemitransverse
Posterior column

Correct Answer: Both-column

Explanation:

DISCUSSION: The fracture is a both-column fracture in the Judet/Letournel classification and a C3 in the AO classification. There is extension into the sacroiliac joint along the pelvic brim and comminution along the posterior column above the sciatic notch. Both the anterior and posterior columns are separately broken and displaced. However, the defining feature of a both-column pattern, as seen in this patient, is that all articular fragments are on fracture fragments and no joint surface is left intact to the axial skeleton above. The use of three-dimensional images makes it easier to view the location of the fracture fragments and the amount and direction
of displacement.
REFERENCES: Helfet DL, Beck M, Gautier E, et al: Surgical techniques for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 533-603.
Tile M: Describing the injury: Classification of acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 427-475.
Brandser E, Marsh JL: Acetabular fractures: Easier classification with a systematic approach. Am J Roentgenol 1998;171:1217-1228.

Question 20:

Options:

Continue physical therapy
Latissimus dorsi transfer
Arthroscopic rotator cuff repair
Pectoralis major transfer
Reverse total shoulder arthroplasty

Correct Answer: Pectoralis major transfer

Explanation:

Question 21:

Options:

Amyotrophic lateral sclerosis
Cubital tunnel syndrome
Normal aging
Cervical radiculopathy

Correct Answer: Cervical radiculopathy

Explanation:

Question 22:

- Which of the following advantages does the use of a vascularized fibula graft have over a nonvascularized fibula graft?

Options:

Begins to remodel and hypertrophy more quickly
Provides a better scaffold for osteoconduction
Reduces the risk of early fracture
Reduces technical difficulty
Lowers donor site morbidity

Correct Answer: Begins to remodel and hypertrophy more quickly

Explanation:

Question 23:

Options:

Spring ligament reconstruction
Lateral column lengthening
Medial-displacing calcaneal osteotomy
Medial cuneiform opening-wedge osteotomy

Correct Answer: Medial-displacing calcaneal osteotomy

Explanation:

Question 24:

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Options:

uniformly present, and are positioned posterior to the injured ligament.
uniformly present, with one positioned anterior and the other positioned posterior to the injured ligament.
variably present, and are positioned posterior to the injured ligament.
variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Correct Answer: variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Explanation:

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.
View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed
.
26

Question 25:

Options:

Transforaminal epidural injection
Laminotomy and limited diskectomy
Laminotomy and complete diskectomy
Laminectomy and complete diskectomy
Laminotomy, diskectomy, and arthrodesis

Correct Answer: Laminotomy and limited diskectomy

Explanation:

Question 26:

Options:

protected weight bearing and anti-inflammatory drugs.
core decompression of the femoral head.
vascularized free fibular grafting to the femoral head.
bipolar hemiarthroplasty of the hip.
total hip arthroplasty.

Correct Answer: protected weight bearing and anti-inflammatory drugs.

Explanation:

Question 27:

Options:

immediate proximal right tibial physeal arrest.
immediate distal right femoral physeal arrest.
a shoe lift and follow-up in 2 years.
observation with the expectation that the discrepancy may correct itself and not require surgery.
limb lengthening of the shorter left limb.

Correct Answer: observation with the expectation that the discrepancy may correct itself and not require surgery.

Explanation:

Question 28:

Options:

Glucose tolerance test
CBC count with differential
Urethral swab and culture
HLA-B27
Antiphospholipid antibody

Correct Answer: HLA-B27

Explanation:

Question 29:

Options:

Reverse shoulder arthroplasty
Hemiarthroplasty
Resurfacing of the humeral head
Arthroscopic debridement
Shoulder fusion

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 30:

Which of the following is considered a contraindication to functional bracing for the treatment of humeral shaft fractures?

Options:

A closed midshaft fracture accompanied by a radial nerve palsy prior to an attempt at reduction
A fracture with more than 30 degrees of varus angulation prior to reduction
A distal one third spiral fracture
A fracture caused by a low-velocity hand gun treated initially with wound debridement and antibiotics
An inability to maintain less than 30 degrees of varus and 20 degrees of anterior or posterior angulation after reduction

Correct Answer: An inability to maintain less than 30 degrees of varus and 20 degrees of anterior or posterior angulation after reduction

Explanation:

DISCUSSION: Most closed humeral shaft fractures and fractures caused by a low-velocity hand gun can be managed nonsurgically with closed reduction and application of a coaptation splint followed by a functional brace. Contraindications to use of the functional brace include:
1) massive soft-tissue or bone loss; 2) an unreliable or noncompliant patient; and 3) an inability to maintain acceptable fracture alignment of up to 20 degrees of anterior or posterior angulation, 30 degrees of varus or valgus angulation, and greater than 3 cm of shortening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.
Sarmiento A. Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486.

Question 31:

Options:

Increased pain walking down stairs
Increased pain while using a stationary bike
Increased pain with coughing or sneezing
Increased pain after driving a car for a long distance
Pain that is worst first thing in the morning and gradually improves as the day goes on

Correct Answer: Increased pain while using a stationary bike

Explanation:

Question 32:

Options:

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

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

Explanation:

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

Question 33:

Options:

Resistance to adhesive wear
Resistance to abrasive wear
Resistance to fatigue wear
Resistance to creep

Correct Answer: Resistance to abrasive wear

Explanation:

Question 34:

The Lisfranc ligament connects the base of the

Options:

first metatarsal and the medial cuneiform.
first metatarsal and the base of the second metatarsal.
first metatarsal and the middle cuneiform.
second metatarsal and the medial cuneiform.
second metatarsal and the middle cuneiform.

Correct Answer: second metatarsal and the medial cuneiform.

Explanation:

Question 35:

Options:

Continue with a more aggressive passive range-of-motion exercise program.
Perform an open release.
Revise the humeral component and increase retroversion.
Revise the humeral component alone after osteotomizing more of the humeral neck and seating the component lower.
Remove the glenoid component to decrease tension in the rotator cuff.

Correct Answer: Perform an open release.

Explanation:

Question 36:

Options:

Humeral head arthroplasty
Total shoulder arthroplasty
Reverse shoulder arthroplasty
Arthroscopic debridement/capsular release
Corticosteroid injection and physical therapy

Correct Answer: Total shoulder arthroplasty

Explanation:

The patient has classic "arthritis of dislocation." Procedures done years ago were designed to enhance shoulder stability by limiting external rotation. However, it is now understood that limiting external rotation results in significant alteration of joint mechanics and kinematics, thus leading to the development of osteoarthritis. The average age of patients who develop `arthritis of dislocation` is 45 years old. Despite the young age of these patients, total shoulder arthroplasty offers the most predictable improvement in pain and function. However, the patient must be made aware of the need to protect the arm from excessive loads to protect the glenoid implant. Because there is complete loss of articular cartilage and incongruent joint surfaces, there is no role for arthroscopic debridement and capsular release. Injections offer little, if any, chance of improvement with the prior history of nonresponse. Physical therapy predictably makes patients worse because loading the arthritic joint generates more pain. Reverse shoulder arthroplasty is reserved for elderly patients with severe rotator cuff deficiency. A humeral head arthroplasty, while potentially more ideal than a total shoulder arthroplasty because of glenoid concerns, would likely not offer pain relief in the face of the significant glenoid involvement and incongruity.

Question 37:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 38:

- Which of the following types of sarcoma of the bone is most sensitive to external beam radiation?

Options:

Ewings tumor
Parosteal osteosarcoma
Dedifferentiated chondrosarcoma
Low grade intramedullary chondrosarcoma
High grade intramedullary osteosarcoma

Correct Answer: Ewings tumor

Explanation:

Question 39:

Options:

use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.
oral warfarin with a goal INR between 2.0 and 3.0.
low-dose warfarin for 3 weeks postsurgically beginning 48 hours after surgery.
no prophylaxis because this patient already is partially anticoagulated secondary to her liver disease.

Correct Answer: use of mechanical prophylaxis (eg, pneumatic calf compressors) while in the hospital.

Explanation:

The 2011 AAOS Clinical Practice Guideline,
Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty
, recommends the use of mechanical prophylaxis for patients at increased risk for bleeding (including those with liver disease or hemophilia). This recommendation is the consensus of the workgroup that established these guidelines because there was insufficient evidence to justify a stronger recommendation in this clinical scenario. The other responses use no prophylaxis or pharmacological prophylaxis. Pharmacological prophylaxis is not recommended in patients who are at increased risk for bleeding.

Question 40:

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 41:

Options:

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

Correct Answer: Bristow-Latarjet

Explanation:

Question 42:

Options:

Physical therapy including ultrasound and gentle stretches
Closed manipulation of the shoulder
MRI and possible rotator cuff repair
Open glenohumeral reduction, with possible lesser tuberosity transfer
Shoulder hemiarthroplasty

Correct Answer: Open glenohumeral reduction, with possible lesser tuberosity transfer

Explanation:

Question 43:

Options:

continued physical therapy that focuses on stretching and advances to strengthening in 4 weeks.
a cortisone injection into the subacromial space.
revision rotator cuff repair.
a sling with an abduction pillow for 2 weeks, followed by a stretching program.
open rotator cuff debridement without repair.

Correct Answer: revision rotator cuff repair.

Explanation:

Question 44:

Options:

Incision and drainage of the humerus
Sling immobilization of the left upper extremity
Total body bone scan
A course of oral antibiotics and recheck in 1 week DISCUSSION-The MRI scan shows a large abscess along most of the humerus. Incision and drainage of the abscess is indicated. A bone scan will not add any additional information regarding location of the problem.Immobilization will not address the origin of the problem. Oral antibiotics are not adequate for this abscess.

Correct Answer: Incision and drainage of the humerus

Question 45:

Options:

Correction of the flatfoot deformity
Achilles tendon lengthening followed by orthotic support
Excision of the tarsal coalition
Sinus tarsi debridement
Triple arthrodesis

Correct Answer: Correction of the flatfoot deformity

Explanation:

The patient has a calcaneonavicular tarsal coalition. Symptoms of calcaneonavicular coalitions typically are seen between the ages of 10 and 14 years. The cause of pain has not been clearly established. It has been postulated that the coalition stiffens with maturity and microfractures can result, producing pain. Resection of a calcaneonavicular coalition generally has been associated with a satisfactory result. Soft-tissue interposition, most commonly using the extensor digitorum brevis muscle,
appears to be helpful. A hindfoot arthrodesis (usually triple) would be reserved if coalition resection proves to be unsuccessful. Achilles tendon lengthening and orthotic support, as well as debridement of the sinus tarsi, are not expected to result in a satisfactory outcome. The patient does not have a flatfoot deformity.
(SBQ13PE.64) A 5-year-old boy presents to clinic for evaluation of bilateral foot deformities shown in Figure 1. He is fully active and has no pain. The feet appear normal when he is sitting on the examination table, and there is supple passive motion at the subtalar joint. Passive ankle dorsiflexion is to neutral with knee in extension and 15 degrees with knee in flexion. What is the most appropriate next step?
Review
Topic
Spine MRI
Standing radiographs of the bilateral feet
Gastrocnemius stretching and nightime use of ankle foot orthosis
Gastrocnemius stretching and use of UCBL orthotic when ambulating
Gastrocnemius stretching
The patient is presenting with bilateral flexible pes planovalgus (or flexbile flatfoot). The most appropriate treatment in patients with a tight heel cord and no pain is gastrocnemius stretching
A flexible flatfoot in a child typically resolves spontaneously. Radiographs are typically indicated when there is pain to rule out other conditions. Treatment for patients without pain includes observation and gastrocnemius stretching. If there is pain, soft arch support or a more rigid UCBL can be used, but orthotics do not change the natural history. In patients with continued tightness in the heel cord despite aggressive stretching, gastrocnemius lengthening may be necessary.
Mosca reviews the management of flexible flatfeet in children and adolescents. He reports that there is no compelling evidence that an arch can be created with use of
orthotics. He proposes the following algorithm: patients with asymptomatic flatfeet are observed; symptomatic flatfeet with tight heel cords undergoing stretching until they become asymptomatic; symptomatic flatfeet with tight heel cords that do not respond to stretching (rare cases) are considered for surgery.
Figure A shows a young a patient with bilateral flatfeet when standing. Incorrect Answers:
abnormalities can seen in patients with cavovarus deformity Answer 2: Radiographs are indicated when there is pain to rule out other conditions. Answer 3: Ankle foot orthoses are not used for pes planovalgus Answer 4: UCBL would be indicated if the patient was having pain.
(SBQ13PE.42) Submuscular bridge plating is appropriate treatment for which of the following?
Review Topic
A 2-month-old female with displaced, spiral, mid-diaphyseal femur fracture
A 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with
<2cm shortening
A 7-year old boy with a transverse, non-comminuted mid-diaphyseal femur fracture
A 7-year-old boy with a highly comminuted mid-diaphyseal femur fracture
A 15-year-old girl with a displaced butterfly fragmented mid-diaphyseal femur fracture
Submuscular bridge plating is appropriate for length-unstable femur fractures in skeletally immature patients ages 6 years and older.
Traditional plating of diaphyseal femur fractures in children has been abandoned due to the large incision and significant periosteal stripping involved. Submuscular plating with limited incisions and percutaneously applied fixation is a more biologically friendly way to achieve rigid internal fixation in length-unstable fracture patterns. External fixation is another acceptable option for these fractures. Locked plating, on the other hand, provides an 'internal external fixator,' avoids pin site issues and allows rapid mobilization while providing a biologically favorable environment for healing.
Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. They concluded that there was insufficient evidence regarding submuscular bridge plating to include it in the guideline.
Flynn et al. review the management of pediatric femoral shaft fractures. The note that
the narrow indications for plating of pediatric femoral fractures are open fractures, multiple trauma, head injury or compartment syndrome in patients less than 12 years old. Plating allows rigid fixation with readily available equipment and allows for rapid mobilization.
Hedequist et al. present a Technical Tricks paper in which they detail their surgical technique for submuscular bridge plating. They recommend this fixation strategy for patients between age 6 and skeletal maturity with comminuted diaphyseal femur fractures that are not easily treated by other methods.
Illustration A shows a preoperative and postoperative radiograph of a comminuted pediatric femur fracture treated with submuscular plating.
Incorrect answers:
(SBQ13PE.88) A 12-month-old boy attends a government regulated childcare center. His parents are called after a fall. Non-accidental trauma has been ruled out. On physical examination the right elbow is swollen and tender. He is unwilling to allow you to move the arm. Radiographs of the elbow are shown in Figure A. What is the orthopaedic management of this injury?
Review Topic
Observation only
Elbow sling for 3 to 4 weeks
Rigid elbow immobilisation for 4 to 5 weeks
Admit for 24-48 hours for continuous intracompartmental pressure measurements
Operative fixation with percutaneous pinning PREFERRED RESPONSE 5
This patient presents with a distal humeral physeal separation. The most appropriate treatment would be closed reduction with internal fixation with percutaneous pins.
Displaced distal humerus physeal separation is typically seen in children under the age of 3 and has a high association with child abuse. The diagnosis can be a difficult as radiographs of a distal humeral physeal separation may be subtle. Often, radiographs show no obvious fracture, but can appear like an elbow dislocation since the secondary ossification centers have not yet developed. MRI or arthrogram can be used to aid in diagnosis.
Shrader et al. reviewed pediatric supracondylar fractures and pediatric physeal elbow fractures. They state the key to diagnosis of distal humerus physeal separation is the assessment is the radial head–capitellum relationship. These injuries should be fixed with closed reduction and smooth wire pinning. An elbow arthrogram may be considered intraoperatively for these patients because of the difficulty visualizing the distal humeral anatomy in children so young.
Skaggs et al. reviewed the diagnosis and management of pediatric elbow fractures. He states that child abuse should be suspected in all cases of elbow fracture when the child is less than 3 years of age and/or the injury pattern occur from a shearing mechanism. The displacement of physeal elbow fractures is almost always posteromedial.
Figure A shows AP and lateral radiographs with posteromedial displacement of the radial and ulnar shafts relative to the distal humerus. This is consistent with distal humeral physeal separation.
Incorrect Answers:

Question 46:

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50? Review Topic

Options:

Ulnar nerve
Radial nerve
Posterior interosseous nerve
Superficial radial nerve
Median nerve

Correct Answer: Radial nerve

Explanation:

Question 47:

Options:

Sural nerve injury
Tethering of the flexor hallucis longus by fracture fragments
Medial plantar nerve neuropathy
Weakness of the tibialis posterior
Unrecognized foot compartment syndrome

Correct Answer: Sural nerve injury

Explanation:

Question 48:

Options:

As strain rate increases, both elastic modulus and ultimate strength increase
As strain rate increases, elastic modulus remains unchanged but ultimate strength increases
As strain rate increases, elastic modulus increases but ultimate strength decreases
As strain rate increases, both elastic modulus and ultimate strength decrease
As strain rate increases, elastic modulus increases but ultimate strength remains unchanged

Correct Answer: As strain rate increases, both elastic modulus and ultimate strength increase

Explanation:

Question 49:

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

Options:

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

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

Explanation:

Question 50:

Options:

arthroscopic loose body removal.
arthroscopic debridement and loose body removal for osteochondritis dissecans of the capitellum.
annular ligament reconstruction for posttraumatic posterior subluxation of the radial head.
radial head resection for congenital type II dislocation of the radial head.
lateral collateral ligament reconstruction for posterolateral rotatory instability.

Correct Answer: lateral collateral ligament reconstruction for posterolateral rotatory instability.

Explanation:

Question 51:

Options:

Acute hematogenous osteomyelitis
Kohler’s disease
Tarsal coalition
Tuberculosis
Lisfranc fracture-dislocation

Correct Answer: Tuberculosis

Explanation:

Question 52:

Options:

Conventional osteosarcoma
Myositis ossificans
Osteochondroma
Parosteal osteosarcoma
Dedifferentiated parosteal osteosarcoma

Correct Answer: Dedifferentiated parosteal osteosarcoma

Explanation:

DISCUSSION: Dedifferentiated parosteal osteosarcoma designates high-grade transformation of conventional low-grade parosteal osteosarcoma. Unlike conventional parosteal osteosarcoma, where wide surgical excision alone is considered adequate treatment, patients with dedifferentiated osteosarcoma are treated with neoadjuvant chemotherapy and wide local resection. Recognition of dedifferentiated areas with angiography can localize the area that should be biopsied and thus render an accurate diagnosis. Percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome.
REFERENCES: Sheth DS, Yasko AW, Raymond AK, et al: Conventional and dedifferentiated parosteal osteosarcoma: Diagnosis, treatment, and outcome. Cancer 1996;78:2136-2145.
Lewis VO, Gebhardt MC, Springfield DS: Parosteal osteosarcoma of the posterior aspect of the distal part of the femur: Oncological and functional results following a new resection technique. J Bone Joint Surg Am 2000;82:1083-1088.

Question 53:

Options:

Anterior cord syndrome
Central cord syndrome
Brown-Sequard syndrome
Posterior cord syndrome
Spinal shock

Correct Answer: Anterior cord syndrome

Explanation:

Question 54:

Options:

ACL reconstruction and subsequent proximal tibial osteotomy
ACL reconstruction alone
Distal femoral osteotomy with simultaneous ACL reconstruction
Proximal tibial osteotomy with subsequent ACL reconstruction

Correct Answer: Proximal tibial osteotomy with subsequent ACL reconstruction

Explanation:

Question 55:

What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint? Review Topic

Options:

Concavity compression
Isometric articular ligaments
Increased tensile force of the capsule
Biceps tendon
Deltoid contraction

Correct Answer: Concavity compression

Explanation:

Question 56:

Options:

posterior C1-2 fusion.
anterior C2-3 fusion.
Gardner-Wells traction for 6 weeks, followed by 6 weeks of halo vest immobilization.
halo vest immobilization.
a hard collar.

Correct Answer: halo vest immobilization.

Explanation:

Question 57:

Options:

rigid open reduction and internal fixation of the os acromiale with autologous bone graft.
arthroscopic repair of the rotator cuff and acromioplasty.
arthroscopic excision of the os acromiale.
arthroscopic decompression of the supraglenoid cyst.
open distal clavicle excision (Mumford procedure).

Correct Answer: rigid open reduction and internal fixation of the os acromiale with autologous bone graft.

Explanation:

Question 58:

Options:

Macrophages
Osteoclasts
Osteoblasts
Monocytes
Histiocytes

Correct Answer: Osteoblasts

Explanation:

Question 59:

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

Options:

Polyethylene wear
Instability
Patellar complications
Malalignment

Correct Answer: Instability

Explanation:

Question 60:

Options:

Total elbow arthroplasty
Open reduction and internal fixation
Radial head arthroplasty
Sling and swathe
Bone stimulator

Correct Answer: Total elbow arthroplasty

Explanation:

Question 61:

--The patient is offered a VPHTO. What aspect of his history will determine the most appropriate VPHTO technique?

Options:

Prior arthroscopy
Current smoking history
BMI of 22
Age of 40

Correct Answer: Current smoking history

Explanation:

DISCUSSION FOR QUESTIONS 13 THROUGH 16
This patient has a classic presentation of postmeniscectomy medial compartment arthritis. The appropriate diagnostic study is weight-bearing radiographs to confirm the diagnosis. An MRI scan will reveal medial compartment arthritis but will not provide information about alignment. A CT scan would be appropriate to detect an occult fracture; however, this condition is not suspected in this clinical scenario. An ultrasound can provide information about fluid collection around the knee or a deep vein thrombosis; however, these conditions also are not suspected in this clinical scenario.
Because the patient has a correctable deformity (gaps 3 mm with valgus stress) and his symptoms are localized to the involved compartment, a trial of a medial unloader brace is appropriate both diagnostically and therapeutically. If unloading the medial compartment resolves the patient’s symptoms, he would be an excellent candidate for an osteotomy. An MRI scan may be obtained to evaluate ligamentous integrity or to evaluate degenerative involvement of the lateral and patellofemoral compartment for presurgicalplanning of an osteotomy; however, the integrity of the medial meniscus has no clinical importance in a patient with severe medial compartment arthritis. A repeat corticosteroid injection is not indicated within 1 month of his last injection, and referral to pain management is not appropriate with other options available to help this patient.A VPHTO is the appropriate intervention considering the patient’s young age, high-functional occupation,examination, radiographic findings, and response to medial unloader bracing. A revision knee arthroscopy would be appropriate for a recurrent medial meniscus tear, but not in a patient with severe medial compartment arthritis. The patient’s young age and high functional requirements are contraindications to TKA. The presence of severe arthritis is a contraindication to medial meniscus transplant. The patient is a candidate for a VPHTO. The technical options include a medial opening-wedge or a lateral closing-wedge osteotomy. Both techniques have advantages and disadvantages; however, a medial opening-wedge osteotomy is contraindicated in a smoker because of concern for nonunion. As a result,current smoking history is the only factor listed that would influence the technique used. The history of prior arthroscopy has no relevance in the decision about which type of osteotomy is appropriate. Normal BMI is between 18.5 and 24.9, so this patient’s BMI is considered normal and would not affect the surgical technique (if this patient were obese, a lateral closing-wedge osteotomy would be considered, but this is controversial). His age of 40 is an indication for HTO but does not influence technique.

Question 62:

What is the most likely type of pathology seen in Figure 16?

Options:

Tumor
Infection
Inflammatory
Congenital
Trauma

Correct Answer: Tumor

Explanation:

Question 63:

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 64:

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Options:

Lateral placement of the femoral component
Medial placement of the patellar component
Internal rotation of the tibial component
Varus alignment of the proximal tibia

Correct Answer: Internal rotation of the tibial component

Explanation:

DISCUSSION
Internal malrotation of the femoral or tibial component is associated with lateral tracking of the patella in TKA. Lateral placement of the femoral component and medial placement of the patella component can aid in preventing lateral tracking of the patella. Varus alignment of the proximal tibia has not been associated with patella maltracking.
RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 65:

Options:

Positive froment sign with the ulnar palm flat on a table
Weak thumb abduction with the dorsal palm flat on a table
Inability to flex the thumb with the palm flat on a table
Inability to extend the thumb with the palm flat on a table

Correct Answer: Inability to extend the thumb with the palm flat on a table

Explanation:

Question 66:

Which of the following is considered the most common complication of the impaction grafting technique for femoral revision surgery?

Options:

Loss of fixation
Osteolysis
Bone graft resorption
Early stem subsidence
Infection

Correct Answer: Early stem subsidence

Explanation:

Question 67:

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Options:

Positive finger adduction test and finger escape sign
Positive grip and release test and rapid opening and closing of the hand
Positive jaw jerk reflex
Extensor Babinski response
Loss of proprioception in the great toes

Correct Answer: Positive jaw jerk reflex

Explanation:

Question 68:

Options:

Skin
Lung
Brain
Heart
Kidney

Correct Answer: Kidney

Explanation:

Question 69:

Options:

Subtalar fusion
Neuroplasty of the superficial peroneal nerve
Neuroplasty of the sural nerve and implant removal
Excision and burial of the sural nerve in deep muscle or vein
Electromyography/nerve conduction velocity studies to evaluate local nerve entrapment versus radiculopathy

Correct Answer: Excision and burial of the sural nerve in deep muscle or vein

Explanation:

Question 70:

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

Options:

Prior shoulder joint infection
Pseudoparalysis
Prior partial acromioplasty
Absent glenohumeral joint space narrowing
Axillary neuropathy

Correct Answer: Axillary neuropathy

Explanation:

Question 71:

Options:

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

Correct Answer: hemivertebra excision.

Explanation:

Question 72:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

Explanation:

Question 73:

Options:

Metastatic carcinoma (thyroid)
Multiple myeloma
Lymphoma
Synovial cell sarcoma
Osteomyelitis

Correct Answer: Multiple myeloma

Explanation:

Question 74:

Options:

Revision total knee arthroplasty with extensor mechanism allograft
Revision total knee arthroplasty with liner change and primary quadriceps repair
Resection knee arthroplasty and arthrodesis with antegrade nail
Two-stage revision total knee arthroplasty with extensor mechanism allograft

Correct Answer: Revision total knee arthroplasty with extensor mechanism allograft

Explanation:

Question 75:

Atraumatic suprascapular nerve compression usually occurs at which of the following anatomic locations if it develops atraumatically? Review Topic

Options:

Scalenus anterior
Suprascapular and spinoglenoid notches
Cervical rib
Conjoined tendon
Subcoracoid

Correct Answer: Suprascapular and spinoglenoid notches

Explanation:

Question 76:

Options:

Brodie’s abscess
Hyperparathyroidism
Stress fracture
Enchondroma
Osteoid osteoma

Correct Answer: Osteoid osteoma

Explanation:

DISCUSSION: Osteoid osteoma is a round or oval, well-circumscribed lesion with a
radiolucent nidus. A small area of calcification may be present within the center of the nidus. The radiolucent nidus is surrounded by a thick rim of sclerotic bone. These diagnostic
features are frequently better seen on CT. An increase in cyclooxygenase activity has been demonstrated within osteoid osteomas, which may explain why aspirin and other nonsteroidal anti-inflammatory drugs classically relieve the pain associated with these lesions.
REFERENCES: Kneisl JS, Simon MA: Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-185.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 121-130.

Question 77:

A 9-year-old girl has pain over the fifth toe that is aggravated by shoe wear. Clinical photographs are shown in Figures 28a and 28b. Treatment of this deformity should consist of

Options:

extensor digitorum longus tenotomy.
extensor digitorum longus tenotomy with dorsal fifth metatarsophalangeal (MTP) joint capsulotomy.
dorsal V-Y plasty for skin contracture, combined with extensor digitorum longus tenotomy and dorsal fifth MTP capsulotomy.
a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).
plantar proximal phalangeal resection.

Correct Answer: a dorsal and plantar racquet-shaped incision around the fifth toe, combined with extensor digitorum longus tenotomy and circumferential fifth MTP joint release (Butler procedure).

Explanation:

DISCUSSION: The major obstacle to overcome in the surgical treatment of this cock-up deformity is recurrence. Dorsal releases can be performed; however, chronic dislocation of the fifth MTP joint usually needs to be addressed with plantar release as well. Chronic dorsal soft-tissue contractures may be overcome with translation of the toe into a plantar-based incision, as described originally by Cockin and accredited to Butler. This is the treatment of choice. Resection of the proximal phalanx improves symptoms but induces a secondary deformity; this procedure is usually reserved for skeletally mature individuals.
REFERENCES: Black GB, Grogan DP, Bobechko WP: Butler arthroplasty for correction of adducted fifth toe: A retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441.
Paton RW: V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249.
Coughlin MJ, Mann RA: Lesser toe deformities, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 5. St Louis, MO, Mosby, 1986, pp 132-157.

Question 78:

The most appropriate next surgical procedure is

Options:

synovectomy.
debridement, synovectomy, and placement of a thicker polyethylene liner.
resection arthroplasty and placement of a cement antibiotic spacer.
conversion to total knee arthroplasty (TKA).

Correct Answer: conversion to total knee arthroplasty (TKA).

Explanation:

Question 79:

Which of the following abnormalities has been observed in a higher than expected frequency in patients with metal-on-metal hip bearings?

Options:

Renal cell carcinoma
Leukocyte chromosomal aberrations
Carcinomas of the gastrointestinal tract
Soft-tissue sarcomas
Thyroid carcinoma

Correct Answer: Leukocyte chromosomal aberrations

Explanation:

Question 80:

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Options:

Ulnar
Median
Superficial radial
Lateral antebrachial cutaneous
Medial antebrachial cutaneous

Correct Answer: Superficial radial

Explanation:

Pin track infections and sensory injuries are among the most common complications of external fixation for distal radius fractures. The proximal pins of most distal radius external fixators are placed in the “bare area” of the distal radius, about four finger-breadths above the radial styloid. This corresponds to the area where the dorsal sensory branch of the radial nerve penetrates the fascia dorsal to the brachioradialis tendon to become a subcutaneous structure. Injury to the superficial radial nerve may produce painful dysesthesias and neuromas.
(SBQ12TR.106) A 67-year-old female sustains the injury shown in Figure A after a trip and fall. When discussing the outcomes of surgery with the patient, which of the following statements is true?
Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 81:

Options:

remain 2 cm at maturity.
decrease slowly until the limb lengths equalize.
increase at a constant rate of 2 cm per year.
increase markedly because of complete failure of tibial growth.
increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Correct Answer: increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Explanation:

DISCUSSION: Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a “multiplier method,” as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements.
REFERENCES: Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting
limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446.
Moseley CF: A straight-line graph for leg length discrepancies. Clin Orthop 1978;136:33-40.

Question 82:

The knee arthroplasty type associated with the highest 5-year revision rate is

Options:

medial unicondylar arthroplasty.
mobile-bearing total knee arthroplasty (TKA).
patellofemoral arthroplasty.
lateral unicondylar knee arthroplasty (UKA).

Correct Answer: patellofemoral arthroplasty.

Explanation:

DISCUSSION
Revision rates for UKA at 10 years are lower than 5% at specialty centers. However, the 10-year revision rate associated with UKA in registries such as the National Joint Registry for England and Wales is 2 to 3 times that of TKA. Among partial knee replacements, patellofemoral arthroplasty is associated with the highest revision rate at every time interval.
CLINICAL SITUATION QUESTIONS 167 THROUGH 169
Figures 167a and 167b are the radiographs of a middle-age man. He is a noncompliant patient who has severe insulin-dependent diabetes and a below-knee amputation on the right side. He is usually in a wheelchair, does not use a prosthesis, transfers using a walker, and resides in an institution. He had an infection in the left leg years ago, which was treated successfully with intravenous antibiotics (the details are unknown). His left knee is mildly painful, swollen but not warm, has limited range of motion (40-140 degrees), and is grossly unstable.

Question 83:

Options:

union.
symptomatic pulmonary complications.
infection.
transfusion requirements.
required secondary procedures.

Correct Answer: union.

Explanation:

Question 84:

Options:

Type I acromion
Type III acromion
Meso os acromiale
Meta os acromiale
Pre os acromiale

Correct Answer: Meso os acromiale

Explanation:

DISCUSSION: The MRI scans reveal a meso os acromiale with edema at the site in a skeletally mature patient.
REFERENCES: Sher JS: Anatomy, biomechanics, and pathophysiology of rotator cuff disease, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, p 23.
Sammarco VJ: Os acromiale: Frequency, anatomy, and clinical implications. J Bone Joint Surg Am 2000;82:394-400.

Question 85:

Options:

Tibial polyethylene exchange
Revision of the femoral and tibial components and conversion to a posterior stabilized insert
Revision of femoral and tibial components to a constrained rotating hinge prosthesis
Isolated femoral component revision and upsizing the femoral implant with a new PCL-retaining polyethylene insert

Correct Answer: Revision of the femoral and tibial components and conversion to a posterior stabilized insert

Explanation:

DISCUSSION
Video 99 for reference
This patient has valgus knee alignment, and, after undergoing appropriate bone resections and soft-tissue balancing, has demonstrated a tight PCL on trial reduction as evidenced by lift-off of the trial insert as described by Scott and Chmell. The appropriate maneuver is PCL recession with partial release of tight (usually anterolateral) PCL fibers. However, for this patient, instability resulted in increased anterior translation. At this stage, the options are to convert to either a deeper-dish insert with increased sagittal conformity or a posterior stabilized insert. The only appropriate choice among the responses is use of an insert with increased sagittal conformity to prevent excessive anterior translation. Increasing the polyethylene could improve stability in flexion, but, considering there is good stability in extension, this likely would lead to an inability to achieve full extension. The patient’s valgus deformity, flexion contracture, correction with release of the iliotibial band, and posterolateral capsule predispose him to increased risk for peroneal nerve palsy. His symptoms at follow-up suggest knee flexion
instability with pain, swelling, and difficulty descending stairs. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant depending on the condition of the ligaments likely is needed to address his symptoms. The difference in extension vs flexion stability makes polyethylene exchange a poor option. There is no reason to believe a constrained rotating hinge design is necessary. Repeat use of a PCL-retaining insert is not recommended.

Question 86:

Options:

Ehlers-Danlos syndrome
Traumatic anterior instability
Humeral head osteonecrosis
Internal impingement
Partial-thickness supraspinatus tear

Correct Answer: Internal impingement

Explanation:

Question 87:

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

Options:

Staphylococcus aureus
Brucella melitensis
Haemophilus influenzae
Kingella kingae
Streptococcus pneumonia

Correct Answer: Staphylococcus aureus

Explanation:

Question 88:

Options:

Distal femoral osteotomy
Proximal tibial osteotomy
Medial unicompartmental knee arthroplasty
Total knee arthroplasty (TKA)

Correct Answer: Proximal tibial osteotomy

Explanation:

Question 89:

Options:

Adhesive capsulitis
Sling immobilization
Thermal chondrolysis
Subacromial impingement
Axillary nerve injury

Correct Answer: Axillary nerve injury

Explanation:

Question 90:

Options:

Intracompartmental pressure monitoring
Immobilization of the knee in a flexed position
Fasciotomy of the thigh
MRI scan of the femur This athlete has experienced a quadriceps contusion with hemorrhage and swelling into the anterior compartment of the thigh. Initial treatment for these injuries is immobilization of the knee in flexion to reduce the amount of bleeding into the anterior compartment. Rest and anti-inflammatory medication may be used in the rehabilitation process but should not take the place of immobilization in flexion. The compartments are soft and therefore, there is no indication for fasciotomy. MRI scan of the femur may demonstrate hematoma in the anterior thigh compartment but is not required to make the diagnosis.

Correct Answer: Immobilization of the knee in a flexed position

Explanation:

Question 91:

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

Options:

Hepatic
Renal
Respiratory
Gastrointestinal

Correct Answer: Respiratory

Explanation:

Question 92:

Options:

Wide resection alone
Chemotherapy and radiation therapy
Chemotherapy and wide resection
Above-knee amputation
Through-knee amputation

Correct Answer: Chemotherapy and wide resection

Explanation:

Question 93:

Options:

Vigorous physical therapy
Manipulation under anesthesia
Arthroscopic capsular release
Hemiarthroplasty
Arthroscopic capsular plication

Correct Answer: Hemiarthroplasty

Explanation:

DISCUSSION: Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.
REFERENCES: Gerber C, Lambert SM: Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1996;78:376-382.
Spencer EE Jr, Brems JJ: A simple technique for management of locked posterior shoulder dislocations: Report of two cases. J Shoulder Elbow Surg 2005;14:650-652.
Sperling JW, Pring M, Antuna SA, et al: Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg 2004;13:522-527.
Hawkins RJ, Neer CS II, Pianta RM, et al: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
McLaughlin HL: Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34:584-590.

Question 94:

Which of the following tendons is the primary antagonist of the posterior tibialis tendon?

Options:

Anterior tibialis
Achilles
Peroneus brevis
Peroneus longus
Flexor digitorum longus

Correct Answer: Peroneus brevis

Explanation:

Question 95:

Options:

Calcified transverse scapular ligament
Parsonage-Turner syndrome
Spinoglenoid notch cyst
Quadrilateral space syndrome

Correct Answer: Spinoglenoid notch cyst

Explanation:

Question 96:

Options:

Arthroscopic Bankart procedure
Physical therapy
SAWA shoulder brace
Latarjet procedure

Correct Answer: Physical therapy

Explanation:

Question 97:

- In revision hip arthroplasty, which of the following is the 5- to 10-year reported graft failure rate when using structural acetabular allografts in the repair of acetabular deficiencies?

Options:

20% with cemented and uncemented sockets
40% with cemented and uncemented sockets
60% with cemented sockets
90% with cemented and uncemented sockets
90% with cemented sockets

Correct Answer: 40% with cemented and uncemented sockets

Explanation:

Question 98:

Options:

Repeat treatment with a nonweight-bearing cast
Percutaneous lag screw fixation
Addition of a bone stimulator
Injection of bone morphogenic protein

Correct Answer: Percutaneous lag screw fixation

Explanation:

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216.
View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 99:

Options:

infection. B. instability. C. loosening.
periprosthetic fracture.

Correct Answer: periprosthetic fracture.

Explanation:

Question 100:

Options:

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

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

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

Orthopedic MCQ Exam: Arthroplasty, Elbow, Foot, Fracture, Hip | Part 263

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 263

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index