Orthopedic Surgery Board Review MCQs: Trauma, Upper Extremity & Foot | Part 3

A 20-year-old collegiate football player who sustained blunt head trauma during the first half of a game is emotional and confused. During the halftime intermission, his affect, memory, and disorientation are totally resolved and have returned to preinjury baseline. The only residual finding is a very mild headache. He wants to play the second half. What is the most appropriate course of action?

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

A 24-year-old collegiate pitcher has had increasing pain over his medial elbow for 3 months. He has point tenderness over his medial epicondyle and reproduction of his symptoms with a valgus stress test. What phase of the throwing cycle most likely will reproduce his symptoms? Review Topic

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

Percutaneous placement of a lateral proximal tibial locking plate that extends down to the distal third of the leg is associated with postoperative decreased sensation of which of the following distributions?

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

A 22-year-old woman underwent closed reduction and percutaneous pinning with casting of a displaced extra-articular distal radius fracture. The surgery was completed with a supraclavicular regional anesthesia. After the block wears off, she reports new onset dense numbness in the palmar aspect of the thumb, index, and middle fingers as well as severe pain in the hand. What is the next step in management?

A 12-year-old girl has the painful foot deformity seen in Figure 79. You advise her that she has juvenile bunions. How do they differ from adult bunions?

A 20-year-old man is brought to the emergency department after a high-speed motor vehicle accident. His initial blood pressure is 70/40 mm Hg. He is currently receiving intravenous fluids as well as blood. His Focused Assessment with Sonography for Trauma examination did not show any free fluid in his abdomen and his chest radiograph is unremarkable. An AP pelvis radiograph is shown in Figure 15. What is the next most appropriate step in the management of his pelvic injury? Review Topic

A 58-year-old man has had increasing midback pain for 8 weeks. Radiographs reveal mild osteopenia and mild disk degeneration but no fractures or lesions. An MRI of the spine reveals diskitis with a small-intensity signal within the spinal canal that is consistent with an epidural abscess at T11-12. The patient is neurologically intact but in significant pain. CT-guided biopsy of the disk space is positive for methicillin-sensitive Staphylococcus aureus. What is the most appropriate treatment?

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?

intermittent PTH injections increase bone mass, 2) continous infusion lead to bone resorption, and 3) dosing should not continue past 2 yrs. Thus, intermittent parathyroid hormone is anabolic to bone and is used as a treatment of osteoporosis (forteo).

During the cocking and acceleration phases of the overhand throw (pitch), there are several static and dynamic restraints to provide medial elbow support and prevent valgus instability. The dynamic structures found to be most important during these phases of the overhand throw are the flexor digitorum Review Topic

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

Which of the following statements regarding the use of thermal shrinkage during arthroscopic shoulder surgery is most accurate? Review Topic

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by

A 12-year-old boy sustained a grade III open tibial fracture 1 week ago and underwent multiple debridements and fracture fixation. He now has a soft-tissue defect that measures 6 cm × 6 cm, with an area of exposed bone and muscle on the distal medial leg that is a few centimeters proximal to the ankle. Management of the soft-tissue defect should now consist of

A 20-year-old college baseball pitcher reports the insidious onset of medial elbow pain. Examination reveals medial elbow tenderness, a normal neurologic examination, and no obvious valgus laxity. Plain radiographs are normal. MRI scans are shown in Figures 39a and 39b. Management should consist of

Steroids are thought to prevent neurologic deterioration after traumatic spinal cord injury by which of the following mechanisms? Review Topic

A 65-year-old woman fell onto her outstretched right arm and immediately had pain. She has a history of osteoporosis. Examination of the right arm reveals lateral arm swelling, ecchymosis, and she is unable to move the elbow due to pain. Her neurovascular status is intact. Radiographs are shown in Figures 14a and 14b. Appropriate treatment should include

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

A 65-year-old man has had “catching” in front of his knee since he had a total knee arthroplasty 9 months ago. Examination reveals a palpable and audible snap in the anterior aspect of the knee at about 40 degrees of flexion as the knee is being actively extended. A radiograph of the prosthetic knee will most likely show

A well-developed college football player reports swelling and a heaviness in the arm after lifting weights. Examination reveals that distal pulses are normal and equal in both arms. A venogram is shown in Figure 13. What is the most likely cause of this condition?

In infantile idiopathic scoliosis, which of the following factors suggests progression? Review Topic

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

Figures 38a and 38b

Figures 16a and 16b are the radiograph and MR image of a 15-year-old dance athlete with 2 weeks of pain at the left distal femur, a limp, and an inability to dance. Knee motion is 0 to 135 degrees with minimal pain and there is no effusion. Her temperature is 37.0°C, WBC is 12000 /µL (rr, 4500-11000 /µL), CRP is 0.8 mg/L (rr, 0.08-3.1 mg/L), and ESR is 21 mm/h (rr, 0-20 mm/h).

Figures 14a and 14b show the clinical photographs of a patient who was stranded in a subzero region for several days. The photographs were taken the morning after arrival in the hospital. The patient is otherwise healthy and fit, and takes no medication. He has no clinical signs of sepsis. He reports burning pain and tingling in both feet. What is the best treatment?

A 20-year-old woman with a history of subtotal meniscectomy has a painful knee. What associated condition is a contraindication to proceeding with a meniscal allograft?

The use of elevated rim acetabular liners and long femoral necks may result in

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?

A 32-year-old patient reports progressively increasing pain and stiffness after undergoing arthroscopic shoulder stabilization 1 year ago. The stabilization procedure was a Bankart repair with anchor fixation and supplemented with the heat probe. Radiographs are shown in Figures 45a and 45b. What is the most likely diagnosis?

A 78-year-old man with ankylosing spondylitis sustains a minor fall. Shortly afterward he experiences sudden worsening of his chronic back pain and is brought to the emergency department by his caregiver. Radiographs and a CT scan of the spine do not show a clear fracture. What is the most appropriate next step?

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

Six months later, the patient’s fracture has healed and a CT scan to further evaluate the physis is performed (Video 85). Based on these findings, how should you advise the family?

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

Figure below shows the radiograph obtained from a 76-year-old woman who has sharp pain in her groin, thigh, and buttocks that worsens with activity. She has been dealing with this pain for more than a year but is otherwise healthy. Recently, she has begun to notice night pain. The pain no longer responds to NSAIDs. She would like to be able to dance at her daughter's wedding in 4 months and wonders how best to proceed. What is the best next step?

A 10-year-old boy who plays baseball reports acute pain after throwing a softball from the outfield to second base. A radiograph is shown in Figure 26. Management should consist of

A 20-year-old male military recruit reports a 5-day history of progressive deep groin pain that is made worse with weight-bearing activities and running. His initial coronal T2-weighted MRI scan is shown in Figure 75. His initial treatment should consist of which of the following? Review Topic

Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?

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

A 35-year-old man is brought to the emergency department following a motorcycle accident. He is breathing spontaneously and has a systolic blood pressure of 80 mm Hg, a pulse rate of 120/min, and a temperature of 98.6° F (37° C). Examination suggests an unstable pelvic fracture; AP radiographs confirm an open book injury with vertical displacement on the left side. Ultrasound evaluation of the abdomen is negative. Despite administration of 4 L of normal saline solution, he still has a systolic pressure of 90 mm Hg and a pulse rate of 110. Urine output has been about 20 mL since arrival 35 minutes ago. What is the next best course of action?

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. What is the most appropriate next step in treatment?

After sustaining a muscle contusion injury, prolonged immobilization leads to Review Topic

In Charcot-Marie-Tooth disease a progressive deformity develops in the foot. Which functional muscles predominate in deformity formation?

A 56-year-old man with poorly controlled diabetes mellitus has rapidly developing and advancing erythema, warmth and swelling with bullae formation on the left lower extremity. These findings appear to be advancing proximally several millimeters per hour. Culture results are most likely to reveal

What is the primary role of superficial zone protein (SZP) in articular cartilage?

Which of the following prophylactic regimens for the prevention of deep venous thrombosis after knee arthroplasty has received a grade 1A recommendation in favor of its use from the American College of Chest Physicians (ACCP) in the 2004 guidelines?

Figure 36 shows the radiograph of a patient who has hip pain and is unable to ambulate. What is the most appropriate management for this patient?

A 34-year-old woman who is a professional skier (Figure 42)

Figures 54a and 54b are the radiographs of a 23-year-old man who fell from a height and sustained an isolated injury to his right leg. Which of the following is a useful surgical technique to optimize alignment during intramedullary nailing?

Figure 46 shows the AP radiograph of an active 80-year-old patient with an acetabular fracture. The fracture was initially managed nonsurgically; however, the patient is now scheduled to undergo total hip arthroplasty. What is the treatment of choice for the contained acetabular bone defect?

A 20-year-old man has a large soft-tissue mass behind his knee. MRI scans are shown in Figures 10a through 10c. Figure 10d shows a clinical photograph of his chest. The patient’s condition is most likely a result of a defect in what gene?

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management?

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

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

A 16-year-old boy has abdominal and back pain after being involved in a high-velocity head-on motor vehicle accident. He was restrained in the rear of the automobile by a lap belt only. A radiograph and CT scan are shown in Figure 47. The patient has no other injuries. Optimal management should include

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?

Factors contributing to an increased risk of hip fracture include reduced bone mineral density of the femoral neck, cognitive status of the individual, and

Which of the following best characterizes the injury shown in Figure 53? Review Topic

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?

The cavovarus deformity associated with Charcot-Marie-Tooth (CMT) disease is caused by which of the following?

What is the typical axial plane transverse angulation of the thoracic pedicles?

A 46-year-old man reports occasional squeaking of his hip 2 years after undergoing an uneventful total hip arthroplasty. History reveals no pain, physical examination cannot reproduce audible squeaking, and radiographs show appropriate implant position. What is the most appropriate management?

An active 47-year-old woman with rheumatoid arthritis reports forefoot pain and deformity and has difficulty with shoe wear. Examination reveals hallux valgus and claw toes. A radiograph is shown in Figure 10. What is the most appropriate surgical treatment?

A 47-year-old woman with no history of trauma has had a painful, stiff shoulder for the past 3 months. Treatment consisting of subacromial injection and nonsteroidal anti-inflammatory drugs has been ineffective. Her active range of motion is painful and is limited to 90 degrees of abduction, 60 degrees of elevation, 30 degrees of external rotation, and internal rotation to the posterior superior iliac spine. Plain radiographs of the cervical spine and shoulder are normal. Management at this time should consist of

In rotator cuff tear arthropathy with pseudoparalysis, forward elevation of the humerus away from the body is prohibited because of

Which of the following methods most reliably detects mechanical loosening of the hip?

A 51-year-old woman with no preoperative neurologic deficit is undergoing elective anterior cervical diskectomy and fusion (ACDF) with plating and fusion for a C5-6 disk herniation with right-sided neck pain. Thirty minutes into the surgery the neurophysiologic monitoring shows a rapid drop and then loss of amplitude in the right cortical somatosensory-evoked potential waveform. All other waveforms remained normal and unchanged, including right-sided cervical (subcortical) and peripheral (Erb’s point), and those from the left-sided upper extremity and both lower extremities. What is the most likely cause of the change? Review Topic

A 50-year-old man with metastatic renal cell carcinoma has right hip pain. A radiograph and CT scan are shown in Figures 48a and 48b. The first step in management should consist of

A 20-year-old college athlete is seen for follow-up after sustaining an injury at football practice 2 days ago. He reports that he tackled a player and felt neck pain and numbness in both arms. The numbness resolved within seconds, but his neck remains painful and stiff. He denies any history of neck pain or injury. Examination reveals limited neck motion. The neurologic examination and radiographs are normal. MRI scans of the cervical spine are shown in Figure 34. During counseling, the patient, his family, and his coach should be informed that he has an acute cervical disk herniation and cannot play

Which of the following is most commonly associated with an open clavicular fracture?

The MRI scan of the shoulder shown in Figure 2 was performed with the arm in abduction and external rotation. The image reveals what condition?

A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?

A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of

The standard Bankart lesion involves detachment of the labrum along with which of the following capsular ligaments? Review Topic

A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Which of the following best describes the radiographic findings associated with this pelvic injury pattern using the Young-Burgess Classification system?

A 72-year-old woman with rheumatoid arthritis who underwent primary total knee arthroplasty 2 years ago has had diffuse knee pain that developed shortly after the surgery. The patient has difficulty with stair descent and arising from chairs. Evaluation for infection is negative. AP and lateral radiographs are shown in Figure 26. Management should now consist of

Which of the following statements best describes the instantaneous axis of rotation (IAR) for the functional spinal unit? Review Topic

Which of the following ligaments are the primary static restraints to inferior translation of the arm when the shoulder is in 0 degrees of abduction and neutral rotation?

When performing knee arthroplasty, which of the following procedures provides the most consistent fixation for the tibial component?

Figure 23 shows the postoperative radiograph of a patient who underwent an anterior cruciate ligament (ACL) reconstruction (with bone-patella tendon-bone autograft) that failed. He initially had loss of flexion postoperatively. What is the most likely cause of this failure?

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient? Review Topic

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

• A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

A healthy, active 72-year-old man trips and falls, landing on his left hip 10 weeks after an uncomplicated left primary uncemented total hip replacement. A radiograph taken 6 weeks after surgery and before the fall is shown in Figure 1. A radiograph taken after the fall is shown in Figure 2. He is unable to bear weight and is brought to the emergency department. Examination reveals a slightly shortened left lower extremity and some mild ecchymosis just distal to the left greater trochanteric region, but his skin is intact, without abrasions or lacerations. What is the most appropriate treatment?

Figures 30a through 30c show the CT scans and standing lateral radiograph of a 30-year-old woman who was injured in a fall while snowboarding. She is neurologically intact in the lower extremities and has normal rectal tone and sensation. She has tenderness at the thoracolumbar junction but no ecchymosis or palpable defect. Mobilization in a thoracolumbosacral orthosis for this patient has been proven to result in which of the following clinical outcomes? Review Topic

Which of the following findings is the best radiographic indicator of segmental instability at L4-L5?

-What is the most likely diagnosis for her condition?

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Figures 50a and 50b show the standing clinical photographs of a 12-year-old boy who has had increasing pain in the left foot for the past 9 months. He reports that the pain is activity related, aching in nature, and localized to the medial aspect of the midfoot and hindfoot. History reveals that he sustained a puncture wound located superior and posterior to the medial malleolus from a plate glass window 18 months ago. Examination reveals no restriction of ankle or subtalar motion, normal neurovascular status, no masses, and a well-healed 1.5-cm laceration posterior to the superior aspect of the medial malleolus. Inversion strength of the foot is decreased to grade 3/5. Radiographs of the foot show no bony abnormalities. Treatment should consist of

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

A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of

The anterolateral (Watson-Jones) approach to the hip exploits the intermuscular interval between the

A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in

A 17-year-old boy has had a mass in his right thigh for the past 6 months. He denies any history of trauma. Examination reveals that the mass is painless and firm. A radiograph and axial MRI scan are shown in Figures 49a and 49b. What is the most likely diagnosis?

During head-on motor vehicle collisions occurring at highway speeds, airbag-protected individuals have a decreased rate (as compared to non-airbag protected individuals) of all of the following EXCEPT:

A 30-year-old man reports pain and weakness in his right arm. Examination reveals grade 4 strength in wrist flexion and elbow extension, decreased sensation over the middle finger, and decreased triceps reflex. These symptoms are most compatible with impingement on what spinal nerve root?