OITE & AAOS Orthopedic Board Review MCQs | Part 49

About This Board Review Set

This is Part 49 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 49

This module focuses heavily on: Ankle, Dislocation, Fracture, Scoliosis, Shoulder.

Sample Questions from This Set

Sample Question 1: A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?...

Sample Question 2: Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with...

Sample Question 3: A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation...

Sample Question 4: When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?...

Sample Question 5: A 45-year-old woman has had radiating pain in the medial ankle for the past 3 months. Examination reveals a small mass in the retromedial ankle region and a positive Tinel’s sign. An intraoperative photograph and a hematoxylin/eosin biopsy ...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Explanation

DISCUSSION: The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe.
REFERENCES: Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.
Tewes DP, Fischer DA, Fritts HM, et al: MRI findings of acute turf toe: A case report and review of anatomy. Clin Orthop 1994;304:200-203.

Question 2

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Explanation

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased rates of infection. Neither fixation method would increase the time to healing.

Question 3

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function?

Explanation

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.

J Arthroplasty 2003;18:792-798.

Question 4

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Explanation

DISCUSSION: As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
O’Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.
McCord DH, Cunningham BW, Shono Y, et al: Biomechanical analysis of lumbosacral fixation. Spine 1992;17:S235-S243.

Question 5

A 45-year-old woman has had radiating pain in the medial ankle for the past 3 months. Examination reveals a small mass in the retromedial ankle region and a positive Tinel’s sign. An intraoperative photograph and a hematoxylin/eosin biopsy specimen are shown in Figures 24a and 24b. Treatment should consist of

Explanation

DISCUSSION: Neurilemoma is a benign tumor of nerve sheath origin, and peak incidence is in the third through sixth decades. The tumor is well encapsulated on the surface of a peripheral nerve. MRI findings may be significant for a “string sign.” A positive Tinel’s sign in the distribution of the nerve affected may be present. Grossly, the lesion is well encapsulated in a nerve sheath. Microscopically, there are structures referred to as Antoni A (a pattern of spindle cells arranged in intersecting bundles) and Antoni B (areas with less cellularity with loosely arranged cells). These lesions are benign, and treatment should consist of marginal excision. Nerve function may be preserved by careful dissection, excising the lesion parallel to the nerve fascicles so the lesion may be extruded. Recurrence is rare.
REFERENCES: Walling AK: Soft tissue and bone tumors, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1007-1032.
Simon M, Springfield D: Surgery for the Bone and Soft-Tissue Tumors. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, pp 530-531.

Question 6

A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

Explanation

Absolute stability with direct healing by callus formation
Relative stability with indirect healing by callus formation
Absolute stability with direct healing by internal remodeling
Relative stability with indirect healing by internal remodeling
Absolute stability with endochondral bone formation
Definitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole

Question 7

A 45-year-old man sustained the injury shown in Figures 18a through 18c. He is neurologically intact. Which of the following is the most appropriate treatment? Review Topic

Explanation

The CT scan reveals a thoracolumbar compression fracture with some height loss and minimal kyphosis. The T2-weighted MRI scan shows discontinuity of the posterior interspinous and supraspinous ligaments and ligamentum flavum. The STIR images demonstrate a discrete region of hyperintensity in the posterior region at the level of the injury. Thoracolumbar fractures with posterior ligamentous injury are potentially unstable. A lumbar corset brace would provide insufficient immobilization of this injury. A laminectomy alone is not indicated and in fact would further destabilize the injury. Whereas an anterior corpectomy could be performed, it should be accompanied by rigid instrumentation. If nonsurgical management with a TLSO and immediate mobilization is elected, serial radiographs should be obtained in the early post-injury period. Posterior fusion with instrumentation allows mobilization without fear of secondary displacement.

Question 8

A 25-year-old patient presents with a posterior wall/ posterior column acetabular fracture. She is scheduled for open reduction internal fixation through a posterior approach. What position of the leg exerts the least amount of intraneural pressure on the sciatic nerve?

Explanation

DISCUSSION: In the cited study, researchers measured tissue fluid pressure within the sciatic nerve in cadaveric specimens using a pressure transducer. The hip and knee were taken through a combination of ranges and found that the clinically relevant increase in pressure happened with the hip flexed at 90 degrees and the knee fully extended. They concluded that increased intraneural pressure was related to excursion of the nerve as linear distance between the greater sciatic notch and the distal leg increase. Hence, according to the question stem, to avoid traction injury, the reverse position should be implemented (hip extension and knee flexion).

Question 9

-Assuming that the lesion can be covered appropriately and there is no drainage from the lesion, when should the patient be allowed to safely return to wrestling?

Explanation

DISCUSSION FOR QUESTIONS 48 AND 49
This patient has cellulitis, which is typically caused by group A Streptococcus or Staphylococcus. The patient’s lack of improvement with first-line antibiotics is concerning for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA cellulitis is becoming more prevalent in young athletes,and a high index of suspicion is required to provide appropriate intervention during this
aggressive disease process. The diagnosis is typically made clinically without the use of cultures. Oral trimethoprimsulfamethoxazole (a sulfonamide-class drug) double strength twice daily for 10 to 14 days or doxycycline (a tetracycline-class drug) 100 mg twice daily for 10 to 14 days are recommended for first-line treatment of suspected MRSA cellulitis. There is no indication to proceed with irrigation and debridement; however, if the patient develops a soft-tissue abscess or the underlying joint becomes involved, this would be an appropriate intervention. Switching the athlete to an IV cephalosporin (cefazolin) is not likely to be effective against the presumed resistant bacteria.
Ciprofloxacin (a fluoroquinolone-class drug) is effective against many bacteria, but not MRSA. The current recommendation for wrestlers with cellulitis is that return to competition be allowed after 72 hours of antibiotic treatment if there has been no extension of the cellulitis for 48 hours, the lesion can be covered, and there is no drainage from the lesion. The other responses are not current recommendations for return to competition.

Question 10

Figure below shows the radiograph obtained from a 73-year-old woman who returns status post total hip arthroplasty 14 years earlier. She denies pain and has no discomfort on examination. She then undergoes revision total hip arthroplasty with head and liner exchange and bone grafting. After a physical therapy session two days after surgical intervention, she develops inability to dorsiflex the foot while she is sitting in a chair. The initial treatment should consist of

Explanation

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

Question 11

A 13-year-old pitcher is hit in the left intercostal space by a line drive ball. He collapses, is apneic and unresponsive, and his radial pulse is absent. What is the next step in management? Review Topic

Explanation

Sudden death in athletes without structural cardiac damage is referred to as commotio cordis. This is an emergency. The immediate priorities are protection of the airway, starting CPR, and early cardioversion as this patient has an arrhythmia. It is hypothesized to occur from apnea, vasovagal reflex, or ventricular arrhythemia as reported by Maron and associates from the direct impact of the baseball during a vulnerable part of the cardiac rhythm. Janda and associates reported that soft-core baseballs may not differ from standard baseballs with regard to the risk of fatal chest-impact injury while playing baseball. High survival rates are associated with rapid treatment.

Question 12

A B C D E Figures 45a through 45c are the MR images of a 22-year-old woman who has had 6 months of ankle pain related to activities of daily living. She recently completed a course of cast immobilization and protected weight bearing without symptom resolution. Figures 45d and 45e are the intraoperative arthroscopy images after minimal probing. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR images reveal a large cystic medial talar dome osteochondral lesion (OCL) in a patient who has failed nonsurgical treatment. Ankle fusion is inappropriate because the patient has an otherwise normal ankle. Arthroscopic debridement and drilling are appropriate for smaller (< 1.5 cm sq) noncystic lesions. Retrograde drilling and bone grafting is an option in the treatment of cystic OCL if the cartilage surface is intact; however, intraoperative arthroscopy images show that this patient's cartilage surface is unstable. Osteochondral allografts and autografts are effective in the treatment of large cystic talar dome OCLs but are not appropriate for the initial surgical treatment of smaller lesions like this one.
RECOMMENDED READINGS
Hannon CP, Smyth NA, Murawski CD, Savage-Elliott I, Deyer TW, Calder JD, Kennedy JG. Osteochondral lesions of the talus: aspects of current management. Bone Joint J. 2014 Feb;96-B(2):164-71. doi: 10.1302/0301-620X.96B2.31637. Review. PubMed PMID:

Question 13

A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching. Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension. The elbow is stable, but palpation reveals tenderness over the olecranon. Plain radiographs are inconclusive. MRI and CT scans are shown in Figures 20a and 20b. Management should consist of

Explanation

DISCUSSION: The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Griffin LY (ed): Orthopaedic Knowledge Uupdate: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 191-203.

Question 14

The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Explanation

Figure 50A: AP pelvis with a 1 cm lucency in the calcar region of the femoral neck and diffuse osteopenia of the proximal femur. Figure 50B: CT scan of the same patient showing a well demarcated lcm lesion in the femoral neck with an obvious nidus. Careful evaluation of the radiographs is critical in this question. First the obvious osteoid osteoma must be recognized. From there answers 2 and 3 can be eliminated. Neither radiograph reveals any sign that treatment has occurred, and the CT scan shows no signs of extensive involvement, thus answer 5 should also be eliminated. The real key is believing that such diffuse osteoporosis could occur in such a young child, as Jones described in his article from 1969.

Question 15

A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?

Explanation

DISCUSSION: The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.
REFERENCES: Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.
Beals RK, Bryant RE: The treatment of chronic open osteomyelitis of the tibia in adults.

Clin Orthop Relat Res 2005;433:212-217.

Question 16

When planning a research study, the power of the study may be increased by

Explanation

The power of a study refers to the researchers' ability to detect a true association when one exists. Power is defined as 1-beta, with beta being the probability of concluding an association does not exist when one actually does (type II error). Increasing the sample size will increase the power of a study. A power analysis can be performed for both retrospective and prospective studies and is independent of the sample population used.

Question 17

A 26-year-old ballet dancer reports posterolateral ankle pain, especially with maximal plantar flexion. Examination reveals maximal tenderness just posterior to the lateral malleolus, and symptoms are heightened with forced passive plantar flexion. Radiographs are shown in Figures 42a and 42b. What is the most likely cause of the patient’s symptoms?

Explanation

DISCUSSION: The patient has a symptomatic os trigonum caused by impingement that occurs with maximal plantar flexion of the ankle in the demi-pointe or full-pointe position. Patients frequently report posterolateral pain localized behind the lateral malleolus that may be misinterpreted as a disorder of the peroneal tendon. Pain with passive plantar flexion (the plantar flexion sign) indicates posterior impingement, not a problem with the peroneal tendon. The symptoms are not characteristic of a stress fracture, nor do the radiographs show a stress fracture or an osteochondritis dissecans lesion. The os trigonum is modest in its dimensions. The incidence or magnitude of symptoms does not correlate with the size of the fragment. Large fragments may be asymptomatic, while small lesions may create significant symptoms.
REFERENCES: Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.
Hamilton WG: Foot and ankle injuries in dancers, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1241-1276.

Question 18

Which of the following types of osteosarcoma is associated with the best prognosis & long survival?

Explanation

p. 194 (parosteal): Early adequate treatment [of parosteal osteosarcoma] should lead to cure in most patients. A long-term survival rate of 80%-90% is to be expected for patients who have parosteal osteosarcomas without dedifferentiation.”
p. 163 (in Paget’s disease): “Although long-term survival is rare for patients with this type of sarcoma, four patients have survived more than 10 years.”
p. 164 (in irradiated bone): “The location of these tumors in unresectable locations such as the skull, clavicle, scapula, and spine explains the traditionally poor prognosis.”

Question 19

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Explanation

The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.

Question 20

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 21

A 38-year-old man reports right upper extremity pain that radiates from his neck to his anterior arm, dorsoradial forearm, and into the index finger. Examination reveals weakness of the biceps muscle group and loss of his brachioradialis reflex on that side. At which level is he most likely to have a right-sided cervical disk protrusion on an MRI scan? Review Topic 1 C4-C5 2 C5-C6 3 C6-C7

Explanation

The patient has a typical right C6 radiculopathy based on his history and physical examination. A posterolateral disk protrusion at the C5-C6 level is mostly likely to cause a C6 radiculopathy because the C6 nerve roots exit just above the C6 pedicle and therefore would be compressed by a right-sided C5-C6 disk protrusion. In contrast to the lumbar spine, far lateral disk protrusions are not typically described in the cervical spine.

Question 22

7 weeks from injury at a union rate of 94.5%. They concluded that functional bracing has many known benefits and remains a reliable treatment however certain parameters such as functional outcome, residual deformity, and loss of joint motion remain unclear and require further research.

Explanation

OrthoCash 2020
A patient presents with the injury shown in figures A and B. What has been associated with the technique depicted in figures C and D?

Longer operative times
Increased deep surgical infection rates
Unacceptably high malunion/nonunion rates
Slower early return to function
Longer hospital stays Corrent answer: 3
Treatment of Shatzker V and VI tibial plateau fractures with hybrid external fixation is associated with increased malunion and nonunion rates.
Hybrid external fixation for treating tibial plateau fractures involves the use of an external fixator to achieve reduction through ligamentotaxis. Additional fracture reduction is achieved through limited open incisions with fixation augmented through percutaneous cannulated screws. Definitive treatment with this technique avoids soft tissue complications that have been associated with traditional open reduction and internal fixation with bicondylar plating.
However, studies have reported high malunion and nonunion rates due to a lack of rigid fixation.
Bertrand et al. performed a prospective cohort study of patients undergoing either open reduction and internal fixation versus hybrid external fixation for Schatzker V and VI tibial plateau fractures. Hybrid external fixation was associated with significantly shorter operative times but insignificantly increased complication rates. They concluded that there were limited statistically differences between these techniques, but further studies are required before advising hybrid external fixation for higher Schatzker tibial plateau fractures.
Gross et al. performed a retrospective study of patients treated with hybrid external fixation for Shatzker V and VI tibial plateau fractures. The authors found there was an 80% union rate, a 70% satisfactory reduction rate, and a 52% rate of malunion. The development of osteoarthritis was associated with plateau widening, articular comminution, articular step-off, and incorrect mechanical alignment. The authors concluded that hybrid external fixation is an effective means for the treatment of tibial plateau fractures that minimizes tissue dissection, with decreased blood loss, and shorter operative times, but associated with a very high malunion rate.
Hall et al. performed a multicenter randomized controlled trial comparing the treatment of Schatzker V and VI fractures with open reduction and internal fixation with hybrid external fixation. Patients with hybrid external fixation had less intraoperative blood loss, fewer unanticipated secondary procedures, slightly faster return to pre-injury activity at 6 months and 1 year, and shorter
hospital stay. They concluded that both hybrid external fixation and open reduction and internal fixation provide effective means for fracture treatment, but hybrid external fixation avoids soft tissue complications with deleterious consequences.
Figure A is an AP radiograph of the right knee with a Schatzker VI tibial plateau fracture. Figure B is an axial CT slice of the articular surface of the tibia with extensive comminution. Figures C and D are the AP and lateral radiographs of the knee with a hybrid external fixation construct for a tibial plateau fracture
Incorrect answers:
OrthoCash 2020
An 89-year-old female sustained the injury shown in Figure A and underwent a hemiarthroplasty. Which of the following has been associated with increased rates of post-operative dislocation?

Posterior approach
Anterior approach
Anterolateral approach
Use of a bipolar implant
Use of a monopolar implant
The incidence of dislocation after hemiarthroplasty is highest when using a posterior approach.
Elderly femoral neck fractures are one of the most common fractures encountered by orthopaedists and will only become more common as the population continues to age. The displacement of the femoral head is associated with delayed union or nonunion, an increased risk of femoral head necrosis due to disrupted blood flow at the femoral neck, and failure of internal fixation devices. For this reason, displaced femoral neck fractures in older patients are often treated with hemiarthroplasty. Three approaches to hemiarthroplasty have been described: a lateral approach, a posterior approach, and an anterior approach. The posterior approach has been used more historically; however, its use has been called into question as it has been associated with increased dislocation rates.
Parker performed a trial on all patients with intracapsular femoral neck fractures being treated with hemiarthroplasty. Patients were randomized to surgery using either a lateral or posterior approach. They found that there were no statistically significant differences observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. They concluded that both surgical approaches appear to produce comparable functional outcomes.
van der Sijp et al. performed a meta-analysis to compare the outcomes based on approaches for hemiarthroplasty in the treatment of proximal femur fractures. They found 21 studies and found that the posterior approach poses an increased risk of dislocation and reoperation compared to the lateral approach and anterior approaches. They conclude that there are no evident advantages of the posterior approach and its routine use for fracture-related hemiarthroplasty should be questioned.
Figure A is an AP pelvis radiograph demonstrating a displaced right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture?

Exchange humeral nailing
Augmentative plating
Nail removal with open reduction compression plating
Smoking cessation and medical optimization
Nail removal with open reduction and compression plating with bone grafting
This patient has sustained an atrophic nonunion of a humeral shaft fracture treated with an intramedullary nail. The most appropriate definitive treatment is nail removal with open reduction and compression plating with bone grafting.
Most diaphyseal humeral fractures can be managed non-operatively with functional bracing. Operative treatment is indicated under a number of circumstances including open fractures, associated neurovascular injury, proximal and distal articular extension of the fracture, and in patients with other multiple injuries. Surgical stabilization can be accomplished with different implants and techniques. The two most common are plate and screw fixation and intramedullary nailing. Plate fixation has the advantages of potential absolute stability and sparing the rotator cuff from an incision. Intramedullary nailing has to be inserted proximally with potential damage to the rotator cuff. It, however, can be inserted with small incisions. If a nonunion develops after intramedullary nailing, nail removal and compression plating is the preferred treatment choice.
Heineman et al. performed a metanalysis on plate fixation or intramedullary nailing of humeral shaft fractures. They performed a literature search from 1967-2007 comparing nails and plates in patients with humeral shaft fractures that reported complications due to surgery. They found that the risk of a complication is lower when plating a fracture of the humeral shaft than when using an intramedullary nail.
Gerwin et al. performed an anatomical study to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. They found that the radial nerve crosses the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. They found the approach to permit the most visualization was the triceps reflecting approach.
Figure A is a lateral radiograph of an atrophic nonunion of a humeral shaft being stabilized with an intramedullary nail.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man is struck while crossing a major highway and sustains the injury depicted in Figure A. Which of the following statements comparing the techniques in Figure B and C is most accurate?

Technique depicted in Figure B is associated with an increased risk of septic arthritis
Technique depicted in Figure B is associated with increased rate of anterior knee pain
Technique depicted in Figure B is associated with improved postoperative fracture alignment
Technique depicted in Figure C is associated with an increased risk of septic arthritis
Technique depicted in Figure C is associated with improved postoperative fracture alignment
Compared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment.
While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaft
fractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing.
Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low.
Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing.
Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction.
Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique.
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OrthoCash 2020
A 56-year-old woman sustains the closed injury depicted in Figures A-B. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. She also complains of some paresthesias in her thumb and index finger. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. What is the likely mechanism of her paresthesias and what is the most appropriate treatment?

Nerve compression; open reduction internal fixation with open carpal tunnel release
Nerve laceration; open reduction internal fixation with primary nerve repair or grafting
Decreased arterial inflow; fasciotomy with open reduction internal fixation
Reflex sympathetic dystrophy; vitamin C
Nerve compression; repeat closed reduction Corrent answer: 1
This patient is presenting with signs of acute carpal tunnel syndrome (CTS) in the setting of a displaced distal radial fracture. The pathogenesis of acute CTS is nerve compression, requiring urgent open carpal release with open reduction internal fixation (ORIF).
Acute CTS is a well-recognized phenomenon after distal radial fractures. Risk factors include ipsilateral upper extremity fractures, translation of the fracture fragments, and articular distal radius fractures (DRFs). Acute CTS can manifest with paresthesias in the median nerve distribution and opponens pollicis weakness. Acute CTS is an indication for urgent surgical decompression of the median nerve.
Odumala et al. performed a study to evaluate the role of carpal tunnel decompression in the prevention of median nerve dysfunction after buttress plating of DRFs. They reported that prophylactic decompression of the carpal tunnel results in twice the relative odds of developing median nerve dysfunction, which routinely self-resolved. They concluded that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may actually increase postoperative morbidity.
Medici et al. performed a case-control study to investigate whether carpal tunnel release (CTR) during fixation DRFs improves outcomes. They reported no statistically significant difference between the groups in VAS and Mayo Wrist Scores, however, an increased risk of subsequent CTR in the group who underwent ORIF with no CTR at the index procedure. They concluded that the release of the transverse carpal ligament during ORIF may reduce the incidence of postoperative median nerve dysfunction.
Niver et al. reviewed CTS after DRFs. They reported that acute CTS noted at the time of DRF warrants urgent surgical release of the carpal tunnel and fracture fixation, and that delayed CTS presenting after a distal radius fracture has healed may be managed in the standard fashion for CTR. They concluded that there is no role for prophylactic CTR at the time of distal radius fixation in a patient who is asymptomatic.
Figures A and B depict a displaced apex volar DRF and a mildly displaced ulnar styloid fracture.
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OrthoCash 2020
Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury?

Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment
No difference in radiographic outcomes after ORIF vs. closed treatment
No difference in functional outcomes after ORIF vs. closed treatment
Improved functional outcomes with closed treatment vs. ORIF
Improved functional outcomes with external fixation and K wire fixation vs. ORIF
This elderly patient has sustained a closed intra-articular and shortened distal radial fracture (DRF). Many studies have reported no difference in functional outcomes when patients aged 60 and over are treated in a closed manner versus operatively for unstable fractures.
The treatment of DRFs in the elderly population is controversial. A variety of nonoperative and operative treatments are available, including closed reduction and splinting/casting, K wire stabilization, external fixation, and ORIF. While conservative management of DRFs in the elderly is common,
recent systematic reviews and meta-analyses have demonstrated that despite worse radiographic outcomes after closed treatment of unstable fractures, functional outcomes were no different between patients treated closed versus surgically in patients over the age of 60 years.
Ju et al. published a systematic review and meta-analysis comparing treatment outcomes between nonsurgical and surgical treatment of unstable DRFs in the elderly. They reported no significant differences in DASH score, VAS pain score, grip strength, wrist extension, pronation, supination, and ulnar deviation between the groups. They concluded that operative and nonoperative treatments result in similar outcomes in the treatment of unstable DRFs in the elderly, with no impact on subjective function outcome and quality of life with closed treatment.
Diaz-Garcia et al. published a systematic review of the outcomes and complications after treating unstable DRFs in the elderly, comparing various treatment techniques. They reported significant differences in wrist motion, grip strength, DASH score, although these findings may not be clinically meaningful. They concluded that although the operatively treated group had improved radiographic outcomes, functional outcomes were no different when compared to the group treated in a closed manner.
Figure A depicts an unstable intra-articular and shortened DRF. Incorrect Answers:
no difference in functional outcomes between operative and closed treatment modalities for DRF.
OrthoCash 2020
An active 60-year-old woman falls from her attic and presents with the injury in Figure A. She undergoes successful closed reduction and sling immobilization. At follow up, she is unable to move her shoulder. New radiographs are depicted in Figures B and C. What is the next best step?

Continued sling immobilization
Closed reduction percutaneous pinning
Open reduction internal fixation
Hemiarthroplasty
Reverse total shoulder arthroplasty Corrent answer: 3
This active patient presents with a greater tuberosity fracture dislocation. Open reduction internal fixation (ORIF) is indicated, particularly when the greater tuberosity fragment is displaced greater than 5mm.
Many proximal humerus fractures are minimally displaced and respond acceptably to nonoperative management. Isolated greater tuberosity fractures or rotator cuff injuries are associated with shoulder dislocations in the elderly population. The greater tuberosity fragment undergoes deforming forces by the supraspinatus and infraspinatus muscles. In active patients, it is well-accepted that greater tuberosity fracture displacement greater than 5mm is an indication for ORIF to restore their ability to perform overhead activities and prevent impingement.
Schumaier et al. published a review article on the treatment of proximal humerus fractures in the elderly. They highlighted that while bone density was a predictor of reduction quality, social independence was a better predictor of outcome. They concluded that although the majority of minimally displaced fractures can be treated successfully with early physical therapy, treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. They emphasized that there was no clear evidence-based treatment of choice, and the surgeon should consider their comfort level during their decision-making.
George et al. published a review article on greater tuberosity humerus fractures. They reported that these fractures may occur in the setting of anterior shoulder dislocations or impaction injuries against the acromion or superior glenoid, with surgical fixation recommended for fractures with greater than 5 mm of displacement in the general population or greater than 3 mm of displacement in active patients involved in frequent overhead activity. They recommended close followup and supervised rehabilitation to increase successful outcomes.
Figure A depicts a greater tuberosity fracture dislocation of the left shoulder. Figures B and C depict reduction of the glenohumeral joint with residual displacement of the greater tuberosity. Illustrations A and B depict radiographs after ORIF.
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OrthoCash 2020
A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur?

MCL > LCL > anterior capsule
MCL > anterior capsule > LCL
anterior capsule > MCL > LCL
LCL > anterior capsule > MCL
LCL > MCL > anterior capsule Corrent answer: 4
The patient sustained a terrible triad injury of the elbow, which progresses from the LCL to the anterior capsule and then the MCL.
Terrible triad injuries of the elbow are traumatic injuries that occur after a fall on an extended arm that results in a combination of valgus, axial, and posterolateral rotatory forces. The key features of a terrible triad injury include a radial head fracture, a coronoid fracture, and an elbow dislocation. Disruption of the structures in the elbow characteristically occurs from lateral to medial, affecting the LCL first, followed by the anterior capsule and MCL. Outcomes following terrible triad injuries have historically been poor; however, more recent literature has shown that good outcomes can be achieved with surgical stabilization of the elbow followed by an early rehabilitation protocol. Some authors use temporary immobilization, but range-of-motion exercises are typically initiated by 48 hours postoperatively. Active range of motion is particularly important, as it recruits muscles that act as dynamic stabilizers of the elbow. Depending on the injury, method of fixation, and stability that is achieved, the range of motion may be limited to 30° of extension during the early postoperative period but should allow full flexion.
Giannicola et al. (2013) performed a study to determine the critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability (CEI). They found that the first 6 months after surgery represent the critical rehabilitation period to obtain a functional elbow and that elbow flexion recovered at a rate slower than that of the other elbow movements. They recommend that, following CEI surgical treatment, a rehabilitation program should be started promptly and should be continued for at least 6 months because a significant improvement of ROM occurs in this period.
Giannicola et al. (2015) performed a study analyzing the predictability of outcomes of terrible triad injuries (TTI) treated according to current diagnostic and surgical protocols. They found that the current diagnostic and therapeutic protocols allow for satisfactory clinical outcomes in a majority of cases but a high number of major and minor unpredictable complications still persist. Low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery.
McKee et al. performed a review on their standard surgical protocol for the treatment of elbow dislocations with radial head and coronoid fractures. Their surgical protocol included fixation or replacement of the radial head; fixation of the coronoid fracture, if possible; repair of associated capsular and lateral ligamentous injuries; and, in selected cases, repair of the medial collateral ligament and/or adjuvant-hinged external fixation. They found that their surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. They recommend early operative repair with a standard protocol for these injuries.
Figure A is a lateral radiograph of the elbow demonstrating a terrible triad injury with a comminuted radial head/neck fracture, displaced coronoid fracture, and posterior elbow dislocation. Illustration A is a rendered image of the radiograph shown in Figure A with the components labeled.
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OrthoCash 2020
An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw?

Reverse obliquity fracture pattern
Lateral wall thickness
Previous contralateral hip fracture
DEXA T-score <-2.0
Calcar comminution
Lateral wall thickness has been shown to be a predictor of postoperative lateral wall fracture. As the lateral wall thickness decreases, there is an increased chance of fracture.
Lateral wall fracture creates an unstable fracture pattern and increased screw sliding/collapse. This shortens the neck and abductors, leading to worse patient outcomes (radiographic and clinical). Recognition of a thin wall should lead toward the use of an intramedullary device or adjunct use of a trochanteric stabilizing plate with a sliding hip screw device.
Baumgaertner et al. reported that the failure of peritrochanteric fractures that have been treated with a fixed-angle sliding hip-screw device is frequently related to the position of the lag screw in the femoral head. They established the tip-apex distance as the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. Upon reviewing their series, none of the 120 screws with a tip-apex distance of twenty-five millimeters or less cut out, but there was a very strong statistical relationship between an increasing tip-apex distance and the rate of cutout, regardless of all other variables related to the fracture.
Socci et al. performed a literature review of relevant papers and appropriate clinical databases and concluded that fixation of AO 31A1 fractures was best achieved with a sliding hip screw device and that all other types of intertrochanteric hip fractures be fixed with an intramedullary device.
Utrilla et al. reported no difference in outcome in stable fractures, but better mobility at one year following intramedullary fixation of unstable fractures.
Hsu et al. measured the thickness of the lateral wall of patients with AO/OTA 31-A1 and 31-A2 type intertrochanteric hip fractures. They found that the lateral wall thickness was a reliable predictor of postoperative lateral wall fracture for unstable AO Type A2 fractures and concluded that the lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.
Figure A shows a standard obliquity intertrochanteric hip fracture.
Illustration A from the Hsu article demonstrates the measurement of the lateral wall thickness. The distance is measured along a 135-degree angle, between a point 3cm distal to the innominate tubercle of the greater trochanter and the fracture line (midway between the two cortical lines).
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OrthoCash 2020
A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries?

Smaller lateral wall thickness favors sliding hip screw constructs
Unstable fractures are best treated with sliding hip screw constructs
Avoiding distal locking screws in intramedullary implants protects against refracture
Stable fractures have no differences in outcomes between sliding hip screws and intramedullary implants
Implant stability has a greater impact on outcomes rather than reduction quality
Studies have shown that in stable intertrochanteric femur fractures there are no differences in outcomes between sliding hip screws and intramedullary implants.
Intertrochanteric femur fractures are one of the most common fractures in the geriatric population. Implant selection has been a great topic of research with most studies reporting minimal to no differences in outcomes between intramedullary and sliding hip screw constructs in stable fracture patterns.
Unstable fractures, however, are reportedly better treated with a distally locked intramedullary implant. The quality of fracture reduction has a greater impact on the overall outcome than implant selection.
Hsu et al. performed a retrospective study of risk factors for postoperative lateral wall fractures in patients treated with sliding hip screws for intertrochanteric femur fractures. They found that fracture classification and lateral wall thickness, which is measured from 3 cm distal from innominate tubercle and angled 135 degrees to the fracture line, were associated with postoperative lateral wall fracture. They recommended not treating intertrochanteric femur fractures with sliding hip screws if the lateral wall thickness is less than 20.5 mm.
Socci et al. reviewed the literature regarding the treatment of intertrochanteric femur fractures. Based on the literature, they recommend treatment of AO/OTA type 31A1 fractures with sliding hip screws, type 31A2 fractures with short intramedullary implants, and 31A3 fractures with long intramedullary implants. Simple basicervical fractures of the femoral neck can be treated with sliding hip constructs whereas comminuted fractures treated with intramedullary devices due to the inherent instability of the pattern. The most import aspect in fracture healing is the quality of the reduction rather than the choice of implant.
Lindvall et al. performed a retrospective study of refracture rates in patients treated with either long or short cephalomedullary nails. The authors found a 97% union rate with both implant types and refracture not associated with either long or short implants. Rather, refracture was associated with the lack of a distal locking screw. The authors recommended locking intramedullary implants to avoid refracture.
Utrilla et al. performed a randomized control trial of elderly patients treated
with compression hip screw or Trochanteric Gamma Nail for intertrochanteric femur fractures. They reported the only differences between the two implants were quicker operating time, less fluoroscopy use, and better walking with unstable fractures treated with intramedullary implants. The authors recommended either construct for stable fractures, but intramedullary implants for unstable fractures.
Figures A and B are the AP and lateral radiographs of the right hip radiographs demonstrating a simple and minimally displaced intertrochanteric femur fracture, classified as an AO/OTA 31A1 fracture. Illustration A depicts the AO/OTA classification system for proximal femur fractures.
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OrthoCash 2020
A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?

Nail removal with compression plating and open bone grafting
Closed reamed exchange nailing
Nail dynamization
Nail retention with plate augmentation and bone grafting
Electrical bone stimulator Corrent answer: 4
The patient is presenting with a hypertrophic nonunion of the femur below the isthmus, which studies have shown to have a higher union rate when treated with plate augmentation. Retention of the nail allows for full weight-bearing postop.
Hypertrophic nonunion of the femur is the result of fracture site hypermobility with sufficient biology for healing. This is demonstrated with abundant callus formation without bridging trabeculae. Traditionally, this is treated with closed reamed exchange nailing which increased construct stiffness with a larger diameter nail, improved isthmic fit, and extrusion of reaming contents to the nonunion site. However, studies have demonstrated a higher union rate with open plate augmentation, bone grafting, and nail retention. This is due to the ability to correct nonunion site deformity, provide added compression at the nonunion site, and increase fracture site biology with bone graft.
Lynch et al. reviewed the literature regarding the treatment options for femoral nonunions. The literature suggests high union rates when hypertrophic nonunions are treated with exchanged reamed nailing. However, the use of augmentative plate fixation allows for further deformity correction. The proposed mechanism by which exchange reamed nailing is increased construct stiffness with a large diameter nail, usually by 1-2 mm, increased isthmic fit, and autogenous bone graft extrusion into the nonunion site.
Somford et al. performed a systematic review of the surgical treatment of femoral nonunions. Results demonstrate that exchange nailing provides a 73% union rate compared to plate augmentation of 96%. They speculated that there were increased indications for exchange nailing for oligotrophic nonunions in many of the included studies, which may have reduced the union rate. Further, plate augmentation does allow for deformity correction, which can further improve the union rate.
Figures A and B are the AP and lateral radiographs of the femur with hypertrophic nonunion as suggested with the abundant callus formation and broken distal interlock screws. Illustration A and B are the AP and lateral radiographs of the distal femur subsequent plate augmentation and fracture healing.
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OrthoCash 2020
A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?

External fixation with serial doppler examinations
Intramedullary nailing
Open reduction internal fixation using plates and screws
Immediate 2-compartment fasciotomies and external fixation
Immediate 4-compartment fasciotomies and external fixation Corrent answer: 5
This patient has clinical symptoms and signs of leg compartment syndrome and should undergo immediate fasciotomies of all 4 leg compartments, followed by external fixation for fracture stabilization.
Tibial fractures are among the most common reasons for compartment syndromes of the leg. A clinical assessment is key in the diagnosis of acute compartment syndrome. If there is uncertainty, intracompartmental pressure measurement has been advocated to help confirm the diagnosis. An absolute
compartment pressure >30 mm Hg or a difference in diastolic pressure and compartment pressure (delta p) <30 mmHg may help to confirm the necessity for fasciotomy.
McQueen et al. published a report of 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. They reported significant differences in any sequelae of acute compartment syndrome between patients who underwent compartment pressure monitoring and those who had not. They recommended that all patients with tibial fractures should have continuous compartment monitoring to minimize the incidence of acute compartment syndrome.
Mawhinney et al. reported on three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. They reported that the only predisposing factors for the development of compartment syndrome were the surgery and the fracture itself. They concluded that tibial compartment syndrome is a relatively rare but significant complication of tibial nailing.
Figure A is an AP and lateral radiograph of the leg with displaced, comminuted middle third tibia and fibula fractures.
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OrthoCash 2020
A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Decreased arterial inflow; inability to dorsiflex his ankle
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Compartment syndrome initially results from a decrease in venous outflow relative to arterial inflow. This patient has elevated pressures in the lateral compartment of the leg, which is where the superficial peroneal nerve runs to supply sensation to the dorsum of the foot including the hallux and 3rd and 4th toes.
Compartment syndrome results from compromised venous outflow from the leg relative to the arterial inflow. This venous congestion leads to elevated compartment pressures that ultimately lead to compromised arterial inflow without compartment release. There are 4 compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment contains the deep peroneal nerve, the lateral compartment of the leg contains the superficial peroneal nerve, and the deep posterior compartment contains the tibial nerve.
McQueen et al. performed a study to determine risk factors for acute compartment syndrome. They found that young patients, especially men, were most at risk of acute compartment syndrome after injury. They recommend that, when treating such injured patients, the diagnosis should be made early, utilizing measurements of tissue pressure.
Olson et al. published a review on acute compartment syndrome in lower extremity musculoskeletal trauma. They reported that acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death. They report that recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.
Illustration A is a diagram depicting the compartments of the leg and its contents.
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OrthoCash 2020
Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation?
Syme
Traumatic transtibial
Vascular transtibial
Traumatic transfemoral
Vascular transfemoral
The energy expenditure of a vascular transtibial amputation is approximately 40% greater.
The energy expenditure for ambulation increases with lower extremity amputation. Diabetics and vasculopathic patients who undergo amputation
have significantly increased energy requirements compared with nondiabetic patients undergoing amputations for trauma. The metabolic cost for a vascular transtibial amputation is 40% compared to a 25% increase in normal patients who sustain a traumatic amputation.
Huang et al. used a mobile instrument system to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. They found that in comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.
Pinzur et al. performed a study to measure cardiac function and oxygen consumption in 25 patients who underwent amputation for peripheral vascular disease (PVD), and in five similarly aged control patients without PVD. They found Normal walking speed and cadence decreased and oxygen consumption per meter walked increased with more proximal amputation. They conclude that peripheral vascular insufficiency amputees function at a level approaching their maximum functional capacity and more proximal amputation levels, the capacity to walk short or long distances is greatly impaired.
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OrthoCash 2020
A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?

It may be performed in a minimally invasive manner
It involves minimal soft tissue stripping
It leads to higher union rates
It allows the surgeon to address all sites of injury through one approach
This patient has sustained a right hip fracture-dislocation with fractures of the femoral head and posterior wall. The TFO allows the surgeon to address all sites of injury through a single approach.
Femoral head fracture-dislocations are a result of high-energy trauma. Treatment ranges from closed reduction and conservative management to total hip arthroplasty. Intermediate options include open reduction and internal fixation or excision of fracture fragments. Complications of this injury include post-traumatic hip arthritis, avascular necrosis, and heterotopic ossification.
The injury is further complicated when a fracture of the acetabulum is concomitantly present. There has been no consensus treatment on this injury constellation as it presents quite rarely. The TFO is one approach that allows the surgeon to treat and stabilize both injuries concurrently. It should be noted that a surgical hip dislocation is performed in conjunction with the TFO to allow access to the femoral head.
Solberg et al. performed a retrospective study of patients sustaining Pipkin IV fracture/dislocations with a TFO. They had 12 patients over a 6 month period. They found that all patients healed radiologically and one patient developed osteonecrosis. 10 out of 12 patients had good to excellent outcomes. They concluded that using a surgical protocol with TFO rendered clinical results
comparable to previously reported outcomes in a series of isolated femoral head fractures.
Giannoudis et al. performed a systematic review to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. They reported that fracture-dislocations were managed with emergent closed reduction, followed by definite treatment, aiming at an anatomic restoration of both fracture and joint incongruity. They concluded that neither the TFO nor an anterior approach seems to endanger femoral head blood supply compared to the posterior one, with the TFO possibly providing better long-term functional results and lower incidence of major complication rates.
Henle et al. reported on the result of 12 patients of femoral head fractures with associated posterior wall fractures treated with a TFO. They found good to excellent results in 10 patients. The two patients with poor outcome developed avascular necrosis of the femoral head and underwent total hip arthroplasty.
Heterotopic ossification was seen in five patients. They concluded that the TFO may lead to favorable outcomes in this injury constellation.
Figure A is an AP radiograph of the right hip demonstrating a femoral head fracture-dislocation. Figure B is an axial CT image demonstrating a posterior wall fracture. Figure C is an axial CT image demonstrating a femoral head fragment within the acetabulum. Illustration A is the Pipkin classification of femoral head fractures: Type I is below the fovea, Type II is above the fovea, Type III is associated with a femoral neck fracture, and Type IV is associated with an acetabular fracture.
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OrthoCash 2020
A 30-year-old male is brought to your emergency department following a motor vehicle collision at high speed. He is intubated in the field for airway protection but is hemodynamically stable. Subsequent workup shows a displaced acetabular fracture, in addition to an intracranial bleed and liver laceration which do not require surgery. When placing an antegrade anterior column screw, what radiographic view should be used to avoid intra-pelvic screw penetration?
Iliac oblique view with hip and knee flexed
Iliac oblique inlet view
Obturator oblique view with hip and knee flexed
Obturator oblique outlet view
Obturator oblique inlet view Corrent answer: 2
The iliac oblique inlet view will best show the the anterior-posterior placement of an anterior column ramus screw.
Percutaneous and limited-open acetabular fixation is becoming increasingly common as it avoids the morbidity of extensile pelvic dissection and allows early mobilization. However, it relies heavily on a mastery of radiographic landmarks and ability to interpret these images to reduce fracture fragments without direct visualization. Slight deviations of the fluoroscopy beam and/or fracture displacement will distort the radiographic image. Without a facile ability to interpret these and make appropriate adjustments, percutaneous fixation will be extremely onerous.
Starr et al. described their early techniques for percutaneous and limited-open acetabular fixation. They first implemented this for minimally displaced fracture patterns but have expanded these to a wider range of pathology. They cite the benefit of earlier mobilization in the poly-traumatized patient as great use for this technique.
Mauffrey et al. reviewed radiograph utilization during acetabular fracture care. Though CT has added tremendously to demonstrating subtleties of acetabular fractures, they state the use of AP and orthogonal iliac and obturator oblique Judet views cannot be overlooked. Interpreting these radiographs allows the surgeon to recreate 2-dimensional images into a 3-dimensional fracture pattern and better understand the character of the injury.
Illustrations A and B demonstrate the iliac oblique inlet view and obturator oblique outlet views, respectively.
Illustration C demonstrates the relationship of the critical structures at risk of injury during anterior column screw placement. Illustrations D and E show the starting point with screw trajectory, and position of the hip during posterior column screw.
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OrthoCash 2020
A 34-year-old male sustains the injury shown in Figures A and B. Which factor has been found to be elevated in the synovial fluid and contributes to post-traumatic arthritis?

TGF-Beta
RANKL
IL-2
IL-6
cAMP
The patient has sustained a tibial plafond or pilon fracture as depicted in Figures A and B. IL-6 is one of many inflammatory molecules that has been found to be elevated in the synovial fluid following an intra-articular ankle fracture.
Post-traumatic arthritis following intra-articular fractures is a known complication. It commonly appears 1-2 years following injury and is related to chondrocyte death at the margins. There has not been shown to be any association between prolonged non-weight bearing, poor patient compliance with weight-bearing restrictions, and hardware reactions with the development of post-traumatic arthritis. However, literature has shown that the inflammatory molecules present in the synovial fluid can have a significant effect on the development of posttraumatic arthritis. Important inflammatory factors that have been found to be elevated include IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10.
Adams et al. looked at the synovial fluid of 21 patients with an intra-articular ankle fracture and used the un-injured ankle as a control. They found the inflammatory molecules of GM-CSF, IL-10, IL-1 beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10 were all elevated. They concluded that these inflammatory molecules may play a role in posttraumatic arthritis development.
Adams et al. looked at the synovial fluid of 7 patients from his previous 21 patients that had intra-articular ankle fractures. They found that IL-6, IL-8, MMP-1, MMP-2, and MMP-3 were significantly elevated in comparison to the uninjured ankle. They concluded that the sustained elevated intra-articular inflammatory environment is a potential contributor to post-traumatic arthritis.
Figures A and B are sagittal and axial CT slices, respectively, that depict a tibial plafond or pilon fracture.
Incorrect Answers:
immune system.
OrthoCash 2020
A 29-year-old female presents to the trauma bay from the scene of a high-speed motor vehicle accident. She is found to have a closed intraarticular distal radius fracture with a concomitant ulnar styloid base fracture. She subsequently undergoes ORIF of the distal radius fracture with a volar locking plate. The ulnar styloid fracture is not addressed. Which of the following, if present, is least likely to affect functional outcomes?
Ulnar styloid nonunion
DRUJ instability
Articular step-off >3mm
Radial shortening
Workers compensation claim Corrent answer: 1
Ulnar styloid non-unions do not affect the overall outcome of hand or wrist function following ORIF of distal radius fractures.
Ulnar styloid base fractures can be associated with DRUJ disruption and TFCC rupture. The DRUJ should be independently evaluated following ORIF of the distal radius. Without instability, unlar styloid fractures do not need to be addressed. If instability exists, the DRUJ should be treated as a separate entity, typically cross-pinned using k-wires. The result of ulnar styloid nonunions are inconsequential to the overall outcome of patients undergoing distal radius ORIF.
Daneshvar et al review the effects of ulnar styloid fractures on patients sustaining distal radius fractures. They report that patients with a concomitant ulnar styloid fracture had a slower recovery of wrist flexion and grip strength compared to those with an isolated distal radius fracture. They conclude, however, that even the presence of an ulnar styloid nonunion did not significantly affect outcomes.
Buijze et al review the clinical impact of united versus non-united fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. They report no difference in motion, strength or outcome scores
between the united and non-united groups at 6 months follow up. They conclude that nonunion of the ulnar styloid does not have an effect on the overall outcome of hand or wrist function.
Incorrect Answers:
OrthoCash 2020
Which of the following proximal humerus fractures has the highest likelihood of developing humeral head ischemia?

Posteromedial calcar length of the humeral head less than 8 mm and a loss of medial hinge are among the most reliable predictors of ischemia in the surgical management of humeral head fractures.
Proximal humerus fractures are classified based on the Neer classification, in which 4 parts are described: greater tuberosity, lesser tuberosity, articular surface, and the shaft. A fragment is considered a part if it is greater than 45 degrees angulated or displaced >1cm. The posterior humeral circumflex artery is the main blood supply to the humeral head. Following ORIF, humeral head ischemia may occur and is associated with the initial fracture pattern. Several factors including <8mm of calcar length attached to the articular segment, disruption of the medial hinge, displacement >10mm and angulation >45 degrees have been associated with a disruption of the vascular supply to the humeral head.
Campochiaro et al review Hertel’s criteria of calcar length and medial hinge integrity and its reliability in predicting humeral head necrosis. They reported a 3.7% incidence of ischemia across all 267 fractures evaluated. In those patients that developed AVN, 30% had all of the predictors described by Hertel, however, in the non-AVN group, only 4.7% had these same findings.
They concluded that while Hertel’s criteria are helpful, they may not be sufficient and the authors recommended 3-dimensional evaluation of any fracture involving the calcar.
Xu et al reviewed avascular necrosis in patients with proximal humerus fractures who were treated surgically. They reported on 291 patients throughout 7 studies in which there was no difference in the incidence of AVN for those treated surgically or nonoperatively. However, they concluded through subgroup analysis looking at different fixation constructs that, plate fixation specifically was associated with a higher risk of AVN than conservative management of proximal humerus fractures.
Figure A demonstrates a proximal humerus fracture with a medial calcar length of >8mm attached to the articular segment. Figure B is a proximal humerus fracture with a displaced greater tuberosity fragment. Figure C demonstrates a proximal humerus fracture with a medial calcar length of <8mm attached to the articular segment. Figure D is a displaced metadiaphyseal proximal humerus fracture in a skeletally immature patient. Figure E is a radiograph of a metadiaphyseal proximal humerus fracture in a skeletally mature patient with a medial calcar length >8mm.
Incorrect Answers:
OrthoCash 2020
A 34-year-old man presents with the closed injury depicted in Figure A after a high energy twisting injury. Which of the other injuries below is most commonly associated with his known injury?

Nondisplaced medial malleolus vertical shear fracture
Nondisplaced Volkmann's fragment
Nondisplaced Chaput's fragment
Nondisplaced lateral wall talar fracture
Posterior inferior tibiofibular ligament disruption Corrent answer: 2
This patient has sustained a distal third tibial shaft spiral fracture, which is commonly associated with nondisplaced posterior tibial plafond fractures, with the classic Volkmann's fragment.
Prior to operative management, distal third spiral tibial shaft fractures should always be evaluated for intra-articular extension. As this commonly associated injury can be missed on plain radiographs, an ankle CT is often recommended. This is especially important when intramedullary fixation is used for definitive management of the tibial shaft fracture, as nail insertion can displace a
previously nondisplaced intraarticular fracture. Anterior to posterior lag screw fixation prior to nailing may be useful in these cases.
Sobol et al. investigated the incidence of concomitant posterior malleolar fractures (PMFs) in operative distal third spiral tibial shaft fractures. They reported that spiral distal third tibial shaft fractures were identified with an ipsilateral posterior malleolus fracture in 92.3% of cases. They recommended a preoperative ankle CT in all cases with this specific fracture morphology to properly diagnose this commonly associated injury.
Hou et al. investigated the posterior malleolar fracture association with spiral tibial shaft fractures. They reported that plain radiography (both preoperative and intraoperative) resulted in rare identification of these associated injuries, which resulted in missed injuries. They concluded that a CT or MRI ankle may be a higher yield method to detect these injuries.
Figure A demonstrates a distal third spiral tibial shaft fracture. Illustration A is a schematic demonstrating the Volkmann, Chaput, and medial malleoli intraarticular fragments of the distal tibia.
Incorrect Answers:

OrthoCash 2020
An 18-year-old male is admitted for a diaphyseal, open, tibial shaft fracture after falling off a motorcycle. He has a past medical history of nicotine dependence and obesity. He undergoes provisional splinting by the resident on call and is noted to be "neurovascularly intact" following splint placement. Throughout the evening, however, the patient has an increasing narcotic requirement and develops pain with passive stretch of his toes. What factor listed below is most associated with his progressive symptoms overnight?
Age < 20
Male gender
Body mass index >/ 30 kg/m^2
Open fracture
Nicotine use
The highest prevalence of compartment syndrome is found in patients aged 12-19 years, followed by 20-29 years.
One theory for the higher prevalence of compartment syndrome in younger patients is increased muscle mass in this cohort. If there is more muscle in a compartment, there is less room for swelling. On the flip side, elderly or deconditioned patients who have less muscle or fatty atrophy may be better able to accommodate muscle swelling. Additionally, a diaphyseal fracture location is associated with a higher risk of compartment syndrome. Again, this may be due to the fact that there is more muscle than tendon, and thus more swelling, in the proximal leg.
Shadgan et al. retrospectively reviewed 1,125 patients with diaphyseal tibia fractures to look for risk factors associated with the development of compartment syndrome. Compartment syndrome occurred in approximately 8% of patients with this injury. They concluded that younger patients were at a higher risk of developing compartment syndrome and that male gender, open fracture, and intramedullary nailing were not risk factors.
Beebe et al. set out to determine the correlation between the OTA/AO classification of tibia fractures and the development of compartment syndrome. they conducted a retrospective review of a prospectively collected database comprising 2,885 fractures. They concluded that age, sex, and the OTA/AO classification were highly predictive for the development of compartment syndrome in this cohort.
McQueen et al. similarly looked at predictors of compartment syndrome after tibial fractures in a retrospective cohort study. There were 1,388 patients in their study with ages ranging from 12-98; identical to the Shadgan study, 69% of patients were male. They concluded the strongest risk factor was age, with the highest prevalence in 12 to 19-year-olds.
Park et al. additionally analyzed 414 patients with tibia fractures in a retrospective cohort study. The main outcome measure of this study was the rate of clinically determined compartment syndromes requiring fasciotomy by anatomic region. The found that diaphyseal fractures were more frequently associated with the development of compartment syndrome than proximal (next most common site) and distal tibia fractures, specifically in younger patients.
Incorrect Answers:
OrthoCash 2020
Figure A is the radiograph of a 79-year-old female with elbow pain following a fall. Compared with a total elbow artrhoplasty, open reduction and internal fixation would most likely result in?

Greater Mayo Elbow Performance Score
Greater Disabilities of the Arm, Shoulder and Hand Score
Increased flexion-extension arc
Increased reoperation rate
Decreased complication rate Corrent answer: 4
This patient sustained a comminuted distal humerus fracture. Open reduction and internal fixation (ORIF) is found to have higher repoeration rates compared with total elbow arthroplasty (TEA) in the elderly: 27% versus 12%, respectively.
Distal humerus fractures account for approximately 30% of elbow fractures. There is often a low energy mechanism of injury in the elderly patient. While ORIF and TEA may be utilized in bicolumnar distal humerus fractures in the elderly patient, recent literature has demonstrated favorable outcomes with TEA in this aged cohort. TEA is indicated in the low demand osteoporotic patients with bicolumnar distal humerus fractures that are not amendable to ORIF. Utilization of TEA has demonstrated greater functional outcome scores, greater motion, less complications, and a lower revision rate.
Mckee et al. conducted a prospective, randomized, controlled trial comparing functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with ORIF or primary semiconstrained TEA. They reports that patients who underwent TEA had significantly better motion, performance and outcome scores, lower reoperation rates compared with the ORIF group. They concluded that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF and that TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation.
Githens et al. performed a systematic review and meta-analysis to analyze outcomes and complication rates in elderly patients with intra-articular distal humerus fractures being treated with either TEA or ORIF with locking plates. They report that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion.
However, they found a non-statistical trend toward a higher rate of major complications and reoperation after ORIF. They conclude that the quality of study methodology was generally weak and ongoing research including prospective trials and cost analysis is indicated.
Figure A is the AP radiograph of a comminuted bicolumnar distal humerus
fracture. Illustration A are the radiographs of a comminuted distal humerus fracture in an elderly patient treated with a TEA. Illustration B is the postoperative radiographs of a comminuted distal humerus fracture treated with ORIF.
Incorrect Answers:

OrthoCash 2020
Figure A is the postoperative radiograph of an 82-year-old female who was treated with a cephalomedually nail for a left intertrochanteric hip fracture. Which of the following is the most common complication following use of this device?

Anterior perforation of distal femur
Breakage of the screw
Implant cutout
Malunion
Nonunion
Intertrochanteric hip fractures are most commonly treated with a cephalomedullary nail. The most common complication following utilization of a cephalomedullary nail is implant failure and cutout.
Intertrochanteric hip fractures are extra-capsular injuries that are common in the elderly osteoporotic patient. These injuries carrry a 20-30% mortality rate in the first year following fracture. Femoral cephalomedullary nails are often used to treat these injuries. Often a helical blade or screw may be used to provide fixation within the femoral neck. Overall, the most common complication following use of this device is implant failure and cutout, which occurs most commonly within 3 months following surgery. A known risk factor of this complication is an increased tip-apex distance, with a 60% failure rate reported with a distance exceeding 45mm.
Gardner et al. reviewed the use of a helical blade device to stabilize
intertrochanteric hip fractures. They reported a mean telescoping in unstable and stable fractures of 4.3 mm and 2.6 mm, respectively. They also found that blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. They concluded that position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping.
Haidukewych et al. reviewed patients with failed internal fixation of a hip fracture. They report that salvage options are dependent on the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. They conclude that in younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. Conversely, in older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty is recommended.
Figure A is the AP radiograph of the right hip treated with a cephalomedullary nail. Illustration A demonstrates screw cutout.
Incorrect Answers:

OrthoCash 2020
Figure A is the radiograph of a 42-year-old female who presents to the trauma bay following a motor vehicle collision. She subsequently undergoes ORIF through a posterior approach. Iatrogenic injury to which nerve in Figure B is most likely with this approach?

Question 23

A 25-year-old woman undergoes surgical treatment of a displaced proximal humeral fracture via a deltopectoral approach. At the first postoperative visit, she reports a tingling numbness along the anterolateral aspect of the forearm. What structure is most likely injured?

Explanation

DISCUSSION: Sensation along the anterolateral aspect of the forearm is supplied by the lateral antebrachial cutaneous nerve, the terminal branch of the musculocutaneous nerve. The musculocutaneous nerve can be injured by proximal humeral fractures or dislocations, and is also at risk during surgical exposure if excessive retraction is placed on the conjoint tendon. The musculocutaneous nerve enters the conjoint tendon 1 cm to 5 cm distal to the coracoid process.
REFERENCES: McIlveen SJ, Duralde XA, D’Alessandro DF, et al: Isolated nerve injuries about the shoulder. Clin Orthop 1994;306:54-63.
Warner JP: Frozen shoulder: Diagnosis and management. J Am Acad Orthop Surg

1997;5:130-140.

Question 24

Which of the following statements is true regarding articular cartilage?

Explanation

The one role of collagen in articular cartilage is to provide the structural framework to resist swelling under high osmotic tissue pressures created by aggrecan. Type II collagen is the predominant type in articular cartilage.
Proteoglycans, the most common of which is aggrecan, are produced by chondrocytes and give articular cartilage its hydrophilic properties. Multiple glycosaminoglycans (GAGs), such as chondroitin and keratin can attach to core proteins to form aggrecans. Link proteins then help aggrecans interact with hyaluronic acid. The negative charge of this complex helps create a strong osmotic gradient, which attracts water and increases tissue pressures. Normal aging involves a decrease in the water content of the extracellular matrix while osteoarthritis is associated with increased water content, which leads to loss of strength and elasticity.
Chen et al. evaluated the strain and depth related properties of articular cartilage in bovine models. They found that the zero-strain permeability, zero-strain equilibrium confined compression modulus, and deformation dependence constant differed among the layers of cartilage. They suggest that the complex strain-dependent properties of articular cartilage of different thickness and location have clinical implications for tissue engineering.
Illustration A is a diagram depicting the extracellular matrix of articular cartilage. Incorrect Answers:

Question 25

A 53-year-old man has a 4- x 5-cm high-grade soft-tissue sarcoma in the midthigh. As part of the staging evaluation, regional nodes should be assessed by

Explanation

DISCUSSION: In general, soft-tissue metastases to regional nodes are a relatively rare occurrence (less than 5% overall). The incidence of lymphatic metastasis is highest for synovial sarcoma, rhabdomyosarcoma, clear cell sarcoma, and epithelioid sarcoma. Regional nodes should be assessed clinically. CT is not used to routinely assess regional nodes. Evaluation of a sentinal node is not indicated because of the low incidence of regional nodal involvement. Fine needle aspiration may be indicated to assess clinically suspicious nodes. Prophylactic inguinal node dissection is contraindicated because it may lead to unnecessary complications such as lymphedema.
REFERENCE: Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 26

A 55-year-old active left-hand-dominant woman sustains a minimally displaced (less than 2 mm displaced) left proximal humerus fracture that involves fractures of the greater tuberosity and surgical neck. Her activities include tennis and golf. What is the best treatment for this patient?

Explanation

DISCUSSION
Literature guiding indications for surgical vs nonsurgical treatment of proximal humerus fractures is not definitive. Many of the recommendations are based on older, nonrandomized series. Newer data suggest that surgical and nonsurgical treatment provide comparable results. Although surgical treatment is preferred for treatment of displaced fractures, fractures with minimal displacement are best managed without surgery.
RECOMMENDED READINGS
Hauschild O, Konrad G, Audige L, de Boer P, Lambert SM, Hertel R, Südkamp NP. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg. 2013 Oct;133(10):1385-93. doi:10.1007/s00402-013-1798-2. Epub 2013 Jul 3. PubMed PMID: 23820852.View Abstract at PubMed
Bell J-R, Cadel ER. Shoulder trauma: Bone. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:319-337.

Question 27

A 25-year-old carpenter falls on his outstretched arm. What physical finding best correlates with the lesion seen on the MRI scan shown in Figure 3?

Explanation

DISCUSSION: The MRI scan shows disruption of the subscapularis muscle. Subscapularis rupture is associated with weakness in internal rotation as shown with a positive lift-off test as described by Gerber and Krushell. The belly press test also has been shown to be a useful clinical test for this problem. Weakness in external rotation and abduction is more consistent with supraspinatus and infraspinatus tears. Deltoid atrophy is associated with an axillary nerve injury. Loss of biceps contour is associated with rupture of the long head of the biceps.
REFERENCES: Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Greis PE, Kuhn JE, Schultheis J, et al: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589-593.

Question 28

Figure 7 shows the radiograph of a 64-year-old man who has neck pain and weakness of the upper and lower extremities following a motor vehicle accident. Examination reveals 3/5 quadriceps and 4/5 hip flexors but no ankle dorsiflexion or plantar flexion. His intrinsics are 1/5, with finger flexors of 3/5. He is awake, alert, and cooperative. Management should consist of

Explanation

DISCUSSION: In patients with facet dislocations and an incomplete neurologic deficit, early decompression of the canal via reduction of the dislocation generally is considered safe if the patient is alert and can cooperate. However, patients who cannot cooperate with serial neurologic examinations during the reduction are at risk for increased deficit secondary to herniated nucleus pulposus, and MRI should be performed prior to either closed or
open reduction.
REFERENCES: Star AM, Jones AA, Cotler JM, et al: Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068-1072.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocations using traction weight up to 140 pounds. Spine 1993;18:386-390.

Question 29

Which of the following complications is uniquely associated with an anterior approach to the lumbosacral junction?

Explanation

DISCUSSION: Retrograde ejaculation is a sequela of injury to the superior hypogastric plexus. The structure needs protection, especially during anterior exposure of the lumbosacral junction. The use of monopolar electrocautery should be avoided in this region. The ideal exposure starts with blunt dissection just to the medial aspect of the left common iliac vein, sweeping the prevertebral tissues toward the patient’s right side. Although erectile dysfunction can be seen after spinal surgery, it is not typically related to the surgical exposure because erectile function is regulated by parasympathetic fibers derived from the second, third, and fourth sacral segments that are deep in the pelvis and are not at risk with the anterior approach. The other choices are complications of spinal surgery but are not uniquely associated with an anterior L5-S1 exposure.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine, ed 1. New York, NY, Springer-Verlag, 1983, p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 30

Figures 1 and 2 display the radiographs obtained from a woman who had volar plating of the distal radius 8 months earlier. Two days ago, she noticed she could not actively extend her thumb. What is the most appropriate treatment that would restore active thumb extension?

Explanation

EXPLANATION:
Although the fracture is aligned in anatomic position, prominence of a least one of the distal screws is evident on the lateral radiographic view. The prominent screw is the most likely cause of the EPL tendon rupture. If the patient chooses surgical treatment, the best option would be removal of the offending hardware combined with extensor indicis proprius to EPL tendon transfer. Intercalary grafting would also be an acceptable option. If the tendon transfer were to be performed alone, the prominent screw(s) could rupture the transferred tendon as well. Also, it is rarely possible to repair the EPL tendon primarily in such cases, because this rupture is an attrition type. Casting would obviously not provide any benefit in this situation, and IP arthrodesis would not be the first surgical treatment option. This problem can be avoided by using shorter screws or not placing screws in plate holes that direct screws into the third dorsal extensor compartment. Intraoperative fluoroscopy and special views, such as the carpal shoot-through view, are useful for avoiding this complication.

Question 31

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

Explanation

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

Question 32

Figure 26 shows the clinical photograph of a patient who has developed a residual limb ulcer following a traumatic transtibial amputation 2 years ago. What is the preferred treatment to resolve the ulcer?

Explanation

DISCUSSION: The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
REFERENCES: Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.
Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Relat Res 1999;361:108-115.

Question 33

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Explanation

DISCUSSION:
Some authors have reported the incidence of lateral femoral cutaneous nerve neuropraxia following hip arthroplasty with the direct anterior approach to be near 80%, but resolution of the sensory deficits has been observed in most patients over time. Femoral nerve palsy has been reported to occur in .64% to 2.3% direct lateral (Hardinge) and anterolateral (Watson-Jones) approaches, and the superior gluteal nerve may be injured with proximal extension of the abductor muscular dissection. The posterior approach has been reported to be associated with sciatic nerve injury, especially in cases of dysplasia. Pudendal nerve injury has not been reported with the anterior, anterolateral, direct lateral, or posterior approaches to hip
arthroplasty. It has been reported following hip arthroscopy and the use of a traction table, however.

Question 34

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

Explanation

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 35

Flexion-distraction injuries of the thoracolumbar spine are most frequently associated with injury to what organ system?

Explanation

DISCUSSION: In patients with flexion-distraction injuries of the thoracolumbar spine, 50% have associated, potentially life-threatening, visceral injuries that occasionally are diagnosed hours or even days after admission. Based on these findings, consultation with a general surgeon is recommended. Blunt and penetrating injuries to the cardiopulmonary system or aorta sometimes can be seen with this type of injury, but they are no more common than with other types of thoracolumbar fractures because of the relatively mild bony injury anteriorly. Neurologic trauma with this type of fracture is also somewhat rare.
REFERENCES: Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 351-360.
Inaba K, Kirkpatrick AW, Finkelstein J, et al: Blunt abdominal aortic trauma in association with thoracolumbar spine fractures. Injury 2001;32:201-207.

Question 36

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Explanation

DISCUSSION: A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%.
REFERENCES: Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.
Itoi E, Kuelchle DK, Newman SR, Morrey BF, An KN: Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546-550.

Question 37

A 49-year-old man is seeking a second opinion for continued knee pain and swelling. He went to his primary doctor for swelling "on top of his knee," and he says his doctor drained some clear fluid. He noted that his condition improved for about 1 week before the swelling returned. He now has increasing pain and redness around his kneecap. Examination reveals significant swelling of his prepatellar bursa, with erythema over the bursa that extends to the surrounding skin. His temperature in the office is 101.7°F. What is the next step in treatment for this patient? Review Topic

Explanation

This patient has septic prepatellar bursitis. Padding, cold therapy, compression, nonsteroidal anti-inflammatory drugs, and aspiration are thought to be acceptable treatments for aseptic prepatellar bursitis; they have little role in septic bursitis. Antibiotics along with aspiration or placement of a percutaneous drain have been associated with success in some cases of septic prepatellar bursitis, but the standard treatment is complete bursectomy with systemic antibiotics.

Question 38

What is the most serious complication that may occur with a ceramic-on-ceramic bearing in a total hip prosthesis?

Explanation

Fortunately, due to improvements in strength and quality control, fracture of a modern ceramic hip bearing is very rare. However, when a ceramic bearing does fracture, numerous fragments may become embedded in the capsular tissues. During revision, the surgeon must make every reasonable effort to locate and remove these fragments. Among other complications, fragments that remain behind can become entrapped between the bearing surfaces of the new implant and initiate severe wear. In normal use, ceramic bearings have excellent wear resistance. Squeaking may be extremely annoying to the patient, but is not inherently dangerous and sometimes resolves spontaneously. Dislocation is a serious complication regardless of the type of bearing, but it sometimes may be treated without requiring a reoperation and, if revision is required, it typically is not as problematic as with a fractured ceramic bearing. Infection is to be avoided, but it is not a complication directly related to the use of a ceramic bearing.

Question 39

Figure 91 is the radiograph of a 20-year-old man who kicked a door while intoxicated. At the emergency department, his leg is placed into a long-leg cast. After 2 hours, he reports increasing pain, numbness, and tingling in his toes. What is the most appropriate initial treatment?

Explanation

Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 40

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

Explanation

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

Question 41

Figure 35 shows a postoperative radiograph of a femur fracture proximal to a total knee prosthesis that was treated by open reduction and blade plate fixation 9 months ago. What is the most likely reason the previously well seated screw has backed out of the central portion of the plate?

Explanation

[Radiograph: An A-P view of the distal femur. There is patchy increased radiodensity in the mid-plate region at the level of the fracture, which was just distal to the middle-distal third junction. The screw in the middle hole of the plate has backed out approximately 1 cm. There is no obvious fracture line at this time. The lateral cortex is not intact.]
The referenced article clearly states that the major cause of failure of fractures to heal is nonunion. From the radiograph it appears the screw at one time was long enough. While the distal fragment perhaps has some disuse osteopenia there is no focal area of what could be considered osteonecrosis. We are not given any history of possible infection even though this could be the case.

Question 42

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Explanation

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 43

A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.” He could not finish the game but was able to bear weight with a limp. He has had two similar episodes but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was otherwise ligamentously stable, and there were no other noteworthy findings.Figures 3 and 4 are this patient's proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

Explanation

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair.
Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Question 44

Survival rates for children with soft-tissue sarcoma other than rhabdomyosarcoma are best correlated with

Explanation

DISCUSSION: In review of 154 patients with nonrhabdomyosarcoma, Rao reported that histologic grade, tumor invasiveness, and adequate surgical margin were the most important prognostic factors. Histologic subtype, use of adjuvant chemotherapy, and patient age were not as important. Size related to degree of invasiveness was not statistically significant.
REFERENCES: Rao BN: Nonrhabdomyosarcoma in children: Prognostic factors influencing survival. Semin Surg Oncol 1993;9:524-531.
Andrassy R, et al: Non-rhabdomyosarcoma Soft-Tissue Sarcomas: Pediatric Surgical Oncology. Philadelphia, PA, WB Saunders, p 221.

Question 45

A 36-year-old woman is wearing an ankle-foot orthosis for a foot drop secondary to spastic hemiplegia following a postpartum stroke 2 years ago. Knee and hip motion and strength are within normal ranges. She has undergone multiple rounds of physical therapy but has seen no improvement over the past several months. No improvement has been recorded by electromyography (EMG) studies over the past year. Examination reveals a 5-degree plantar flexion contracture with clonus, heel varus, and compensatory knee hyperextension when standing. She has 4/5 power in the tibialis anterior and gastrocnemius soleus complex with resistance testing. Everters are 2/5 to resistance testing. EMG gait studies show that the tibialis anterior demonstrates activity during both swing and stance phase that is increased during swing phase. Premature firing of the triceps surae is noted when positioning the foot in equinus prior to floor contact. What is the most appropriate management?

Explanation

DISCUSSION: The patient has a dynamic varus deformity secondary to spasticity of the tibialis anterior during stance phase with inverter/everter imbalance. The patient still has active motion of the tibialis anterior; therefore, an out-of-phase posterior tibial tendon transfer should not be performed. The same is true of the Bridle procedure. Transfer of the posterior tibialis in this patient may also result in subsequent planovalgus deformity. Lengthening of the Achilles tendon through a percutaneous tenotomy will restore dorsiflexion and decrease clonus from the stretch response. If adequate dorsiflexion is not obtained intraoperatively, then posterior tibialis tendon lengthening may be considered. A split tibialis anterior tendon transfer to the lateral cuneiform, or, transfer of the entire tendon to the cuneiform should correct the varus component and compensate for the weakened peroneals.
REFERENCES: Yamamoto H, Okumura S, Morita S, et al: Surgical correction of foot deformities after stroke. Clin Orthop Relat Res 1992;282:213-218.
Piazza SJ, Adamson RL, Moran MF, et al: Effects on tensioning errors in split transfers of tibialis anterior and posterior tendons. J Bone Joint Surg Am 2003;85:858-865.
Morita S, Muneta T, Yamamoto H, et al: Tendon transfers for equinovarus deformed foot caused by cerebrovascular disease. Clin Orthop Relat Res 1998;350:166-173.

Question 46

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

Explanation

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

Question 47

A 23-year-old male college quarterback presents with acute left shoulder pain after being tackled. A radiograph of the injury is shown in figure A. After successful closed reduction, what shoulder position should be avoided in order to minimize the risk of a repeat injury? Review Topic

Explanation

The patient presents with a traumatic posterior shoulder dislocation and radiographic evidence of a reverse Hill-Sachs type injury. The patient should avoid adduction, 90 degrees flexion, and internal rotation in order to decrease the risk of re-dislocation.
Shoulder stability is achieved through the both dynamic and static stabilizers. The static stabilizers include the bony morphology of the joint, glenoid labrum, capsule, and glenohumeral ligaments. The contributions of the glenohumeral ligaments to shoulder stability are dependent upon the position of the humerus relative to the glenoid. Posterior stability is afforded to the joint by the superior glenohumeral ligament (SGHL) and the posterior band of the inferior glenohumeral ligament (IGHL). The SGHL specifically is taught and provides posterior stability with the shoulder in flexion, adduction, and internal rotation.
Kim et. al. reviewed their experience treating 27 athletes diagnosed with traumatic posterior shoulder instability and treated with arthroscopic posterior labral repair and capsular shift. Most patients were found to have an incompletely stripped posterior capsulolabral complex. After arthroscopic repair and shift, all 26 of the 27 patients treated had improved shoulder function and objective scores, a stable shoulder, and were able to return to sport.
Millett et. al. reviewed posterior shoulder instability. They describe the static restraints of the posterior shoulder as the SGHL, posterior band of IGHL, and the coraohumeral ligament (CHL). The SGHL and CHL are both taught in the position of flexion, adduction, and internal rotation, whereas the posterior band of the IGHL is taught in abduction. They describe posterior instability occuring secondary to overhead sports due to repetitive microtrauma causing gradual capsular failure.
Figure A is an axillary radiograph of the left shoulder demonstrating a posterior dislocation and an engaging reverse Hill-Sachs lesion.
Incorrect Answers:

Question 48

A 29-year-old recreational basketball player has developed pain to the distal aspect of her patella that occurs during warm-ups and returns toward the end of the game. She reports no history of trauma, effusions, instability, and no mechanical symptoms. On examination, she is point tender at the inferior pole of the patella, lacks patella apprehension, and has a Q-angle of 15°. She has no ligamentous laxity. Radiographs are unremarkable. What is the best next step?

Explanation

Patellar tendinopathy is a relatively common condition in athletes for which repetitive jumping is the norm, especially volleyball and basketball athletes. The prevalence has been reported to be up to 32% in professional basketball players. Initial management is nonoperative in nature with eccentric exercises providing the most reliable clinical results. The other selections have not demonstrated consistent longterm results.

Question 49

A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and

Explanation

The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended.

Question 50

A 72-year-old woman who was doing well after undergoing total shoulder arthroplasty for arthritis 4 months ago is suddenly unable to elevate her arm. Examination reveals 70 degrees of external rotation compared with 45 degrees on the uninvolved side, and she is unable to lift her hand off her lower back. Radiographs are shown in Figures 43a through 43c. Treatment should consist of

Explanation

DISCUSSION: Results of treatment of subscapularis rupture are best when immediate repair is performed. When the cause of the anterior instability is the result of rupture of the subscapularis tendon and the component position is acceptable, revising the position of the component is unnecessary. Restoring the coracoacromial arch and subacromial decompression are related to superior instability and rotator cuff pathology, respectively, and would not correct the instability caused by subscapularis rupture.
REFERENCES: Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM: Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 51

A 10-lb, 2-oz infant who was born via a difficult breech delivery 12 hours ago is now being evaluated for hip pain. Although the infant is resting comfortably, examination reveals that the patient is not moving the right lower extremity and manipulation of the right hip causes the infant to cry. The Galeazzi sign is positive. An AP radiograph of the pelvis shows proximal and superior migration of the right proximal femoral metaphysis. What is the most likely diagnosis?

Explanation

DISCUSSION: Transphyseal fractures of the proximal femur at birth are more likely to occur in large newborns after a difficult delivery. At rest, the patients are comfortable and show a pseudoparalysis; however, passive motion of the lower extremity results in discomfort. Teratologic hip dislocations will have a positive Galeazzi sign, but are not painful. Development of a septic hip would be unlikely within 12 hours postpartum. Congenital coxa vara is typically painless. Postpartum ligamentous laxity might account for a positive Ortolani sign, but is painless.
REFERENCES: Weinstein JN, Kuo KN, Millar EA: Congenital coxa vara: A retrospective review. J Pediatr Orthop 1984;4:70-77.
Beaty JH: Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 409-425.

Question 52

Figure 70 is the radiograph of a 14-year-old girl with increasing posterior ankle pain, especially during pointe technique exercises. Nonsurgical measures such as modification, stretching, and injection have been unsuccessful. Which nerve is most vulnerable to injury during endoscopic excision of this lesion?

Explanation

DISCUSSION
The pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

Question 53

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Explanation

produce higher levels of SMN protein.
The other choices are not associated with spinal muscular atrophy.Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy.

Question 54

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Explanation

The extensor carpi radialis brevis is most often cited as the anatomic location of pathology in lateral epicondylitis. Histologic examination demonstrates noninflammatory tissue, primarily angiofibroblastic tendinosis though normal tendon histology is also present. There is usually no evidence of acute inflammation or chondroblastic tissue, or significant calcium deposition.

Question 55

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Explanation

DISCUSSION: Cervical laminectomy is an accepted treatment for multilevel cervical spondylotic myelopathy. When the compression is posterior, laminectomy addresses it directly; when the compression is anterior, it is addressed indirectly (the spinal cord floats posteriorly away from the anterior compression). Preexisting kyphosis is a contraindication to laminectomy because the cord is unable to float posteriorly away from the anterior compression, and the risk for increasing kyphosis is significant. Kyphosis after laminectomy is more likely to develop in younger patients who have fewer degenerative changes to stabilize the spine.
REFERENCES: Malone DG, Benzyl EC: Laminotomy and laminectomy for spinal stenosis causing radiculopathy or myelopathy, in Clark CR (ed.): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 817-825.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 673-680.

Question 56

A 32-year-old woman has had progressive left foot pain over the first metatarsophalangeal (MTP) joint. Footwear is becoming problematic. There is full range of motion of the first MTP with medial eminence pain. Her weightbearing radiograph reveals a hallux valgus angle (HVA) of 35 degrees and a 1-2 intermetatarsal angle (IMA) of 10 degrees. What is the best next step?

Explanation

DISCUSSION
Patients with painful progressive hallux valgus are surgical candidates. Presurgical evaluation includes radiographic examination. The IMA between the first and second metatarsals as well as the HVA must be measured. If the IMA is smaller than 15 degrees and the HVA is smaller than 35 degrees, a distal osteotomy is preferred. Distal soft-tissue reconstruction is only useful for IMAs smaller than 11 degrees and HVAs smaller than 25 degrees. Proximal osteotomies and the Lapidus bunionectomy are reserved for larger hallux valgus deformities with IMAs exceeding 15 degrees and HVAs exceeding 35 degrees.
RECOMMENDED READINGS
Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Distal Chevron Osteotomy: Preoperative Radiological Factors Contributing to Long-Term Radiological Recurrence of Hallux
Valgus. Foot Ankle Int. 2014 Sep 5. pii: 1071100714548703. [Epub ahead of print] PubMed PMID: 25192724. View Abstract at PubMed
Fakoor M, Sarafan N, Mohammadhoseini P, Khorami M, Arti H, Mosavi S, Aghaeeaghdam A. Comparison of Clinical Outcomes of Scarf and Chevron Osteotomies and the McBride Procedure in the Treatment of Hallux Valgus Deformity. Arch Bone Jt Surg. 2014 Mar;2(1):31-

Question 57

Which of the following represents the most appropriate treatment at this time?

Explanation

DISCUSSION FOR QUESTIONS 104 THROUGH 106:
This is a classic presentation of a giant cell tumor. It is a benign aggressive bone tumor consisting of distinct undifferentiated mononuclear cells. Most occur in patients 30 years to 50 years of age (90% are older than age 20 years) and affect woman more than men. Pain and swelling for 2 to 3 months is classic.The most common location is the distal femur. The biopsy specimen shows multinucleated giant cells amid a background of mononuclear cells. This benign tumor may rarely metastasize to the lung (less than 2% of the time). A CT scan of the chest is required to rule out any further lesions. Curettage, with local adjuvants, such as phenol, cryotherapy, or argon beam, and cementation represents the best treatment option at this time.
CLINICAL SITUATION FOR QUESTIONS 107 THROUGH 109
An otherwise healthy 65-year-old man reports progressive and unrelenting back pain for the last 6 weeks that is nonmechanical in nature. He denies leg pain, weakness, bowel or bladder symptoms, and any significant past medical history. His pain is increased at night. Examination reveals pain with percussion throughout his thoracic spine. He is neurologically intact. AP and lateral radiographs of the thoracic and lumbar areas show diffuse osteopenia with no fractures.

Question 58

What preoperative factor correlates best with the outcome of rotator cuff repair?

Explanation

DISCUSSION: The size of the rotator cuff tear in both anteroposterior and mediolateral dimensions has been found to correlate best with outcome. Older patient age and rupture of the long head of the biceps tend to be associated with larger tears and, therefore, may be associated indirectly with a poorer outcome.
REFERENCES: Iannotti JP: Full-thickness rotator cuff tears: Factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95.
Iannotti JP, Bernot MP, Kuhlman JR, Kelley MJ, Williams GR: Postoperative assessment of shoulder function: A prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg 1996;5:449-457.

Question 59

A 6-month-old child has the deformity seen in Figure 10. There are no other known associated problems. What is the etiology of this condition? Review Topic

Explanation

The radiograph demonstrates a type IV radial clubhand (radial dysplasia) with complete absence of the radius. This is a pre-axial deficiency usually with complete absence of the thumb. The condition is thought to be caused by an injury to the formation of the apical ectodermal ridge early in embryology. It is not an inherited condition unless it is associated with other syndromic problems. It is not known to be associated with specific teratogens. Fibroblast growth factor is involved in angiogenesis, wound healing, and embryonic development, but is not known to be associated with radial clubhand.

Question 60

What is the structure indicated by the letter “A” in Figure 21?

Explanation

DISCUSSION: The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter “A” is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter “C” and the annular ligament is indicated by the letter “B.” The transverse ligament is a component of the medial collateral ligament complex.
REFERENCES: Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1993, p 30.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 61

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

Explanation

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

Question 62

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Explanation

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

Question 63

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

Explanation

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

Question 64

A year-old woman has a year history of gradually increasing diffuse and global right knee pain. Her main issues are difficulty with stairs, stiffness with prolonged sitting, and swelling. She has taken NSAIDs and has received intra-articular steroid injections, all with decreasing efficacy. Her right knee examination reveals a range of motion of 15° to 80° with a fixed deformity to varus and valgus stress. Her symptoms are no longer manageable nonsurgically. Radiographs reveal a degree mechanical axis deformity. When using the measured resection technique during total knee arthroplasty (TKA), the best way to avoid femoral malrotation is to reference the

Explanation

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

Question 65

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present.
REFERENCES: McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.
Thometz J: Tarsal coalition. Foot Ankle Clin 2000;5:103-118.

Question 66

Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic

Explanation

Failure to reconstruct a torn anterior cruciate ligament or posterior cruciate ligament at the time of posterolateral corner (PLC) repair or reconstruction dramatically increases the likelihood of PLC failure. Uncorrected varus malalignment places extensive tension on a PLC reconstruction and is a well recognized cause of failure. Valgus malalignment and medial collateral ligament reconstruction are not recognized means of failure.

Question 67

Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes

Explanation

DISCUSSION: The use of gamma radiation to sterilize polyethylene will result in the formation of free radicals in the material that increase the susceptibility of the material to oxidation and wear. The packaging can also have an impact. If the polyethylene is packaged in air, the oxygen in the packaging can significantly oxidize the material on the shelf prior to clinical use. Gas plasma and ethylene oxide sterilization do not appear to increase oxidation of polyethylene.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 449-486.
Wright TM: Ultra-high molecular weight polyethylene, in Morrey BF (ed): Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991, pp 37-46.
Collier JP, Sutula LC, Currier BH, et al: Overview of polyethylene as a bearing material: Comparison of sterilization methods. Clin Orthop 1996;333:76-86.
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Question 68

A 27-year-old man now reports dorsiflexion and inversion weakness after an automobile collision 6 months ago in which compartment syndrome developed isolated to the anterior and deep posterior compartments. Examination reveals the development of a progressive cavovarus deformity, but the ankle and hindfoot remain flexible. In addition to Achilles tendon lengthening, which of the following procedures is most likely to improve the motor balance of his foot and ankle? Review Topic

Explanation

Fracture non-union
Avascular necrosis
Skin necrosis
Plantar flexion weakness
Ankle stiffness
Figure A shows an avulsion fracture of the calcaneal tuberosity. Immediate open reduction and internal fixation is required to prevent wound complications.
Displaced avulsion fractures of the calcaneal tuberosity should be managed urgently to prevent necrosis of the soft tissues overlying the heel. In these injuries, the Achilles tendon is securely attached to the fractured tuberosity. Urgent closed reduction and casting is usually not possible due to the power and proximal pull of the triceps surae. Surgical fixation is required. The best treatment modality is open reduction and bone-to-bone fixation with screws. Closed reduction and percutaneous pinning fixation is not strong enough to provide a stable fixation of the tuberosity.
Lui reported on avulsion fractures of the bony insertion of the Achilles tendon at the calcaneus. He stated that screw fixation alone is not sufficient for repair of these injuries. His technique involved two suture anchors used capture the small bone fragment to the calcaneus. This allowed for the pull of the triceps surae to be neutralized and early physical therapy.
Hess et al. looked at a case series of calcaneal tuberosity avulsion fractures that were
treated in a delayed fashion. All three patients with posterior tuberosity calcaneal avulsion fractures developed skin necrosis because of a delay in treatment.
Figure A shows a displaced posterior tuberosity calcaneal avulsion fracture. Illustration A shows skin breakdown overlying the posterior tuberosity calcaneal avulsion fracture.
Incorrect Answers:

Question 69

Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?

Explanation

DISCUSSION: The most important aspect in the decision for surgery in an acetabular fracture is the ability of the femoral head to remain concentrically reduced under the dome in AP and Judet oblique views of the pelvis. If this parameter is present, then the need for surgery is determined by other aspects such as fragmentation, age, incongruity, and displacement. If the head remains stable under the dome without traction, there is sufficient acetabular dome to provide stability, and nonsurgical treatment may be appropriate.
REFERENCES: Tile M: Assessment and management of acetabular fractures, in Tile M (ed): Pelvic and Acetabular Fractures, ed 2. Baltimore, MD, Williams and Wilkins, 1995, pp 305-354.
Letournel E: Acetabular fractures: Classification and management. Clin Orthop 1980;151:81-106.
Letournel E, Judet R: Fractures of the Acetabular, ed 2. Berlin, Springer-Verlag, 1993, pp 29-49.

Question 70

Figure 36 shows an AP radiograph of a 65-year-old man who reports activity-related groin pain. History reveals that he underwent total hip arthroplasty 12 years ago. What is the most likely diagnosis?

Explanation

DISCUSSION: The AP radiograph demonstrates extensive periacetabular osteolysis. The central hole eliminator has dissociated from the shell and migrated into a lytic defect in the ischium. In a retrieval study, most periacetabular osteolytic lesions had a clear communication pathway with the joint space. Lesions with communication to the joint via several pathways or through a central dome hole (as in this patient) were larger and more likely to be associated with cortical erosion. Although periprosthetic tumors have been described, they are rare and particle-induced inflammation around a prosthesis does not seem to increase the risk for carcinogenesis.
REFERENCES: Visuri T, Pulkkinen P, Paavolainen P: Malignant tumors at the site of total hip prosthesis: Analytic review of 46 cases. J Arthroplasty 2006;21:311-323.
Bezwada HP, Shah AR, Zambito K, et al: Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty. J Arthroplasty 2006;21:242-248.
Kitamura N, Naudie DD, Leung SB, et al: Diagnostic features of pelvic osteolysis on computed tomography: The importance of communication pathways. J Bone Joint Surg Am 2005;87:1542-1550.

Question 71

A study was conducted in 500 patients to measure the effectiveness of a new growth factor in reducing healing time of distal radial fractures. The authors reported that average healing time was reduced from 9.2 to 8.9 weeks (P < 0.0001). Because the difference was highly statistically significant, they recommended routine clinical use of this drug despite its high cost. A more appropriate interpretation of these results is that they are

Explanation

DISCUSSION: The results are statistically significant (at the arbitrary level of P < 0.05). That is, they indicate a probability of only 1/10,000 that the observation that the drug is effective in reducing healing time by 0.3 weeks occurred by chance selection of the study subjects. However, because the statistical power of a study increases with the number of subjects included (sample size), a difference that is trivial clinically can occur with a very high level of statistical significance (a very small P-value) if enough patients are included in the study. Because of this, the P-value alone, no matter how small, does not establish clinical significance or importance. Rather, the clinical significance of the observed difference must be assessed taking into consideration the medical importance of the difference if it is, in fact, true in the general population. In this example, the reduction in healing time of only a few days is probably clinically unimportant, particularly if the use of the new growth factor is expensive, complex, and/or has substantial side effects.
REFERENCE: Ebramzadeh E, McKellop H, Dorey F, et al: Challenging the validity of conclusions based on P-values alone: A critique of contemporary clinical research design and methods. Instr Course Lect 1994;43:587-600.

Question 72

The parents of a previously healthy 3-year-old child report that she refused to walk on awakening. Examination later in the day reveals that the patient can walk but with a noticeable limp. She has a temperature of 99.5 degrees F (37.5 degrees C). Range of motion measurements are shown in Figure 50. An AP pelvis radiograph is normal. Laboratory studies show a WBC count of 9,000/mm 3 and an erythrocyte sedimentation rate of 10 mm/h. Management should consist of

Explanation

DISCUSSION: The patient has the typical history and presentation of transient synovitis of the hip, a condition that is more common in children age 2 to 5 years but which may affect children up to 12 years. The discomfort typically is noted on awakening, and the child will refuse to walk. Later in the day, the pain commonly improves and the child can walk but will have a limp. Mild to moderate restriction of hip abduction is the most sensitive range-of-motion restriction. The extent of the evaluation for transient synovitis depends on the intensity and duration of symptoms. Because she has been afebrile for the past 24 hours, observation is the management of choice. In the differential diagnosis of suspected transient synovitis, septic arthritis of the hip is the primary disorder to exclude. Osteomyelitis of the proximal femur also should be considered. In most patients, clinical examination will differentiate of these disorders to a reasonable certainty. Plain radiographs are normal in the early stage of an infectious process. Ultrasonography shows increased fluid in the hip joint in both transient synovitis and septic arthritis. MRI can differentiate the two conditions; however, this test would require general anesthesia and is not required in most patients in this age group. If a child with transient synovitis has a concurrent infectious process such as an upper respiratory tract infection or otitis media, the temperature will most likely be elevated. In this situation, a full evaluation for an infectious process and initiation of IV antibiotics should be considered. This would include radiographs, CBC count, erythrocyte sedimentation rate, blood cultures, aspiration of the hip joint, and IV antibiotics.
REFERENCES: Del Beccaro MA, Champoux AN, Bockers T, Mendelman PM: Septic arthritis versus transient synovitis of the hip: The value of screening laboratory tests. Annals Emerg Med 1992;21:1418-1422.
Kehl DK: Developmental coxa vara, transient synovitis, and idiopathic chondrolysis of the hip, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1035-1058.

Question 73

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

Explanation

The 18-year old competitive tennis player with no ligamentous laxity and x-ray findings consistent with a Hill-Sachs lesion and loss of glenoid contour has an instability severity index score (ISIS) of 9, which is associated with a >70% chance of recurrent instability after a arthroscopic Bankart procedure.
The surgical management of anterior shoulder instability consists of both arthroscopic and open approaches. The guiding principles for treatment are the restoration of the normal glenoid labrum anatomy and retensioning of the inferior glenohumeral ligament which is achieved via soft-tissue reconstructions (repair of any labral detachment +/- capsular shift) or bony procedures (such as transfer of the coracoid process).
Ahmed et al. reviewed 302 patients who had undergone arthroscopic Bankart repair and capsular shift for the treatment of recurrent anterior glenohumeral instability. The prevalence of patient and injury-related risk factors for recurrence was assessed. The rate of recurrent glenohumeral instability after arthroscopic Bankart repair and capsular shift was 13.2%. The risk of recurrence was independently predicted by the patient’s age at surgery, the severity of glenoid bone loss, and the presence of an engaging Hill-Sachs lesion.
Balg et al. identified risk factors for recurrent instability after arthroscopic Bankart procedure in 131 consecutive patients. Age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an AP radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour were all identified as risk factors. These factors were integrated into a 10-point preoperative instability severity index score (ISIS). Patients with a score over 6 points had an unacceptable recurrence risk of 70%.
Illustration A summarizes the components of the ISIS as developed by Balg and Boileau.
Incorrect Answers:

Question 74

Ewing’s sarcoma of bone most commonly occurs in which of the following locations?

Explanation

DISCUSSION: Ewing’s sarcoma typically occurs in the major long tubular bones, with the femur the most common location. The flat bones of the pelvis are the second most common location. Ewing’s sarcoma occurs in the fibula but with a lower incidence than that seen in the major tubular bones. Ewing’s sarcoma infrequently occurs in the metacarpals or the vertebral bodies.
REFERENCES: Simon M, Springfield D, et al: Ewing’s Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 287.
Wold LA, et al: Ewing’s Sarcoma: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 210-211.

Question 75

-Video 3 shows the physical examination of the right hip of a 14-day-old full-term female infant. There is no history of breech presentation, she was born vaginally, and is the second child born to her mother. She is otherwise healthy and has been eating and gaining weight appropriately. What is the most appropriate course of action at this time?

Explanation

Question 76

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

Explanation

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

Question 77

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment?

Explanation

DISCUSSION: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

Question 78

Where is the underlying defect in a rhizomelic dwarf with the findings shown in Figure 5?

Explanation

DISCUSSION: The radiograph shows the typical findings of achondroplasia. The defect is in fibroblast growth factor receptor 3. The pedicles narrow distally in the lumbar spine. The pelvis is low and broad with narrow sciatic notches and ping-pong paddle-shaped iliac wings. This is often called a champagne glass pelvis. Type I collagen abnormalities are typically found in osteogenesis imperfecta, and type II collagen defects are found in spondyloepiphyseal dysplasia and Kneist syndrome. COMP is defective in multiple epiphyseal dysplasia. Sulfate transport defects are seen in diastrophic dysplasia.
REFERENCES: Johnson TR, Steinbach LS: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 809-812.
Caffey J: Achondroplasia of the pelvis and lumbosacral spine: Some roentgenographic features. Am J Roentgenol 1958;80:449.

Question 79

What is the most common pediatric soft-tissue sarcoma?

Explanation

DISCUSSION: Soft-tissue sarcomas are the sixth most common cancer in children. Rhabdomyosarcoma is the most common type of pediatric soft-tissue sarcoma. Nearly 50% of rhabdomyosarcomas are diagnosed in children who are age 5 years or younger. Unfortunately, there has not been a significant increase in survival in children with metastatic rhabdomyosarcoma despite aggressive therapy including multiple-drug chemotherapy regimens.
REFERENCE: Wexler LH, Helman LJ: Pediatric soft tissue sarcomas. CA Cancer J Clin 1994;44:211-247.

Question 80

During stabilization of a slipped capital femoral epiphysis, the screw penetrates into the joint. The screw is repositioned so that it is within the femoral head. This transient penetration of the hip joint will most likely lead to

Explanation

DISCUSSION: Chondrolysis may be associated with unrecognized permanent penetration of the joint space by a pin or screw. However, transient penetration by the guide wire or screw is not associated with this problem. One study described 11 hips in which there was transient intraoperative penetration of the joint space by a guide wire or screw. These patients were followed for at least 2 years, with none showing any clinical or radiographic evidence of chondrolysis. Another retrospective study of 55 slipped epiphyses described 11 hips with transient intraoperative pin penetration, with none showing development of chondrolysis. There are no studies to suggest that transient pin penetration leads to osteonecrosis, stiffness, or premature physeal closure.
REFERENCES: Zionts LE, Simonian PT, Harvey JP Jr: Transient penetration of the hip joint during in situ cannulated-screw fixation of slipped capital femoral epiphysis. J Bone Joint Surg Am 1991;73:1054-1060.
Vrettos BC, Hoffman EB: Chondrolysis in slipped upper femoral epiphysis: Long-term study of the etiology and natural history. J Bone Joint Surg Br 1993;75:956-961.

Question 81

A 72-year-old man with a history of Parkinson’s disease, stable coronary artery disease, and mild renal insufficiency is seen for hip arthroplasty. Which of the following is considered the most appropriate bearing of choice?

Explanation

DISCUSSION: The most appropriate bearing of those listed would be a large diameter metal head on cross-linked polyethylene. Because of the renal insufficiency, metal-on-metal should be avoided because metal ions are renally excreted. Ceramic-on-ceramic implants are not necessary in this patient because of the patient’s limited activity and life expectancy, as well as the downside of increased cost, the small but definite risk of ceramic fracture, and the increased technical demands of inserting ceramic implants. A highly cross-linked liner is favored to allow for maximum head size as the patient may be at increased risk of dislocation because of his neurologic disorder.
REFERENCES: Bragdon CR, Greene ME, Freiberg AA, et al: Radiostereometric analysis comparison of wear of highly cross-linked polyethylene against 36- vs 28-mm femoral heads. J Arthroplasty 2007;22:125-129.
MacDonald SJ: Metal-on-metal total hip arthroplasty: The concerns. Clin Orthop Relat Res 2004;429:86- 93.

Question 82

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Explanation

Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.

Question 83

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

Explanation

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

Question 84

Figure 1 depicts an intraoperative photograph obtained following proximal row carpectomy. The black dot denotes the capitate. The top of the figure is radial and the bottom of the figure is ulnar. Surgical disruption of the structure identified by the forceps would result in

Explanation

EXPLANATION:
The structure identified by the forceps is the radioscaphocapitate ligament. During a proximal row carpectomy, it is very important to identify and protect this ligament. Compromise of the ligament would result in ulnar translocation of the carpus and early failure of the proximal row carpectomy procedure. If the ligament is injured during surgery, immediate repair should be performed. Green and associates discuss the importance of the radioscaphocapitate ligament in stabilizing the carpus after this procedure is performed. Nakamura and associates compared 3-mm, 6-mm, and 10-mm radial styloidectomies, and only the 3-mm styloidectomy subsequently preserved carpal stability. Compromise of the radioscaphocapitate ligament occurred when larger portions of the radial styloid were excised. Distal radioulnar joint instability would result only from the disruption of the distal radioulnar joint stabilizers. Avascular necrosis would not occur, because the capitate receives its blood supply mainly from the palmar vessels. Finally, loss of active thumb IP flexion would not occur, because the flexor pollicis longus tendon would remain intact even if ligament compromise were to occur.

Question 85

..Figures 87a through 87e are the radiograph, MRI scans, and biopsy specimen of an 83-year-old woman who is experiencing pain in her distal thigh with activity and at night. She has undergone total hip arthroplasty for hip osteoarthritis. The most appropriate treatment is

Explanation

CLINICAL SITUATION FOR QUESTIONS 88 through 92
Figures 88a and 88b are the radiographs of a 70-year-old woman with a remote history of localized renal cell carcinoma. She has insidious onset of right shoulder pain that worsens with any activity and at night. She appears otherwise healthy.

Question 86

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Explanation

The radiograph shows us a pelvic inlet view of an APC II or III pelvic ring injury with syndesmotic disruption greater than 5cm, and a right SI joint disruption as well. APC (and some VS) injuries are associated with increases in pelvic volume allowing occult blood loss. All of the responses are viable options, but on a spectrum of timing. ORIF and CRPSF are both more elective options that require appropriate pre-operative planning and a stable patient, not to be undertaken in a hemodynamically unstable patient. The article referenced from JBJS 2002 reviewed 150 patients with pelvis fractures and the use of angiography for the management of “haemorrhage.” They concluded/recommended skeletal stabilization as the first line of treatment, followed by possible laparotomy and packing of pelvic retroperitoneum as a second line of treatment, with pelvic angiography and embolization only in those patients that were unresponsive to both previous interventions. They based their recommendations also on anatomical studies that suggested that the surfaces of the fracture and veins, rather than arteries, were the major sources of bleeding in these patients. External pelvic stabilization in their study included external fixators, pneumatic anti-shock garments, and pelvic clamps.
Cook RE, Keating JF, Gillespie I: The role of angiography in the management of haemorrhage from major fractures of the pelvis. J Bone Joint Surg Br 2002;84:178-182.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp395-405.
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Question 87

A 55-year-old woman is referred for evaluation of a painful knee replacement. She underwent total knee arthroplasty (TKA) more than 1 year ago without perioperative complications but has had consistent pain since the surgery. The patient’s preoperative radiographs and postoperative radiographs are shown in Figures below. Examination reveals medial laxity during valgus stress testing and range of motion of 0° to 70°. Her erythrocyte sedimentation rate and C-reactive protein level are normal. What is the best next step?

Explanation

DISCUSSION:
The radiographs show substantial valgus malalignment of the femoral component, with lateral mechanical axis deviation. Clinically, by examination she displays instability and stiffness as a result. Revision knee replacement is appropriate and should consist of total revision to stemmed femoral and tibial components with a varus-valgus constrained insert, given the likely attenuation of the medial collateral ligament. Open debridement with ligament balancing and polyethylene exchange do not address the underlying cause and are inappropriate. Distal femoral osteotomy is not useful in the setting of previous total knee replacement. Nonsurgical treatment with an unloader brace would be ineffective in correcting the alignment.

Question 88

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

Explanation

DISCUSSION: The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.
Herscovici D Jr, Sanders RW, Scaduto JM, et al: Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 2003;17:683-688.

Question 89

A 21-year-old minor league pitcher reports decreasing velocity and ability to target his pitches over the last 2 months. He notes that his arm will start to feel heavy in the later innings and notes pain in the posterior aspect of his shoulder in the late cocking phase of his motion. He denies any specific event that initiated his symptoms. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. Supine range of motion of the right shoulder in 90 degrees of abduction reveals external rotation to 100 degrees and internal rotation to 25 degrees. The left shoulder has 95 degrees of external rotation and 60 degrees of internal rotation. He has pain with an O'Brien's maneuver and a negative apprehension sign. What is the next most appropriate step in management? Review Topic

Explanation

The patient has glenohumeral internal rotation deficit with posterior capsular tightness; therefore, initial management should be directed at physical therapy and posterior capsular stretching. The total arc of motion (external rotation + internal rotation) should be equal between the shoulders. He has a deficit of 30 degrees in his throwing shoulder. A "sleeper stretch" is a common way for patients to stretch the posterior capsule and involves lying on the involved side with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and pushing the forearm toward the table. Subacromial injection is not indicated because the pathology of an internal rotation contracture is located within the glenohumeral joint space and not the subacromial space. A sling might be useful for comfort but will not resolve his symptoms. There is no indication for arthroscopy, SLAP repair, or anterior-inferior capsulolabral plication at this time.

Question 90

Within the intervertebral disk, aggrecan is primarily responsible for: Review Topic

Explanation

Aggrecan's primary function in the intervertebral disc is to maintain water content.
Aggrecan, the most abundant proteoglycan within the intervertebral disk, is a hydrophillic molecule which helps attract and maintain water within the disc. This is important to maintain compressive strength. Early in life aggrecan has a high percentage of chondroitin sulfate chains. With aging this gradually changes to higher percentage of keratin sulfate. Other proteoglycans include decorin and versican. Decorin is believed to regulate cell cycles and influence fibrillogensis. Versican is a large extra-cellular matrix proteoglycan involved in cell adhesion and migration.
Roughley et al. provide a review of biologic changes within the intervertebral disc during development, maturation, and degeneration. They note that aggrecan works to maintain water content within the disc, thus improving its compressive strength. Aggrecan content decreases with age leading to a loss of compressive strength.
Illustration A shows the structure of aggrecan.
Incorrect answers:

Question 91

A 52-year-old woman slips in her bathroom and strikes her right hand on a cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in Figures 5a through 5c. What is the most appropriate treatment?

Explanation

DISCUSSION: Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 92

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 93

A 20-year-old professional female jockey who is wearing a helmet is thrown from her horse. What is the most likely location of her injury?

Explanation

DISCUSSION: The incidence of injury associated with horseback rising is estimated to
be one per 350 riding hours to one per 1,000 riding hours. Of these injuries, approximately
15% to 27% are severe enough to warrant hospital admission. Significant and serious injuries in equestrian activities are associated with recreational riders and those not wearing a helmet. Head and spine injuries are more common in recreational and nonhelmeted riders. Extremity injuries are more common in professional and helmeted riders. Professional riders are less likely to be admitted to the hospital than recreational riders, and are about half as likely to be disabled
at 6 months after injury as recreational riders.
REFERENCES: Lim J, Puttaswamy V, Gizzi M, et al: Pattern of equestrian injuries presenting to a Sydney teaching hospital. ANZ J Surg 2003;73:567-571.
Petridou E, Kediloglou S, Belechri M, et al: The mosaic of equestrian-related injuries in Greece. J Trauma 2004;56:643-647.

Question 94

Figure 29 shows the radiograph of a 55-year-old patient who has recurrent total hip dislocation. Dislocation is most likely to occur in this patient when the hip is in which of the following positions?

Explanation

DISCUSSION: The patient has an acetabular component that is placed in excessive anteversion; this is confirmed by the shoot-through radiograph. The most common reasons for dislocation of a total hip replacement include inappropriate positioning of the components, inadequate abductor tension, or impingement. Implants placed without adequate total anteversion tend to dislocate posteriorly, and implants with excessive anteversion tend to dislocate anteriorly. Superior dislocations can occur if the acetabular component is placed in a severely vertical position with inadequate lateral coverage.
REFERENCE: Paterno SA, Lachiewicz PF, Kelley SS: The influence of patient-related factors and the position of the acetabular component on the rate of dislocation after total hip replacement. J Bone Joint Surg Am 1997;79:1202-1210.

Question 95

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Explanation

Radiographic assessment of the pelvis is an essential part of the initial evaluation of trauma patients. In addition to an AP radiograph, 40-degree caudal (inlet) and 40-degree cephalad (outlet) views are obtained. The caudal/inlet view is useful for detecting the integrity of the pelvic ring because it shows the sacroiliac joints and the sacrum, which can help detect either sacroiliac dislocations or sacral fractures and their displacement in the anterior-posterior plane. The outlet view detects superior or inferior displacement and sagittal plane flexion or rotation of the pelvis. A lateral radiograph of the sacrum identifies transverse fractures of the sacrum and coccyx and the degree of their displacement. A lateral view should be obtained in instances of bilateral sacral fractures and U-shaped sacral fractures in which there are bilateral vertical fractures through the sacral foramina that connect with a transverse fracture line between the second or third sacral segments. Some patients with these fractures have sacral fracture-dislocations with spinopelvic dissociation and a high incidence of neurologic injuries. The lateral view discloses the extent of displacement of the upper sacral segment (usually S2 forward on S3) and the resultant kyphotic deformity.

Question 96

A 45 year-old woman who has not reached menopause yet falls from a standing height and sustains a distal radius fracture. A DEXA scan reveals a T-score of -2.2. Which of the following treatments is indicated in this patient?

Explanation

The current recommendations for further prevention of any fragility fracture include 1200-1500mg of elemental calcium intake per day and 400-800 IU of vitamin D per day. Of note, these doses are indicated only for prevention and not sufficient for active treatment of osteoporosis (T score less than -2.5).
Medications that are approved by the FDA for active treatment of osteoporosis: alendronate, risedronate, raloxifene, estrogen, calcitonin. These medications and preventative measures help to reduce fragility fractures by as much as 50%.
Freedman et al. performed a retrospective study that looked at a cohort of patients with fragility fractures and then looked at the type and frequency of osteoporosis related interventions. They found that only 60% of patients actually were either prescribed a medication, given a referral, or ordered additional workup (DEXA scan).
Schulman et al. reviewed a series of 80 female patients regarding osteoporosis and bone health, and found that the outpatient sports medicine office setting was an excellent opportunity to educate patients on these topics. The patients' post-education test scores increased significantly after a brief counseling session, and increases in daily calcium intake and exercise levels were also seen.

Question 97

A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion? Review Topic

Explanation

The clinical presentation is consistent with post-traumatic elbow stiffness following an elbow fracture-dislocation. Supervised exercise therapy with static elbow splinting over a 6 month period has shown to have a significant improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
Post-traumatic elbow stiffness is often difficult to manage. The ultimate goal of treatment is to restore a functional range of elbow motion (30° to 130°). Nonoperative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static progressive elbow splinting with a turnbuckle, alongside aggressive physical therapy, has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Doornberg et al. looked at a retrospective case series of 29 patients with posttraumatic elbow stiffness. They showed that static progressive splinting can help gain additional motion when standard exercises fail to produce additional improvements.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Figure A shows a posterior elbow dislocation with an associated medial epicondyle fracture. Figure B shows ORIF of the fracture seen in Figure A. Illustration A shows a static progressive turnbuckle elbow splint used for post-traumatic elbow stiffness.
Incorrect Answers:

Question 98

In children between the ages of 4 and 8 years, the major blood supply to the femoral head comes from the

Explanation

DISCUSSION: From birth until the age of 4 years, the primary blood supply to the femoral head is from the medial and lateral circumflex arteries that traverse the femoral neck. After the age of 4 years, the contribution of the lateral femoral circumflex artery, which traverses the anterior portion of the femoral neck, becomes negligible. The posterosuperior and posteroinferior retinacular vessels, branches of the medial femoral circumflex artery, become the primary blood supply to the epiphysis. The contribution of the artery of the ligamentum teres is minimal after the age of 4 years.
REFERENCES: Hughes LO, Beaty JH: Fractures of the head and neck of the femur in children. J Bone Joint Surg Am 1994;76:283-292.
Ogden JA: Changing patterns of proximal femoral vascularity. J Bone Joint Surg Am 1974;56:941-950.

Question 99

A 12-year-old boy reports limping and chronic knee pain that is now inhibiting his ability to participate in sports. Clinical examination and radiographs of the knee are normal. Additional evaluation should include Review Topic

Explanation

While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.

Question 100

Figure 27 shows the radiograph of a 26-year-old man who sustained a closed head injury and a closed elbow dislocation 6 weeks ago. Examination reveals 65 degrees to 115 degrees of flexion, and intensive physical therapy has resulted in no improvement. A decision regarding the timing of surgical correction of the contracture should be based on

Explanation

DISCUSSION: The patient has heterotopic ossification, a more common finding in patients who have sustained head injuries. Treatment will require removal of the heterotopic bone and anterior and posterior capsulectomies. The main concern about timing is the possible recurrence of heterotopic bone. While an extended wait was once thought necessary, this is no longer true. The timing is based on the time since injury and evidence of bone maturation on plain radiographs. A sharp marginal demarcation of the new bone and a trabecular pattern within it are usually present 3 to 6 months after onset, indicating that it is safe to proceed with surgical excision. It is not necessary to wait more than 6 months. Bone scan results are not good indicators because they may remain “hot” for long periods of time. The levels of alkaline phosphatase and serum calcium-phosphorus product do not need to be measured.
REFERENCE: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 325-335.

Full Question & Answer Text (for Search Engines)

Question 1:

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Options:

Sesamoid fracture
Phalangeal fracture
Osteochondral lesion
Disruption of the plantar plate
Rupture of the flexor hallucis tendon

Correct Answer: Disruption of the plantar plate

Explanation:

Question 2:

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Options:

increased rates of soft-tissue infection.
greater initial construct stiffness and peak load until failure.
a slower return of digital range of motion.
an earlier time to bony union.

Correct Answer: greater initial construct stiffness and peak load until failure.

Explanation:

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased
rates of infection. Neither fixation method would increase the time to healing.

Question 3:

Options:

Resurfacing hemiarthroplasty
Resurfacing hemiarthroplasty with fascial glenoid resurfacing
Resurfacing hemiarthroplasty with cemented glenoid component
Stemmed hemiarthroplasty
Stemmed total shoulder arthroplasty

Correct Answer: Stemmed hemiarthroplasty

Explanation:

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.
J Arthroplasty 2003;18:792-798.

Question 4:

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Options:

Addition of sublaminar wires to the midlumbar spine
Cross-linking of the longitudinal rods
Use of multiple claw hook fixation in the upper thoracic spine
Use of large-diameter rods and pedicle screws
Fixation into both the ilium and the sacrum

Correct Answer: Fixation into both the ilium and the sacrum

Explanation:

Question 5:

Options:

chemotherapy.
radiation therapy.
marginal excision.
wide excision.
above-knee amputation.

Correct Answer: marginal excision.

Explanation:

Question 6:

A 54-year-old woman sustains the injury seen in Figures 71a and 71b. The injury involves her nondominant extremity. What should the patient be told regarding her expected outcome?

Options:

She should expect to return to full function and regain full range of elbow motion.
Reduction and casting has equivalent outcomes to those of surgical treatment.
This type of injury is associated with a high rate of complications.
Nerve dysfunction is commonly associated with this injury.
Ulnohumeral instability is the major complication seen with this fracture pattern.

Correct Answer: This type of injury is associated with a high rate of complications.

Explanation:

This is a Bado type 2 (posterior) Monteggia lesion, which is associated with higher rates of complications than other types of Monteggia lesions. The injury is associated with indirect high-energy trauma and less often pathologic causes. Of the four types of Monteggia lesions, the type 2 or posterior type is associated with the worst prognosis. These injuries are best treated surgically with dorsal plating of the ulna and reduction with fixation or arthroplasty of the radial head. The major complications seen with this injury pattern are nonunion and plate failure. Almost all patients have some loss of elbow range of motion. Satisfactory results based on functional scores for this injury are not universal. Neurologic injury and ulnohumeral instability are unusual with this type of injury. Full functional recovery is not expected with nonsurgical management.
(SBQ12TR.101) An otherwise healthy young adult male sustains a transverse radial shaft and ulna fracture. He undergoes definitive surgical fixation with two nonlocking compression plates (LCPs) as shown in Figure A. What is the principle of this fixation technique on bone healing?
Absolute stability with direct healing by callus formation
Relative stability with indirect healing by callus formation
Absolute stability with direct healing by internal remodeling
Relative stability with indirect healing by internal remodeling
Absolute stability with endochondral bone formation
Definitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole

Question 7:

A 45-year-old man sustained the injury shown in Figures 18a through 18c. He is neurologically intact. Which of the following is the most appropriate treatment? Review Topic

Options:

A lumbar corset
A thoracolumbosacral orthosis (TLSO) and immediate mobilization with repeat scans in 6 weeks
Anterior corpectomy and fusion alone
Posterior laminectomy without fusion
Posterior fusion with instrumentation

Correct Answer: Posterior fusion with instrumentation

Explanation:

Question 8:

Options:

hip flexion, knee extension
hip extension, knee extension
hip flexion, knee flexion
hip extension, knee flexion
the pressure does not vary based on position

Correct Answer: hip flexion, knee extension

Explanation:

Question 9:

-Assuming that the lesion can be covered appropriately and there is no drainage from the lesion, when should the patient be allowed to safely return to wrestling?

Options:

When the absence of pain is reported by the wrestler for 3 consecutive days
When 72 hours of antibiotics have been administered and there is no extension of the lesion for 48 hours
When laboratory values are within defined limits and the patient remains afebrile for 3 days
When the lesion has decreased in size by 50%

Correct Answer: When 72 hours of antibiotics have been administered and there is no extension of the lesion for 48 hours

Explanation:

DISCUSSION FOR QUESTIONS 48 AND 49
This patient has cellulitis, which is typically caused by group A Streptococcus or Staphylococcus. The patient’s lack of improvement with first-line antibiotics is concerning for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA cellulitis is becoming more prevalent in young athletes,and a high index of suspicion is required to provide appropriate intervention during this
aggressive disease process. The diagnosis is typically made clinically without the use of cultures. Oral trimethoprimsulfamethoxazole (a sulfonamide-class drug) double strength twice daily for 10 to 14 days or doxycycline (a tetracycline-class drug) 100 mg twice daily for 10 to 14 days are recommended for first-line treatment of suspected MRSA cellulitis. There is no indication to proceed with irrigation and debridement; however, if the patient develops a soft-tissue abscess or the underlying joint becomes involved, this would be an appropriate intervention. Switching the athlete to an IV cephalosporin (cefazolin) is not likely to be effective against the presumed resistant bacteria.
Ciprofloxacin (a fluoroquinolone-class drug) is effective against many bacteria, but not MRSA. The current recommendation for wrestlers with cellulitis is that return to competition be allowed after 72 hours of antibiotic treatment if there has been no extension of the cellulitis for 48 hours, the lesion can be covered, and there is no drainage from the lesion. The other responses are not current recommendations for return to competition.

Question 10:

Options:

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

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

Explanation:

Question 11:

Options:

Protect the airway and use smelling salts
Protect the airway, move to the shade, and place in reverse Trendelenburg
Protect the airway and protect from seizure activity
Protect the airway, start CPR, and prepare to cardiovert
Protect the airway, and move patient slowly to a spine board

Correct Answer: Protect the airway, start CPR, and prepare to cardiovert

Explanation:

Question 12:

Options:

Ankle fusion
Arthroscopic debridement and drilling
Retrograde drilling and bone grafting
Malleolar osteotomy and osteochondral grafting

Correct Answer: Malleolar osteotomy and osteochondral grafting

Explanation:

Question 13:

Options:

repair of a triceps tendon avulsion.
arthroscopy of the elbow for removal of loose bodies.
arthroscopic removal of a posteromedial olecranon osteophyte.
internal fixation of an olecranon stress fracture.
rest, rehabilitation, and resumption of pitching when the fracture is healed.

Correct Answer: rest, rehabilitation, and resumption of pitching when the fracture is healed.

Explanation:

Question 14:

- The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Options:

disuse osteopenia
paraendocrine effect of the tumor
abnormally increased density on the right side
side effect of the treatment of the lesion
extensive tumor involvement of the left hip

Correct Answer: disuse osteopenia

Explanation:

Question 15:

Options:

Irrigation and debridement of the cystic lesion and 6 weeks of IV antibiotics
Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics
Complete resection of the infected portion of bone, placement of an external fixator to stabilize the tibia, and 6 weeks of IV antibiotics
Amputation
Local debridement of bone and the overlying skin and soft tissues, 6 weeks of IV antibiotics, and free-flap wound coverage

Correct Answer: Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics

Explanation:

DISCUSSION: The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.
REFERENCES: Patzakis MJ, Zalavras CG: Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: Current management concepts. J Am Acad Orthop Surg 2005;13:417-427.
Beals RK, Bryant RE: The treatment of chronic open osteomyelitis of the tibia in adults.
Clin Orthop Relat Res 2005;433:212-217.

Question 16:

When planning a research study, the power of the study may be increased by

Options:

performing a retrospective study.
performing a prospective study.
using a case control design.
decreasing the sample size.
increasing the sample size.

Correct Answer: increasing the sample size.

Explanation:

Question 17:

Options:

Posterior impingement of the os trigonum
Subluxation of the peroneal tendon
Posterior tibial stress fracture
Osteochondritis dissecans of the lateral dome of the talus
Stenosis of the peroneal tendon sheath

Correct Answer: Posterior impingement of the os trigonum

Explanation:

Question 18:

Which of the following types of osteosarcoma is associated with the best prognosis & long survival?

Options:

Parosteal
Periosteal
High-grade intramedullary
Osteosarcoma occurring in Paget’s disease
Osteosarcoma occurring in irradiated bone

Correct Answer: Parosteal

Explanation:

Question 19:

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Options:

cast immobilization for 6 weeks.
brief immobilization followed by rest for 6 weeks.
internal fixation with a compression screw.
internal fixation with a tension band wire.
bone stimulation.

Correct Answer: internal fixation with a compression screw.

Explanation:

Question 20:

Options:

Gradual return to play
Physical therapy program
Custom orthosis
Non-weight-bearing cast
Weight-bearing AP radiograph

Correct Answer: Weight-bearing AP radiograph

Explanation:

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return
to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 21:

Options:

C6 vertebral body
Far lateral C6-C7

Correct Answer: Far lateral C6-C7

Explanation:

Question 22:

Options:

Driesman et al. followed 84 consecutive patients with diaphyseal humeral shaft fractures treated nonoperatively. They found that mobile fracture sites at 6 weeks from injury predicted nonunion with 82% sensitivity and 99% specificity. They concluded that knowledge of fracture motion can help in determining the appropriate management in decision making in nonoperatively treated humeral shaft fractures.
Figures A and B show AP and transthoracic lateral radiographs of a mid diaphyseal spiral humeral shaft fracture, respectively.
Incorrect Answers:

Correct Answer: Driesman et al. followed 84 consecutive patients with diaphyseal humeral shaft fractures treated nonoperatively. They found that mobile fracture sites at 6 weeks from injury predicted nonunion with 82% sensitivity and 99% specificity. They concluded that knowledge of fracture motion can help in determining the appropriate management in decision making in nonoperatively treated humeral shaft fractures.

Explanation:

OrthoCash 2020
A patient presents with the injury shown in figures A and B. What has been associated with the technique depicted in figures C and D?
Longer operative times
Increased deep surgical infection rates
Unacceptably high malunion/nonunion rates
Slower early return to function
Longer hospital stays
Corrent answer: 3
Treatment of Shatzker V and VI tibial plateau fractures with hybrid external fixation is associated with increased malunion and nonunion rates.
Hybrid external fixation for treating tibial plateau fractures involves the use of an external fixator to achieve reduction through ligamentotaxis. Additional fracture reduction is achieved through limited open incisions with fixation augmented through percutaneous cannulated screws. Definitive treatment with this technique avoids soft tissue complications that have been associated with traditional open reduction and internal fixation with bicondylar plating.
However, studies have reported high malunion and nonunion rates due to a lack of rigid fixation.
Bertrand et al. performed a prospective cohort study of patients undergoing either open reduction and internal fixation versus hybrid external fixation for Schatzker V and VI tibial plateau fractures. Hybrid external fixation was associated with significantly shorter operative times but insignificantly increased complication rates. They concluded that there were limited statistically differences between these techniques, but further studies are required before advising hybrid external fixation for higher Schatzker tibial plateau fractures.
Gross et al. performed a retrospective study of patients treated with hybrid external fixation for Shatzker V and VI tibial plateau fractures. The authors found there was an 80% union rate, a 70% satisfactory reduction rate, and a 52% rate of malunion. The development of osteoarthritis was associated with plateau widening, articular comminution, articular step-off, and incorrect mechanical alignment. The authors concluded that hybrid external fixation is an effective means for the treatment of tibial plateau fractures that minimizes tissue dissection, with decreased blood loss, and shorter operative times, but associated with a very high malunion rate.
Hall et al. performed a multicenter randomized controlled trial comparing the treatment of Schatzker V and VI fractures with open reduction and internal fixation with hybrid external fixation. Patients with hybrid external fixation had less intraoperative blood loss, fewer unanticipated secondary procedures, slightly faster return to pre-injury activity at 6 months and 1 year, and shorter
hospital stay. They concluded that both hybrid external fixation and open reduction and internal fixation provide effective means for fracture treatment, but hybrid external fixation avoids soft tissue complications with deleterious consequences.
Figure A is an AP radiograph of the right knee with a Schatzker VI tibial plateau fracture. Figure B is an axial CT slice of the articular surface of the tibia with extensive comminution. Figures C and D are the AP and lateral radiographs of the knee with a hybrid external fixation construct for a tibial plateau fracture
Incorrect answers:
OrthoCash 2020
An 89-year-old female sustained the injury shown in Figure A and underwent a hemiarthroplasty. Which of the following has been associated with increased rates of post-operative dislocation?
Posterior approach
Anterior approach
Anterolateral approach
Use of a bipolar implant
Use of a monopolar implant
The incidence of dislocation after hemiarthroplasty is highest when using a posterior approach.
Elderly femoral neck fractures are one of the most common fractures encountered by orthopaedists and will only become more common as the population continues to age. The displacement of the femoral head is associated with delayed union or nonunion, an increased risk of femoral head necrosis due to disrupted blood flow at the femoral neck, and failure of internal fixation devices. For this reason, displaced femoral neck fractures in older patients are often treated with hemiarthroplasty. Three approaches to hemiarthroplasty have been described: a lateral approach, a posterior approach, and an anterior approach. The posterior approach has been used more historically; however, its use has been called into question as it has been associated with increased dislocation rates.
Parker performed a trial on all patients with intracapsular femoral neck fractures being treated with hemiarthroplasty. Patients were randomized to surgery using either a lateral or posterior approach. They found that there were no statistically significant differences observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. They concluded that both surgical approaches appear to produce comparable functional outcomes.
van der Sijp et al. performed a meta-analysis to compare the outcomes based on approaches for hemiarthroplasty in the treatment of proximal femur fractures. They found 21 studies and found that the posterior approach poses an increased risk of dislocation and reoperation compared to the lateral approach and anterior approaches. They conclude that there are no evident advantages of the posterior approach and its routine use for fracture-related hemiarthroplasty should be questioned.
Figure A is an AP pelvis radiograph demonstrating a displaced right femoral neck fracture.
Incorrect Answers:
OrthoCash 2020
A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture?
Exchange humeral nailing
Augmentative plating
Nail removal with open reduction compression plating
Smoking cessation and medical optimization
Nail removal with open reduction and compression plating with bone grafting
This patient has sustained an atrophic nonunion of a humeral shaft fracture treated with an intramedullary nail. The most appropriate definitive treatment is nail removal with open reduction and compression plating with bone grafting.
Most diaphyseal humeral fractures can be managed non-operatively with functional bracing. Operative treatment is indicated under a number of circumstances including open fractures, associated neurovascular injury, proximal and distal articular extension of the fracture, and in patients with other multiple injuries. Surgical stabilization can be accomplished with different implants and techniques. The two most common are plate and screw fixation and intramedullary nailing. Plate fixation has the advantages of potential absolute stability and sparing the rotator cuff from an incision. Intramedullary nailing has to be inserted proximally with potential damage to the rotator cuff. It, however, can be inserted with small incisions. If a nonunion develops after intramedullary nailing, nail removal and compression plating is the preferred treatment choice.
Heineman et al. performed a metanalysis on plate fixation or intramedullary nailing of humeral shaft fractures. They performed a literature search from 1967-2007 comparing nails and plates in patients with humeral shaft fractures that reported complications due to surgery. They found that the risk of a complication is lower when plating a fracture of the humeral shaft than when using an intramedullary nail.
Gerwin et al. performed an anatomical study to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. They found that the radial nerve crosses the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. They found the approach to permit the most visualization was the triceps reflecting approach.
Figure A is a lateral radiograph of an atrophic nonunion of a humeral shaft being stabilized with an intramedullary nail.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man is struck while crossing a major highway and sustains the injury depicted in Figure A. Which of the following statements comparing the techniques in Figure B and C is most accurate?
Technique depicted in Figure B is associated with an increased risk of septic arthritis
Technique depicted in Figure B is associated with increased rate of anterior knee pain
Technique depicted in Figure B is associated with improved postoperative fracture alignment
Technique depicted in Figure C is associated with an increased risk of septic arthritis
Technique depicted in Figure C is associated with improved postoperative fracture alignment
Compared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment.
While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaft
fractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing.
Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low.
Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing.
Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction.
Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique.
Incorrect Answers:
OrthoCash 2020
A 56-year-old woman sustains the closed injury depicted in Figures A-B. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. She also complains of some paresthesias in her thumb and index finger. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. What is the likely mechanism of her paresthesias and what is the most appropriate treatment?
Nerve compression; open reduction internal fixation with open carpal tunnel release
Nerve laceration; open reduction internal fixation with primary nerve repair or grafting
Decreased arterial inflow; fasciotomy with open reduction internal fixation
Reflex sympathetic dystrophy; vitamin C
Nerve compression; repeat closed reduction
Corrent answer: 1
This patient is presenting with signs of acute carpal tunnel syndrome (CTS) in the setting of a displaced distal radial fracture. The pathogenesis of acute CTS is nerve compression, requiring urgent open carpal release with open reduction internal fixation (ORIF).
Acute CTS is a well-recognized phenomenon after distal radial fractures. Risk factors include ipsilateral upper extremity fractures, translation of the fracture fragments, and articular distal radius fractures (DRFs). Acute CTS can manifest with paresthesias in the median nerve distribution and opponens pollicis weakness. Acute CTS is an indication for urgent surgical decompression of the median nerve.
Odumala et al. performed a study to evaluate the role of carpal tunnel decompression in the prevention of median nerve dysfunction after buttress plating of DRFs. They reported that prophylactic decompression of the carpal tunnel results in twice the relative odds of developing median nerve dysfunction, which routinely self-resolved. They concluded that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may actually increase postoperative morbidity.
Medici et al. performed a case-control study to investigate whether carpal tunnel release (CTR) during fixation DRFs improves outcomes. They reported no statistically significant difference between the groups in VAS and Mayo Wrist Scores, however, an increased risk of subsequent CTR in the group who underwent ORIF with no CTR at the index procedure. They concluded that the release of the transverse carpal ligament during ORIF may reduce the incidence of postoperative median nerve dysfunction.
Niver et al. reviewed CTS after DRFs. They reported that acute CTS noted at the time of DRF warrants urgent surgical release of the carpal tunnel and fracture fixation, and that delayed CTS presenting after a distal radius fracture has healed may be managed in the standard fashion for CTR. They concluded that there is no role for prophylactic CTR at the time of distal radius fixation in a patient who is asymptomatic.
Figures A and B depict a displaced apex volar DRF and a mildly displaced ulnar styloid fracture.
Incorrect Answers:
OrthoCash 2020
Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury?
Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatment
No difference in radiographic outcomes after ORIF vs. closed treatment
No difference in functional outcomes after ORIF vs. closed treatment
Improved functional outcomes with closed treatment vs. ORIF
Improved functional outcomes with external fixation and K wire fixation vs. ORIF
This elderly patient has sustained a closed intra-articular and shortened distal radial fracture (DRF). Many studies have reported no difference in functional outcomes when patients aged 60 and over are treated in a closed manner versus operatively for unstable fractures.
The treatment of DRFs in the elderly population is controversial. A variety of nonoperative and operative treatments are available, including closed reduction and splinting/casting, K wire stabilization, external fixation, and ORIF. While conservative management of DRFs in the elderly is common,
recent systematic reviews and meta-analyses have demonstrated that despite worse radiographic outcomes after closed treatment of unstable fractures, functional outcomes were no different between patients treated closed versus surgically in patients over the age of 60 years.
Ju et al. published a systematic review and meta-analysis comparing treatment outcomes between nonsurgical and surgical treatment of unstable DRFs in the elderly. They reported no significant differences in DASH score, VAS pain score, grip strength, wrist extension, pronation, supination, and ulnar deviation between the groups. They concluded that operative and nonoperative treatments result in similar outcomes in the treatment of unstable DRFs in the elderly, with no impact on subjective function outcome and quality of life with closed treatment.
Diaz-Garcia et al. published a systematic review of the outcomes and complications after treating unstable DRFs in the elderly, comparing various treatment techniques. They reported significant differences in wrist motion, grip strength, DASH score, although these findings may not be clinically meaningful. They concluded that although the operatively treated group had improved radiographic outcomes, functional outcomes were no different when compared to the group treated in a closed manner.
Figure A depicts an unstable intra-articular and shortened DRF. Incorrect Answers:
no difference in functional outcomes between operative and closed treatment modalities for DRF.
OrthoCash 2020
An active 60-year-old woman falls from her attic and presents with the injury in Figure A. She undergoes successful closed reduction and sling immobilization. At follow up, she is unable to move her shoulder. New radiographs are depicted in Figures B and C. What is the next best step?
Continued sling immobilization
Closed reduction percutaneous pinning
Open reduction internal fixation
Hemiarthroplasty
Reverse total shoulder arthroplasty
Corrent answer: 3
This active patient presents with a greater tuberosity fracture dislocation. Open reduction internal fixation (ORIF) is indicated, particularly when the greater tuberosity fragment is displaced greater than 5mm.
Many proximal humerus fractures are minimally displaced and respond acceptably to nonoperative management. Isolated greater tuberosity fractures or rotator cuff injuries are associated with shoulder dislocations in the elderly population. The greater tuberosity fragment undergoes deforming forces by the supraspinatus and infraspinatus muscles. In active patients, it is well-accepted that greater tuberosity fracture displacement greater than 5mm is an indication for ORIF to restore their ability to perform overhead activities and prevent impingement.
Schumaier et al. published a review article on the treatment of proximal humerus fractures in the elderly. They highlighted that while bone density was a predictor of reduction quality, social independence was a better predictor of outcome. They concluded that although the majority of minimally displaced fractures can be treated successfully with early physical therapy, treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. They emphasized that there was no clear evidence-based treatment of choice, and the surgeon should consider their comfort level during their decision-making.
George et al. published a review article on greater tuberosity humerus fractures. They reported that these fractures may occur in the setting of anterior shoulder dislocations or impaction injuries against the acromion or superior glenoid, with surgical fixation recommended for fractures with greater than 5 mm of displacement in the general population or greater than 3 mm of displacement in active patients involved in frequent overhead activity. They recommended close followup and supervised rehabilitation to increase successful outcomes.
Figure A depicts a greater tuberosity fracture dislocation of the left shoulder. Figures B and C depict reduction of the glenohumeral joint with residual displacement of the greater tuberosity. Illustrations A and B depict radiographs after ORIF.
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OrthoCash 2020
A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur?
MCL > LCL > anterior capsule
MCL > anterior capsule > LCL
anterior capsule > MCL > LCL
LCL > anterior capsule > MCL
LCL > MCL > anterior capsule
Corrent answer: 4
The patient sustained a terrible triad injury of the elbow, which progresses from the LCL to the anterior capsule and then the MCL.
Terrible triad injuries of the elbow are traumatic injuries that occur after a fall on an extended arm that results in a combination of valgus, axial, and posterolateral rotatory forces. The key features of a terrible triad injury include a radial head fracture, a coronoid fracture, and an elbow dislocation. Disruption of the structures in the elbow characteristically occurs from lateral to medial, affecting the LCL first, followed by the anterior capsule and MCL. Outcomes following terrible triad injuries have historically been poor; however, more recent literature has shown that good outcomes can be achieved with surgical stabilization of the elbow followed by an early rehabilitation protocol. Some authors use temporary immobilization, but range-of-motion exercises are typically initiated by 48 hours postoperatively. Active range of motion is particularly important, as it recruits muscles that act as dynamic stabilizers of the elbow. Depending on the injury, method of fixation, and stability that is achieved, the range of motion may be limited to 30° of extension during the early postoperative period but should allow full flexion.
Giannicola et al. (2013) performed a study to determine the critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability (CEI). They found that the first 6 months after surgery represent the critical rehabilitation period to obtain a functional elbow and that elbow flexion recovered at a rate slower than that of the other elbow movements. They recommend that, following CEI surgical treatment, a rehabilitation program should be started promptly and should be continued for at least 6 months because a significant improvement of ROM occurs in this period.
Giannicola et al. (2015) performed a study analyzing the predictability of outcomes of terrible triad injuries (TTI) treated according to current diagnostic and surgical protocols. They found that the current diagnostic and therapeutic protocols allow for satisfactory clinical outcomes in a majority of cases but a high number of major and minor unpredictable complications still persist. Low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery.
McKee et al. performed a review on their standard surgical protocol for the treatment of elbow dislocations with radial head and coronoid fractures. Their surgical protocol included fixation or replacement of the radial head; fixation of the coronoid fracture, if possible; repair of associated capsular and lateral ligamentous injuries; and, in selected cases, repair of the medial collateral ligament and/or adjuvant-hinged external fixation. They found that their surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. They recommend early operative repair with a standard protocol for these injuries.
Figure A is a lateral radiograph of the elbow demonstrating a terrible triad injury with a comminuted radial head/neck fracture, displaced coronoid fracture, and posterior elbow dislocation. Illustration A is a rendered image of the radiograph shown in Figure A with the components labeled.
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OrthoCash 2020
An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw?
Reverse obliquity fracture pattern
Lateral wall thickness
Previous contralateral hip fracture
DEXA T-score <-2.0
Calcar comminution
Lateral wall thickness has been shown to be a predictor of postoperative lateral wall fracture. As the lateral wall thickness decreases, there is an increased chance of fracture.
Lateral wall fracture creates an unstable fracture pattern and increased screw sliding/collapse. This shortens the neck and abductors, leading to worse patient outcomes (radiographic and clinical). Recognition of a thin wall should lead toward the use of an intramedullary device or adjunct use of a trochanteric stabilizing plate with a sliding hip screw device.
Baumgaertner et al. reported that the failure of peritrochanteric fractures that have been treated with a fixed-angle sliding hip-screw device is frequently related to the position of the lag screw in the femoral head. They established the tip-apex distance as the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. Upon reviewing their series, none of the 120 screws with a tip-apex distance of twenty-five millimeters or less cut out, but there was a very strong statistical relationship between an increasing tip-apex distance and the rate of cutout, regardless of all other variables related to the fracture.
Socci et al. performed a literature review of relevant papers and appropriate clinical databases and concluded that fixation of AO 31A1 fractures was best achieved with a sliding hip screw device and that all other types of intertrochanteric hip fractures be fixed with an intramedullary device.
Utrilla et al. reported no difference in outcome in stable fractures, but better mobility at one year following intramedullary fixation of unstable fractures.
Hsu et al. measured the thickness of the lateral wall of patients with AO/OTA 31-A1 and 31-A2 type intertrochanteric hip fractures. They found that the lateral wall thickness was a reliable predictor of postoperative lateral wall fracture for unstable AO Type A2 fractures and concluded that the lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.
Figure A shows a standard obliquity intertrochanteric hip fracture.
Illustration A from the Hsu article demonstrates the measurement of the lateral wall thickness. The distance is measured along a 135-degree angle, between a point 3cm distal to the innominate tubercle of the greater trochanter and the fracture line (midway between the two cortical lines).
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OrthoCash 2020
A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries?
Smaller lateral wall thickness favors sliding hip screw constructs
Unstable fractures are best treated with sliding hip screw constructs
Avoiding distal locking screws in intramedullary implants protects against refracture
Stable fractures have no differences in outcomes between sliding hip screws and intramedullary implants
Implant stability has a greater impact on outcomes rather than reduction quality
Studies have shown that in stable intertrochanteric femur fractures there are no differences in outcomes between sliding hip screws and intramedullary implants.
Intertrochanteric femur fractures are one of the most common fractures in the geriatric population. Implant selection has been a great topic of research with most studies reporting minimal to no differences in outcomes between intramedullary and sliding hip screw constructs in stable fracture patterns.
Unstable fractures, however, are reportedly better treated with a distally locked intramedullary implant. The quality of fracture reduction has a greater impact on the overall outcome than implant selection.
Hsu et al. performed a retrospective study of risk factors for postoperative lateral wall fractures in patients treated with sliding hip screws for intertrochanteric femur fractures. They found that fracture classification and lateral wall thickness, which is measured from 3 cm distal from innominate tubercle and angled 135 degrees to the fracture line, were associated with postoperative lateral wall fracture. They recommended not treating intertrochanteric femur fractures with sliding hip screws if the lateral wall thickness is less than 20.5 mm.
Socci et al. reviewed the literature regarding the treatment of intertrochanteric femur fractures. Based on the literature, they recommend treatment of AO/OTA type 31A1 fractures with sliding hip screws, type 31A2 fractures with short intramedullary implants, and 31A3 fractures with long intramedullary implants. Simple basicervical fractures of the femoral neck can be treated with sliding hip constructs whereas comminuted fractures treated with intramedullary devices due to the inherent instability of the pattern. The most import aspect in fracture healing is the quality of the reduction rather than the choice of implant.
Lindvall et al. performed a retrospective study of refracture rates in patients treated with either long or short cephalomedullary nails. The authors found a 97% union rate with both implant types and refracture not associated with either long or short implants. Rather, refracture was associated with the lack of a distal locking screw. The authors recommended locking intramedullary implants to avoid refracture.
Utrilla et al. performed a randomized control trial of elderly patients treated
with compression hip screw or Trochanteric Gamma Nail for intertrochanteric femur fractures. They reported the only differences between the two implants were quicker operating time, less fluoroscopy use, and better walking with unstable fractures treated with intramedullary implants. The authors recommended either construct for stable fractures, but intramedullary implants for unstable fractures.
Figures A and B are the AP and lateral radiographs of the right hip radiographs demonstrating a simple and minimally displaced intertrochanteric femur fracture, classified as an AO/OTA 31A1 fracture. Illustration A depicts the AO/OTA classification system for proximal femur fractures.
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OrthoCash 2020
A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?
Nail removal with compression plating and open bone grafting
Closed reamed exchange nailing
Nail dynamization
Nail retention with plate augmentation and bone grafting
Electrical bone stimulator
Corrent answer: 4
The patient is presenting with a hypertrophic nonunion of the femur below the isthmus, which studies have shown to have a higher union rate when treated with plate augmentation. Retention of the nail allows for full weight-bearing postop.
Hypertrophic nonunion of the femur is the result of fracture site hypermobility with sufficient biology for healing. This is demonstrated with abundant callus formation without bridging trabeculae. Traditionally, this is treated with closed reamed exchange nailing which increased construct stiffness with a larger diameter nail, improved isthmic fit, and extrusion of reaming contents to the nonunion site. However, studies have demonstrated a higher union rate with open plate augmentation, bone grafting, and nail retention. This is due to the ability to correct nonunion site deformity, provide added compression at the nonunion site, and increase fracture site biology with bone graft.
Lynch et al. reviewed the literature regarding the treatment options for femoral nonunions. The literature suggests high union rates when hypertrophic nonunions are treated with exchanged reamed nailing. However, the use of augmentative plate fixation allows for further deformity correction. The proposed mechanism by which exchange reamed nailing is increased construct stiffness with a large diameter nail, usually by 1-2 mm, increased isthmic fit, and autogenous bone graft extrusion into the nonunion site.
Somford et al. performed a systematic review of the surgical treatment of femoral nonunions. Results demonstrate that exchange nailing provides a 73% union rate compared to plate augmentation of 96%. They speculated that there were increased indications for exchange nailing for oligotrophic nonunions in many of the included studies, which may have reduced the union rate. Further, plate augmentation does allow for deformity correction, which can further improve the union rate.
Figures A and B are the AP and lateral radiographs of the femur with hypertrophic nonunion as suggested with the abundant callus formation and broken distal interlock screws. Illustration A and B are the AP and lateral radiographs of the distal femur subsequent plate augmentation and fracture healing.
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OrthoCash 2020
A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?
External fixation with serial doppler examinations
Intramedullary nailing
Open reduction internal fixation using plates and screws
Immediate 2-compartment fasciotomies and external fixation
Immediate 4-compartment fasciotomies and external fixation
Corrent answer: 5
This patient has clinical symptoms and signs of leg compartment syndrome and should undergo immediate fasciotomies of all 4 leg compartments, followed by external fixation for fracture stabilization.
Tibial fractures are among the most common reasons for compartment syndromes of the leg. A clinical assessment is key in the diagnosis of acute compartment syndrome. If there is uncertainty, intracompartmental pressure measurement has been advocated to help confirm the diagnosis. An absolute
compartment pressure >30 mm Hg or a difference in diastolic pressure and compartment pressure (delta p) <30 mmHg may help to confirm the necessity for fasciotomy.
McQueen et al. published a report of 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. They reported significant differences in any sequelae of acute compartment syndrome between patients who underwent compartment pressure monitoring and those who had not. They recommended that all patients with tibial fractures should have continuous compartment monitoring to minimize the incidence of acute compartment syndrome.
Mawhinney et al. reported on three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. They reported that the only predisposing factors for the development of compartment syndrome were the surgery and the fracture itself. They concluded that tibial compartment syndrome is a relatively rare but significant complication of tibial nailing.
Figure A is an AP and lateral radiograph of the leg with displaced, comminuted middle third tibia and fibula fractures.
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OrthoCash 2020
A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Decreased arterial inflow; inability to dorsiflex his ankle
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace
Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Compartment syndrome initially results from a decrease in venous outflow relative to arterial inflow. This patient has elevated pressures in the lateral compartment of the leg, which is where the superficial peroneal nerve runs to supply sensation to the dorsum of the foot including the hallux and 3rd and 4th toes.
Compartment syndrome results from compromised venous outflow from the leg relative to the arterial inflow. This venous congestion leads to elevated compartment pressures that ultimately lead to compromised arterial inflow without compartment release. There are 4 compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment contains the deep peroneal nerve, the lateral compartment of the leg contains the superficial peroneal nerve, and the deep posterior compartment contains the tibial nerve.
McQueen et al. performed a study to determine risk factors for acute compartment syndrome. They found that young patients, especially men, were most at risk of acute compartment syndrome after injury. They recommend that, when treating such injured patients, the diagnosis should be made early, utilizing measurements of tissue pressure.
Olson et al. published a review on acute compartment syndrome in lower extremity musculoskeletal trauma. They reported that acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death. They report that recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.
Illustration A is a diagram depicting the compartments of the leg and its contents.
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OrthoCash 2020
Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation?
Syme
Traumatic transtibial
Vascular transtibial
Traumatic transfemoral
Vascular transfemoral
The energy expenditure of a vascular transtibial amputation is approximately 40% greater.
The energy expenditure for ambulation increases with lower extremity amputation. Diabetics and vasculopathic patients who undergo amputation
have significantly increased energy requirements compared with nondiabetic patients undergoing amputations for trauma. The metabolic cost for a vascular transtibial amputation is 40% compared to a 25% increase in normal patients who sustain a traumatic amputation.
Huang et al. used a mobile instrument system to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. They found that in comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.
Pinzur et al. performed a study to measure cardiac function and oxygen consumption in 25 patients who underwent amputation for peripheral vascular disease (PVD), and in five similarly aged control patients without PVD. They found Normal walking speed and cadence decreased and oxygen consumption per meter walked increased with more proximal amputation. They conclude that peripheral vascular insufficiency amputees function at a level approaching their maximum functional capacity and more proximal amputation levels, the capacity to walk short or long distances is greatly impaired.
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OrthoCash 2020
A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?
It may be performed in a minimally invasive manner
It involves minimal soft tissue stripping
It leads to higher union rates
It allows the surgeon to address all sites of injury through one approach
This patient has sustained a right hip fracture-dislocation with fractures of the femoral head and posterior wall. The TFO allows the surgeon to address all sites of injury through a single approach.
Femoral head fracture-dislocations are a result of high-energy trauma. Treatment ranges from closed reduction and conservative management to total hip arthroplasty. Intermediate options include open reduction and internal fixation or excision of fracture fragments. Complications of this injury include post-traumatic hip arthritis, avascular necrosis, and heterotopic ossification.
The injury is further complicated when a fracture of the acetabulum is concomitantly present. There has been no consensus treatment on this injury constellation as it presents quite rarely. The TFO is one approach that allows the surgeon to treat and stabilize both injuries concurrently. It should be noted that a surgical hip dislocation is performed in conjunction with the TFO to allow access to the femoral head.
Solberg et al. performed a retrospective study of patients sustaining Pipkin IV fracture/dislocations with a TFO. They had 12 patients over a 6 month period. They found that all patients healed radiologically and one patient developed osteonecrosis. 10 out of 12 patients had good to excellent outcomes. They concluded that using a surgical protocol with TFO rendered clinical results
comparable to previously reported outcomes in a series of isolated femoral head fractures.
Giannoudis et al. performed a systematic review to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. They reported that fracture-dislocations were managed with emergent closed reduction, followed by definite treatment, aiming at an anatomic restoration of both fracture and joint incongruity. They concluded that neither the TFO nor an anterior approach seems to endanger femoral head blood supply compared to the posterior one, with the TFO possibly providing better long-term functional results and lower incidence of major complication rates.
Henle et al. reported on the result of 12 patients of femoral head fractures with associated posterior wall fractures treated with a TFO. They found good to excellent results in 10 patients. The two patients with poor outcome developed avascular necrosis of the femoral head and underwent total hip arthroplasty.
Heterotopic ossification was seen in five patients. They concluded that the TFO may lead to favorable outcomes in this injury constellation.
Figure A is an AP radiograph of the right hip demonstrating a femoral head fracture-dislocation. Figure B is an axial CT image demonstrating a posterior wall fracture. Figure C is an axial CT image demonstrating a femoral head fragment within the acetabulum. Illustration A is the Pipkin classification of femoral head fractures: Type I is below the fovea, Type II is above the fovea, Type III is associated with a femoral neck fracture, and Type IV is associated with an acetabular fracture.
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OrthoCash 2020
A 30-year-old male is brought to your emergency department following a motor vehicle collision at high speed. He is intubated in the field for airway protection but is hemodynamically stable. Subsequent workup shows a displaced acetabular fracture, in addition to an intracranial bleed and liver laceration which do not require surgery. When placing an antegrade anterior column screw, what radiographic view should be used to avoid intra-pelvic screw penetration?
Iliac oblique view with hip and knee flexed
Iliac oblique inlet view
Obturator oblique view with hip and knee flexed
Obturator oblique outlet view
Obturator oblique inlet view
Corrent answer: 2
The iliac oblique inlet view will best show the the anterior-posterior placement of an anterior column ramus screw.
Percutaneous and limited-open acetabular fixation is becoming increasingly common as it avoids the morbidity of extensile pelvic dissection and allows early mobilization. However, it relies heavily on a mastery of radiographic landmarks and ability to interpret these images to reduce fracture fragments without direct visualization. Slight deviations of the fluoroscopy beam and/or fracture displacement will distort the radiographic image. Without a facile ability to interpret these and make appropriate adjustments, percutaneous fixation will be extremely onerous.
Starr et al. described their early techniques for percutaneous and limited-open acetabular fixation. They first implemented this for minimally displaced fracture patterns but have expanded these to a wider range of pathology. They cite the benefit of earlier mobilization in the poly-traumatized patient as great use for this technique.
Mauffrey et al. reviewed radiograph utilization during acetabular fracture care. Though CT has added tremendously to demonstrating subtleties of acetabular fractures, they state the use of AP and orthogonal iliac and obturator oblique Judet views cannot be overlooked. Interpreting these radiographs allows the surgeon to recreate 2-dimensional images into a 3-dimensional fracture pattern and better understand the character of the injury.
Illustrations A and B demonstrate the iliac oblique inlet view and obturator oblique outlet views, respectively.
Illustration C demonstrates the relationship of the critical structures at risk of injury during anterior column screw placement. Illustrations D and E show the starting point with screw trajectory, and position of the hip during posterior column screw.
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OrthoCash 2020
A 34-year-old male sustains the injury shown in Figures A and B. Which factor has been found to be elevated in the synovial fluid and contributes to post-traumatic arthritis?
TGF-Beta
RANKL
IL-2
IL-6
cAMP
The patient has sustained a tibial plafond or pilon fracture as depicted in Figures A and B. IL-6 is one of many inflammatory molecules that has been found to be elevated in the synovial fluid following an intra-articular ankle fracture.
Post-traumatic arthritis following intra-articular fractures is a known complication. It commonly appears 1-2 years following injury and is related to chondrocyte death at the margins. There has not been shown to be any association between prolonged non-weight bearing, poor patient compliance with weight-bearing restrictions, and hardware reactions with the development of post-traumatic arthritis. However, literature has shown that the inflammatory molecules present in the synovial fluid can have a significant effect on the development of posttraumatic arthritis. Important inflammatory factors that have been found to be elevated include IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10.
Adams et al. looked at the synovial fluid of 21 patients with an intra-articular ankle fracture and used the un-injured ankle as a control. They found the inflammatory molecules of GM-CSF, IL-10, IL-1 beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10 were all elevated. They concluded that these inflammatory molecules may play a role in posttraumatic arthritis development.
Adams et al. looked at the synovial fluid of 7 patients from his previous 21 patients that had intra-articular ankle fractures. They found that IL-6, IL-8, MMP-1, MMP-2, and MMP-3 were significantly elevated in comparison to the uninjured ankle. They concluded that the sustained elevated intra-articular inflammatory environment is a potential contributor to post-traumatic arthritis.
Figures A and B are sagittal and axial CT slices, respectively, that depict a tibial plafond or pilon fracture.
Incorrect Answers:
immune system.
OrthoCash 2020
A 29-year-old female presents to the trauma bay from the scene of a high-speed motor vehicle accident. She is found to have a closed intraarticular distal radius fracture with a concomitant ulnar styloid base fracture. She subsequently undergoes ORIF of the distal radius fracture with a volar locking plate. The ulnar styloid fracture is not addressed. Which of the following, if present, is least likely to affect functional outcomes?
Ulnar styloid nonunion
DRUJ instability
Articular step-off >3mm
Radial shortening
Workers compensation claim
Corrent answer: 1
Ulnar styloid non-unions do not affect the overall outcome of hand or wrist function following ORIF of distal radius fractures.
Ulnar styloid base fractures can be associated with DRUJ disruption and TFCC rupture. The DRUJ should be independently evaluated following ORIF of the distal radius. Without instability, unlar styloid fractures do not need to be addressed. If instability exists, the DRUJ should be treated as a separate entity, typically cross-pinned using k-wires. The result of ulnar styloid nonunions are inconsequential to the overall outcome of patients undergoing distal radius ORIF.
Daneshvar et al review the effects of ulnar styloid fractures on patients sustaining distal radius fractures. They report that patients with a concomitant ulnar styloid fracture had a slower recovery of wrist flexion and grip strength compared to those with an isolated distal radius fracture. They conclude, however, that even the presence of an ulnar styloid nonunion did not significantly affect outcomes.
Buijze et al review the clinical impact of united versus non-united fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. They report no difference in motion, strength or outcome scores
between the united and non-united groups at 6 months follow up. They conclude that nonunion of the ulnar styloid does not have an effect on the overall outcome of hand or wrist function.
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OrthoCash 2020
Which of the following proximal humerus fractures has the highest likelihood of developing humeral head ischemia?
Posteromedial calcar length of the humeral head less than 8 mm and a loss of medial hinge are among the most reliable predictors of ischemia in the surgical management of humeral head fractures.
Proximal humerus fractures are classified based on the Neer classification, in which 4 parts are described: greater tuberosity, lesser tuberosity, articular surface, and the shaft. A fragment is considered a part if it is greater than 45 degrees angulated or displaced >1cm. The posterior humeral circumflex artery is the main blood supply to the humeral head. Following ORIF, humeral head ischemia may occur and is associated with the initial fracture pattern. Several factors including <8mm of calcar length attached to the articular segment, disruption of the medial hinge, displacement >10mm and angulation >45 degrees have been associated with a disruption of the vascular supply to the humeral head.
Campochiaro et al review Hertel’s criteria of calcar length and medial hinge integrity and its reliability in predicting humeral head necrosis. They reported a 3.7% incidence of ischemia across all 267 fractures evaluated. In those patients that developed AVN, 30% had all of the predictors described by Hertel, however, in the non-AVN group, only 4.7% had these same findings.
They concluded that while Hertel’s criteria are helpful, they may not be sufficient and the authors recommended 3-dimensional evaluation of any fracture involving the calcar.
Xu et al reviewed avascular necrosis in patients with proximal humerus fractures who were treated surgically. They reported on 291 patients throughout 7 studies in which there was no difference in the incidence of AVN for those treated surgically or nonoperatively. However, they concluded through subgroup analysis looking at different fixation constructs that, plate fixation specifically was associated with a higher risk of AVN than conservative management of proximal humerus fractures.
Figure A demonstrates a proximal humerus fracture with a medial calcar length of >8mm attached to the articular segment. Figure B is a proximal humerus fracture with a displaced greater tuberosity fragment. Figure C demonstrates a proximal humerus fracture with a medial calcar length of <8mm attached to the articular segment. Figure D is a displaced metadiaphyseal proximal humerus fracture in a skeletally immature patient. Figure E is a radiograph of a metadiaphyseal proximal humerus fracture in a skeletally mature patient with a medial calcar length >8mm.
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OrthoCash 2020
A 34-year-old man presents with the closed injury depicted in Figure A after a high energy twisting injury. Which of the other injuries below is most commonly associated with his known injury?
Nondisplaced medial malleolus vertical shear fracture
Nondisplaced Volkmann's fragment
Nondisplaced Chaput's fragment
Nondisplaced lateral wall talar fracture
Posterior inferior tibiofibular ligament disruption
Corrent answer: 2
This patient has sustained a distal third tibial shaft spiral fracture, which is commonly associated with nondisplaced posterior tibial plafond fractures, with the classic Volkmann's fragment.
Prior to operative management, distal third spiral tibial shaft fractures should always be evaluated for intra-articular extension. As this commonly associated injury can be missed on plain radiographs, an ankle CT is often recommended. This is especially important when intramedullary fixation is used for definitive management of the tibial shaft fracture, as nail insertion can displace a
previously nondisplaced intraarticular fracture. Anterior to posterior lag screw fixation prior to nailing may be useful in these cases.
Sobol et al. investigated the incidence of concomitant posterior malleolar fractures (PMFs) in operative distal third spiral tibial shaft fractures. They reported that spiral distal third tibial shaft fractures were identified with an ipsilateral posterior malleolus fracture in 92.3% of cases. They recommended a preoperative ankle CT in all cases with this specific fracture morphology to properly diagnose this commonly associated injury.
Hou et al. investigated the posterior malleolar fracture association with spiral tibial shaft fractures. They reported that plain radiography (both preoperative and intraoperative) resulted in rare identification of these associated injuries, which resulted in missed injuries. They concluded that a CT or MRI ankle may be a higher yield method to detect these injuries.
Figure A demonstrates a distal third spiral tibial shaft fracture. Illustration A is a schematic demonstrating the Volkmann, Chaput, and medial malleoli intraarticular fragments of the distal tibia.
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OrthoCash 2020
An 18-year-old male is admitted for a diaphyseal, open, tibial shaft fracture after falling off a motorcycle. He has a past medical history of nicotine dependence and obesity. He undergoes provisional splinting by the resident on call and is noted to be "neurovascularly intact" following splint placement. Throughout the evening, however, the patient has an increasing narcotic requirement and develops pain with passive stretch of his toes. What factor listed below is most associated with his progressive symptoms overnight?
Age < 20
Male gender
Body mass index >/ 30 kg/m^2
Open fracture
Nicotine use
The highest prevalence of compartment syndrome is found in patients aged 12-19 years, followed by 20-29 years.
One theory for the higher prevalence of compartment syndrome in younger patients is increased muscle mass in this cohort. If there is more muscle in a compartment, there is less room for swelling. On the flip side, elderly or deconditioned patients who have less muscle or fatty atrophy may be better able to accommodate muscle swelling. Additionally, a diaphyseal fracture location is associated with a higher risk of compartment syndrome. Again, this may be due to the fact that there is more muscle than tendon, and thus more swelling, in the proximal leg.
Shadgan et al. retrospectively reviewed 1,125 patients with diaphyseal tibia fractures to look for risk factors associated with the development of compartment syndrome. Compartment syndrome occurred in approximately 8% of patients with this injury. They concluded that younger patients were at a higher risk of developing compartment syndrome and that male gender, open fracture, and intramedullary nailing were not risk factors.
Beebe et al. set out to determine the correlation between the OTA/AO classification of tibia fractures and the development of compartment syndrome. they conducted a retrospective review of a prospectively collected database comprising 2,885 fractures. They concluded that age, sex, and the OTA/AO classification were highly predictive for the development of compartment syndrome in this cohort.
McQueen et al. similarly looked at predictors of compartment syndrome after tibial fractures in a retrospective cohort study. There were 1,388 patients in their study with ages ranging from 12-98; identical to the Shadgan study, 69% of patients were male. They concluded the strongest risk factor was age, with the highest prevalence in 12 to 19-year-olds.
Park et al. additionally analyzed 414 patients with tibia fractures in a retrospective cohort study. The main outcome measure of this study was the rate of clinically determined compartment syndromes requiring fasciotomy by anatomic region. The found that diaphyseal fractures were more frequently associated with the development of compartment syndrome than proximal (next most common site) and distal tibia fractures, specifically in younger patients.
Incorrect Answers:
OrthoCash 2020
Figure A is the radiograph of a 79-year-old female with elbow pain following a fall. Compared with a total elbow artrhoplasty, open reduction and internal fixation would most likely result in?
Greater Mayo Elbow Performance Score
Greater Disabilities of the Arm, Shoulder and Hand Score
Increased flexion-extension arc
Increased reoperation rate
Decreased complication rate
Corrent answer: 4
This patient sustained a comminuted distal humerus fracture. Open reduction and internal fixation (ORIF) is found to have higher repoeration rates compared with total elbow arthroplasty (TEA) in the elderly: 27% versus 12%, respectively.
Distal humerus fractures account for approximately 30% of elbow fractures. There is often a low energy mechanism of injury in the elderly patient. While ORIF and TEA may be utilized in bicolumnar distal humerus fractures in the elderly patient, recent literature has demonstrated favorable outcomes with TEA in this aged cohort. TEA is indicated in the low demand osteoporotic patients with bicolumnar distal humerus fractures that are not amendable to ORIF. Utilization of TEA has demonstrated greater functional outcome scores, greater motion, less complications, and a lower revision rate.
Mckee et al. conducted a prospective, randomized, controlled trial comparing functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with ORIF or primary semiconstrained TEA. They reports that patients who underwent TEA had significantly better motion, performance and outcome scores, lower reoperation rates compared with the ORIF group. They concluded that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF and that TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation.
Githens et al. performed a systematic review and meta-analysis to analyze outcomes and complication rates in elderly patients with intra-articular distal humerus fractures being treated with either TEA or ORIF with locking plates. They report that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion.
However, they found a non-statistical trend toward a higher rate of major complications and reoperation after ORIF. They conclude that the quality of study methodology was generally weak and ongoing research including prospective trials and cost analysis is indicated.
Figure A is the AP radiograph of a comminuted bicolumnar distal humerus
fracture. Illustration A are the radiographs of a comminuted distal humerus fracture in an elderly patient treated with a TEA. Illustration B is the postoperative radiographs of a comminuted distal humerus fracture treated with ORIF.
Incorrect Answers:
OrthoCash 2020
Figure A is the postoperative radiograph of an 82-year-old female who was treated with a cephalomedually nail for a left intertrochanteric hip fracture. Which of the following is the most common complication following use of this device?
Anterior perforation of distal femur
Breakage of the screw
Implant cutout
Malunion
Nonunion
Intertrochanteric hip fractures are most commonly treated with a cephalomedullary nail. The most common complication following utilization of a cephalomedullary nail is implant failure and cutout.
Intertrochanteric hip fractures are extra-capsular injuries that are common in the elderly osteoporotic patient. These injuries carrry a 20-30% mortality rate in the first year following fracture. Femoral cephalomedullary nails are often used to treat these injuries. Often a helical blade or screw may be used to provide fixation within the femoral neck. Overall, the most common complication following use of this device is implant failure and cutout, which occurs most commonly within 3 months following surgery. A known risk factor of this complication is an increased tip-apex distance, with a 60% failure rate reported with a distance exceeding 45mm.
Gardner et al. reviewed the use of a helical blade device to stabilize
intertrochanteric hip fractures. They reported a mean telescoping in unstable and stable fractures of 4.3 mm and 2.6 mm, respectively. They also found that blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. They concluded that position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping.
Haidukewych et al. reviewed patients with failed internal fixation of a hip fracture. They report that salvage options are dependent on the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. They conclude that in younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. Conversely, in older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty is recommended.
Figure A is the AP radiograph of the right hip treated with a cephalomedullary nail. Illustration A demonstrates screw cutout.
Incorrect Answers:
OrthoCash 2020
Figure A is the radiograph of a 42-year-old female who presents to the trauma bay following a motor vehicle collision. She subsequently undergoes ORIF through a posterior approach. Iatrogenic injury to which nerve in Figure B is most likely with this approach?

Question 23:

Options:

Medial cord of the brachial plexus
Radial nerve
Median nerve
Axillary nerve
Musculocutaneous nerve

Correct Answer: Musculocutaneous nerve

Explanation:

Question 24:

Which of the following statements is true regarding articular cartilage?

Options:

The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties
Water accounts for approximately 25% of the mass of cartilage
Multiple aggrecan molecules link together to form glycosaminoglycans
The positive charge formed by aggrecan molecules helps to create the high osmotic swelling pressure of cartilage
Type II collagen helps prevent swelling of articular cartilage which would otherwise occur due to high osmotic pressures

Correct Answer: The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties

Explanation:

Question 25:

A 53-year-old man has a 4- x 5-cm high-grade soft-tissue sarcoma in the midthigh. As part of the staging evaluation, regional nodes should be assessed by

Options:

CT of the pelvis and groin.
sentinal node biopsy.
clinical examination.
fine needle aspiration.
prophylactic inguinal node dissection.

Correct Answer: clinical examination.

Explanation:

Question 26:

Options:

- Nonsurgical treatment
- Percutaneous skeletal fixation
- Open reduction and internal fixation
- Total shoulder arthroplasty

Correct Answer: - Nonsurgical treatment

Explanation:

DISCUSSION
Literature guiding indications for surgical vs nonsurgical treatment of proximal humerus fractures is not definitive. Many of the recommendations are based on older, nonrandomized series. Newer data suggest that surgical and nonsurgical treatment provide comparable results. Although surgical treatment is preferred for treatment of displaced fractures, fractures with minimal displacement are best managed without surgery.
RECOMMENDED READINGS
Hauschild O, Konrad G, Audige L, de Boer P, Lambert SM, Hertel R, Südkamp NP. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg. 2013 Oct;133(10):1385-93. doi:10.1007/s00402-013-1798-2. Epub 2013 Jul 3. PubMed PMID: 23820852.
View
Abstract at PubMed
Bell J-R, Cadel ER. Shoulder trauma: Bone. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:319-337.

Question 27:

A 25-year-old carpenter falls on his outstretched arm. What physical finding best correlates with the lesion seen on the MRI scan shown in Figure 3?

Options:

Weakness in external rotation
Weakness in abduction
Positive lift-off test
Loss of biceps contour
Deltoid atrophy

Correct Answer: Positive lift-off test

Explanation:

Question 28:

Options:

halo vest immobilization.
MRI.
Gardner-Wells tongs and closed reduction.
posterior open reduction and fusion.
observation until the patient’s general medical status improves, followed by closed reduction via Gardner-Wells tongs.

Correct Answer: Gardner-Wells tongs and closed reduction.

Explanation:

Question 29:

Which of the following complications is uniquely associated with an anterior approach to the lumbosacral junction?

Options:

Nerve root injury
Erectile dysfunction
Dural tear
Pulmonary embolism
Retrograde ejaculation

Correct Answer: Retrograde ejaculation

Explanation:

Question 30:

Options:

Removal of hardware with tendon transfer
Repair of the extensor pollicis longus (EPL) tendon primarily
Thumb interphalangeal (IP) arthrodesis
Nonsurgical treatment with cast placement keeping the thumb in a fully extended position for 4 weeks

Correct Answer: Removal of hardware with tendon transfer

Explanation:

Question 31:

Options:

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

Correct Answer: a rigid collar for 6 weeks.

Explanation:

Question 32:

Options:

Avoid wearing the prosthesis until the ulcer is healed and perform local wound care.
Obtain a new prosthesis with an energy-storing foot to dampen impact.
Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.
Excise the wound and advance the soft-tissue envelope.
Perform a distal tibiofibular bone bridge and advance the soft-tissue envelope.

Correct Answer: Perform local wound care in conjunction with modification of the prosthetic socket and cushioned liner.

Explanation:

DISCUSSION: The first step in the treatment of an amputation residual limb (stump) ulcer is local wound care and adjustment of the residual limb-prosthetic interface, as well as adjusting prosthetic alignment. Surgical revision should be undertaken only when prosthetic modification is unsuccessful.
REFERENCES: Murnaghan JJ, Bowker JH: Musculoskeletal complications, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 683-700.
Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Relat Res 1999;361:108-115.

Question 33:

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Options:

Lateral femoral cutaneous
Sciatic
Pudendal
Superior gluteal

Correct Answer: Lateral femoral cutaneous

Explanation:

Question 34:

Options:

2 cm distal to the articular surface of the radial head
1 cm distal to the articular surface of the radial head
Within a 90-degree arc or safe zone
Within a 120-degree arc or safe zone
Within a 180-degree arc or safe zone

Correct Answer: Within a 90-degree arc or safe zone

Explanation:

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 35:

Flexion-distraction injuries of the thoracolumbar spine are most frequently associated with injury to what organ system?

Options:

Neurologic
Pulmonary
Gastrointestinal
Vascular
Lymphatic

Correct Answer: Gastrointestinal

Explanation:

Question 36:

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Options:

Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament
Posterior inferior glenohumeral ligament
Subscapularis

Correct Answer: Inferior glenohumeral ligament

Explanation:

Question 37:

Options:

Initiate oral antibiotics for 7 days.
Reaspirate the bursa and inject a corticosteroid.
Recommend padding the patella for kneeling and ice.
Perform an open bursectomy and start intravenous antibiotics.

Correct Answer: Perform an open bursectomy and start intravenous antibiotics.

Explanation:

Question 38:

What is the most serious complication that may occur with a ceramic-on-ceramic bearing in a total hip prosthesis?

Options:

Wear
Squeaking
Dislocation
Fracture
Subsidence

Correct Answer: Fracture

Explanation:

Question 39:

Options:

Elevate leg on pillows
Administer IV morphine
Observation of the patient
Bivalve and spread the cast
Apply ice to the lower extremity

Correct Answer: Administer IV morphine

Explanation:

The patient appears to have some indications of a compartment syndrome: increasing pain and signs of nerve compression. Tibia fractures also should heighten the suspicion for a compartment syndrome. Two basic mechanisms of compartment syndrome are that an increase in volume occurs in an enclosed space or there is a decrease in size of the space. In this situation, both are likely occurring; post-fracture swelling is occurring within a closed space and if a cast is in place that may constrict the space even more. One way to increase the available space for swelling would be to bivalve and spread the cast. If the extremity has been casted, then it is vitally important that the cast is bivalved and the surrounding soft dressings under the cast be removed so that all external compression of the compartment has been eliminated. In the face of compartment syndrome, elevation of the limb, masking the pain with morphine, application of ice, or observation alone are all inappropriate.
(SBQ12TR.88) When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?
A fracture of the radial head requiring ORIF
A highly comminuted radial head fracture requiring radial head arthroplasty or resection
An MCL injury requiring repair
A type I avulsion fracture of the coronoid
An anteromedial coronoid fracture
A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture. Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
Incorrect answers:
(SBQ12TR.78) A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure A. What would be the most appropriate treatment for this patient at this time?
Review
Topic
Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 40:

Options:

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

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

Explanation:

Question 41:

- Figure 35 shows a postoperative radiograph of a femur fracture proximal to a total knee prosthesis that was treated by open reduction and blade plate fixation 9 months ago. What is the most likely reason the previously well seated screw has backed out of the central portion of the plate?

Options:

Infection
Nonunion
Improper screw length
Osteonecrosis of the distal fragment
Use of a cortical screw instead of a cancellous screw

Correct Answer: Nonunion

Explanation:

Question 42:

Options:

Dorsiflexion osteotomy of the first metatarsal
Dorsiflexion osteotomy of the first metatarsal combined with anterior transfer of the tibialis posterior
Triplanar osteotomy at the apex of the deformity
Triplanar osteotomy at the apex of the deformity combined with valgus calcaneal osteotomy
Triplanar osteotomy at the apex of the deformity combined with anterior transfer of the tibialis posterior

Correct Answer: Dorsiflexion osteotomy of the first metatarsal

Explanation:

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 43:

Options:

hinged knee bracing, protected weight bearing, and physical therapy.
anteromedialization of the tibial tubercle.
internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
arthroscopic lateral retinacular release.

Correct Answer: internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

Explanation:

Question 44:

Survival rates for children with soft-tissue sarcoma other than rhabdomyosarcoma are best correlated with

Options:

size of the tumor.
histologic grade.
histologic subtype.
use of adjuvant chemotherapy.
age of the patient.

Correct Answer: histologic grade.

Explanation:

Question 45:

Options:

Percutaneous Achilles tendon lengthening
Percutaneous Achilles tendon lengthening and split tibialis anterior transfer to the lateral cuneiform
Percutaneous Achilles tendon lengthening and interosseous posterior tibialis tendon transfer to the peroneus tertius
Percutaneous Achilles tendon lengthening and tenotomy of the long toe flexor tendons
Percutaneous Achilles tendon lengthening, tenotomy of the long toe flexors, and Bridle procedure

Correct Answer: Percutaneous Achilles tendon lengthening and split tibialis anterior transfer to the lateral cuneiform

Explanation:

DISCUSSION: The patient has a dynamic varus deformity secondary to spasticity of the tibialis anterior during stance phase with inverter/everter imbalance. The patient still has active motion of the tibialis anterior; therefore, an out-of-phase posterior tibial tendon transfer should not be performed. The same is true of the Bridle procedure. Transfer of the posterior tibialis in this patient may also result in subsequent planovalgus deformity. Lengthening of the Achilles tendon through a percutaneous tenotomy will restore dorsiflexion and decrease clonus from the stretch response. If adequate dorsiflexion is not obtained intraoperatively, then posterior tibialis tendon lengthening may be considered. A split tibialis anterior tendon transfer to the lateral cuneiform, or, transfer of the entire tendon to the cuneiform should correct the varus component and compensate for the weakened peroneals.
REFERENCES: Yamamoto H, Okumura S, Morita S, et al: Surgical correction of foot deformities after stroke. Clin Orthop Relat Res 1992;282:213-218.
Piazza SJ, Adamson RL, Moran MF, et al: Effects on tensioning errors in split transfers of tibialis anterior and posterior tendons. J Bone Joint Surg Am 2003;85:858-865.
Morita S, Muneta T, Yamamoto H, et al: Tendon transfers for equinovarus deformed foot caused by cerebrovascular disease. Clin Orthop Relat Res 1998;350:166-173.

Question 46:

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

Options:

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

Correct Answer: observation and exercises

Explanation:

Question 47:

Options:

Abduction to 90 degrees with maximal external rotation
Forward elevation to 170 degrees with neutral rotation
Cross-body adduction at 90 degrees flexion, with internal rotation
Extension with maximal internal rotation
Flexion to 90 degrees with maximal external rotation

Correct Answer: Abduction to 90 degrees with maximal external rotation

Explanation:

Question 48:

Options:

Therapy with an emphasis on eccentric exercises
Steroid injection
Platelet-rich plasma
Extracorporeal shock therapy

Correct Answer: Therapy with an emphasis on eccentric exercises

Explanation:

Question 49:

Options:

Continued bracing, physical therapy, and Botox injections in the triceps surae
Peroneus longus to brevis transfer, medializing calcaneal osteotomy, and transfer of the extensor digitorum longus to the peroneus tertius
Peroneus longus to brevis transfer, and transfer of the posterior tibial tendon to the tibialis anterior tendon
Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation
Triple arthrodesis

Correct Answer: Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation

Explanation:

Question 50:

Options:

fascia lata graft to restore the coracoacromial arch.
immediate subscapularis repair.
revision arthroplasty with glenoid reaming to centralize the component.
revision arthroplasty with increased retroversion in the humeral component.
arthroscopic subacromial decompression.

Correct Answer: immediate subscapularis repair.

Explanation:

Question 51:

Options:

Teratologic hip dislocation
Septic right hip
Congenital coxa vara
Transphyseal fracture of the proximal femur
Postpartum ligamentous laxity

Correct Answer: Transphyseal fracture of the proximal femur

Explanation:

Question 52:

Options:

Sural
Deep peroneal
Medial plantar
Posterior tibial

Correct Answer: Sural

Explanation:

Question 53:

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Options:

Peripheral myelin protein 22 (PMP22)
Survival motor neuron I (SMN1)
Survival motor neuron II (SMN2)
Dystrophin

Correct Answer: Survival motor neuron II (SMN2)

Explanation:

Question 54:

Histologic studies of surgically resected tissue in lateral epicondylitis demonstrate which of the following findings? Review Topic

Options:

Chondroblastic proliferation
Angiofibroblastic tendinosis
Significant active inflammation
Primarily calcium deposition
No normal tendon histology

Correct Answer: Angiofibroblastic tendinosis

Explanation:

Question 55:

Contraindications to cervical laminectomy as a treatment for cervical spondylotic myelopathy include which of the following findings?

Options:

Multilevel disease with spinal cord compression
Anterior spinal cord compression
Posterior spinal cord compression
Cervical kyphosis
Ossification of the posterior longitudinal ligament

Correct Answer: Cervical kyphosis

Explanation:

Question 56:

Options:

Distal metatarsal osteotomy
Distal soft-tissue reconstruction
Proximal metatarsal osteotomy
Lapidus bunionectomy

Correct Answer: Distal metatarsal osteotomy

Explanation:

DISCUSSION
Patients with painful progressive hallux valgus are surgical candidates. Presurgical evaluation includes radiographic examination. The IMA between the first and second metatarsals as well as the HVA must be measured. If the IMA is smaller than 15 degrees and the HVA is smaller than 35 degrees, a distal osteotomy is preferred. Distal soft-tissue reconstruction is only useful for IMAs smaller than 11 degrees and HVAs smaller than 25 degrees. Proximal osteotomies and the Lapidus bunionectomy are reserved for larger hallux valgus deformities with IMAs exceeding 15 degrees and HVAs exceeding 35 degrees.
RECOMMENDED READINGS
Pentikainen I, Ojala R, Ohtonen P, Piippo J, Leppilahti J. Distal Chevron Osteotomy: Preoperative Radiological Factors Contributing to Long-Term Radiological Recurrence of Hallux
Valgus. Foot Ankle Int. 2014 Sep 5. pii: 1071100714548703. [Epub ahead of print] PubMed PMID: 25192724.
View Abstract at PubMed
Fakoor M, Sarafan N, Mohammadhoseini P, Khorami M, Arti H, Mosavi S, Aghaeeaghdam A. Comparison of Clinical Outcomes of Scarf and Chevron Osteotomies and the McBride Procedure in the Treatment of Hallux Valgus Deformity. Arch Bone Jt Surg. 2014 Mar;2(1):31-

Question 57:

Which of the following represents the most appropriate treatment at this time?

Options:

Amputation of the leg
Distal femoral replacement
Chemotherapy and radiation therapy with non-weight-bearing until the lesion heals
Curettage, with local phenol and cementation
Hormonal therapy

Correct Answer: Curettage, with local phenol and cementation

Explanation:

Question 58:

What preoperative factor correlates best with the outcome of rotator cuff repair?

Options:

Size of the tear
Age of the patient
Arm dominance
Rupture of the long head of the biceps
Preoperative pain score

Correct Answer: Size of the tear

Explanation:

Question 59:

A 6-month-old child has the deformity seen in Figure 10. There are no other known associated problems. What is the etiology of this condition? Review Topic

Options:

Exposure to teratogens
Multifactorily inherited
A defect of the apical ectodermal ridge
Excess production of fibroblast growth factor
Inherited as an autosomal dominant

Correct Answer: A defect of the apical ectodermal ridge

Explanation:

Question 60:

What is the structure indicated by the letter “A” in Figure 21?

Options:

Annular ligament
Lateral ulnar collateral ligament
Accessory collateral ligament
Radial collateral ligament
Transverse ligament

Correct Answer: Radial collateral ligament

Explanation:

DISCUSSION: The ligaments shown are the components of the lateral collateral ligament complex, and the structure indicated by the letter “A” is the radial collateral ligament. The lateral ulnar collateral ligament is the structure indicated by the letter “C” and the annular ligament is indicated by the letter “B.” The transverse ligament is a component of the medial collateral ligament complex.
REFERENCES: Morrey BF: Anatomy of the elbow joint, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 1993, p 30.
O’Driscoll SW, Bell DF, Morrey BF: Posterolateral rotatory instability of the elbow. J Bone Joint Surg Am 1991;73:440-446.

Question 61:

Options:

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

Correct Answer: Posterior capsular stretching program

Explanation:

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

Question 62:

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Options:

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

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 63:

Options:

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

Correct Answer: MRI of the buttock.

Explanation:

Question 64:

Options:

anteroposterior axis.
tibial intramedullary axis.
posterior condylar axis.
femoral intramedullary axis.

Correct Answer: anteroposterior axis.

Explanation:

Question 65:

Options:

Ankle ligament repair
Resection of the accessory navicular
Resection of the talocalcaneal coalition
Subtalar arthrodesis
Triple arthrodesis

Correct Answer: Resection of the talocalcaneal coalition

Explanation:

Question 66:

Failure of posterolateral corner repair or reconstruction of the knee may be associated with which of the following? Review Topic

Options:

Valgus malalignment
Varus malalignment
Anterior cruciate ligament reconstruction
Posterior cruciate ligament reconstruction
Medial collateral ligament reconstruction

Correct Answer: Varus malalignment

Explanation:

Question 67:

Oxidation of polyethylene after sterilization occurs most rapidly when the implant undergoes

Options:

gamma radiation in air.
gamma radiation in nitrogen.
gamma radiation in argon.
gas plasma exposure.
ethylene oxide exposure.

Correct Answer: gamma radiation in air.

Explanation:

Question 68:

Options:

Anterior tibialis tendon transfer to the dorsolateral midfoot
Posterior tibialis tendon transfer to the dorsolateral midfoot
Peroneus longus tendon transfer to the dorsolateral midfoot
Peroneus brevis tendon transfer to the dorsolateral midfoot
Flexor hallucis longus tendon transfer to the peroneus brevis

Correct Answer: Anterior tibialis tendon transfer to the dorsolateral midfoot

Explanation:

Compartment syndrome of the anterior and deep posterior compartments results in anterior tibialis and posterior tibialis tendon weakness, respectively. Furthermore, the long flexors to the hallux and lesser toes will be weak as well. The intact peroneus longus overpowers the weak anterior tibialis tendon, resulting in plantar flexion of the first metatarsal, cavus, and hindfoot varus. Therefore, transferring the peroneus longus to the dorsolateral midfoot reduces the first metatarsal plantar flexion torque, and possibly augments ankle dorsiflexion torque.
(SBQ12FA.1) Figure A is a radiograph of a healthy, independent 51-year-old male. He is treated with immediate open reduction internal fixation to prevent which of the following complications?
Fracture non-union
Avascular necrosis
Skin necrosis
Plantar flexion weakness
Ankle stiffness
Figure A shows an avulsion fracture of the calcaneal tuberosity. Immediate open reduction and internal fixation is required to prevent wound complications.
Displaced avulsion fractures of the calcaneal tuberosity should be managed urgently to prevent necrosis of the soft tissues overlying the heel. In these injuries, the Achilles tendon is securely attached to the fractured tuberosity. Urgent closed reduction and casting is usually not possible due to the power and proximal pull of the triceps surae. Surgical fixation is required. The best treatment modality is open reduction and bone-to-bone fixation with screws. Closed reduction and percutaneous pinning fixation is not strong enough to provide a stable fixation of the tuberosity.
Lui reported on avulsion fractures of the bony insertion of the Achilles tendon at the calcaneus. He stated that screw fixation alone is not sufficient for repair of these injuries. His technique involved two suture anchors used capture the small bone fragment to the calcaneus. This allowed for the pull of the triceps surae to be neutralized and early physical therapy.
Hess et al. looked at a case series of calcaneal tuberosity avulsion fractures that were
treated in a delayed fashion. All three patients with posterior tuberosity calcaneal avulsion fractures developed skin necrosis because of a delay in treatment.
Figure A shows a displaced posterior tuberosity calcaneal avulsion fracture. Illustration A shows skin breakdown overlying the posterior tuberosity calcaneal avulsion fracture.
Incorrect Answers:

Question 69:

Which of the following parameters is considered most important when assessing an acetabular fracture for surgical indications?

Options:

Age of the patient
Failure to maintain reduction of the head under the dome without traction
Presence of a femoral head impaction lesion
Direction of the femoral head displacement
Fragmentation of the fracture

Correct Answer: Failure to maintain reduction of the head under the dome without traction

Explanation:

Question 70:

Options:

Chondrosarcoma
Infection
Wear-induced osteolysis
Corrosive effect due to dissimilar metals
Metastatic tumor

Correct Answer: Wear-induced osteolysis

Explanation:

DISCUSSION: The AP radiograph demonstrates extensive periacetabular osteolysis. The central hole eliminator has dissociated from the shell and migrated into a lytic defect in the ischium. In a retrieval study, most periacetabular osteolytic lesions had a clear communication pathway with the joint space. Lesions with communication to the joint via several pathways or through a central dome hole (as in this patient) were larger and more likely to be associated with cortical erosion. Although periprosthetic tumors have been described, they are rare and particle-induced inflammation around a prosthesis does not seem to increase the risk for carcinogenesis.
REFERENCES: Visuri T, Pulkkinen P, Paavolainen P: Malignant tumors at the site of total hip prosthesis: Analytic review of 46 cases. J Arthroplasty 2006;21:311-323.
Bezwada HP, Shah AR, Zambito K, et al: Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty. J Arthroplasty 2006;21:242-248.
Kitamura N, Naudie DD, Leung SB, et al: Diagnostic features of pelvic osteolysis on computed tomography: The importance of communication pathways. J Bone Joint Surg Am 2005;87:1542-1550.

Question 71:

Options:

clinically significant.
statistically significant but perhaps not clinically significant.
statistically and clinically significant.
not statistically or clinically significant.
nonconclusive.

Correct Answer: statistically significant but perhaps not clinically significant.

Explanation:

Question 72:

Options:

observation.
technetium Tc 99m bone scan.
MRI of the pelvis.
aspiration of the hip joint.
IV antibiotics.

Correct Answer: observation.

Explanation:

Question 73:

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

Options:

year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour
year old male, who plays hockey recreationally with no laxity and an x-ray showing a loss of glenoid contour
year old female, competitive tennis player with no laxity and x-ray findings of a Hill-Sachs lesion and loss of glenoid contour
year old male, recreational basketball player with ligamentous laxity and x-ray findings of a Hill-Sachs lesion
year old male, competitive football player with no laxity and no abnormal x-ray findings.

Correct Answer: year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour

Explanation:

Question 74:

Ewing’s sarcoma of bone most commonly occurs in which of the following locations?

Options:

Major long tubular bones
Flat bones of the pelvis
Fibula
Metacarpals
Vertebral bodies

Correct Answer: Major long tubular bones

Explanation:

Question 75:

Options:

Observation, with a repeat clinical examination in 2 weeks
Application of a hip abduction device and early follow-up to confirm reduction
Arthrogram and closed reduction of the right hip under general anesthetic, followed by spica casting
Open reduction of the right hip with a capsulorrhaphy DISCUSSION-The video shows an unstable right hip in a female infant. The visual ”clunk“ of the positive Barlow and Ortolani tests is readily evident. Initial treatment in a young infant consists of application of an abduction device to achieve and maintain hip location. Confirmation of successful hip location is usually performed by ultrasound examination. In the United States, the Pavlik harness remains the most commonly used hip abduction device, although others, such as hip abduction braces and the Frejka pillow, are available and have been shown to have similar success. Observation is not necessary when the examination shows clear instability. Arthrogram, closed manipulation, and spica casting are reserved for an older age group (those between 6 and 18 months of age). Open reduction is appropriate if the hip remains dislocated after 18 months of age.

Correct Answer: Application of a hip abduction device and early follow-up to confirm reduction

Question 76:

Options:

Disk herniation
Synovial cyst
Arachnoid cyst
Epidural lipomatosis

Correct Answer: Synovial cyst

Explanation:

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

Question 77:

Options:

Arthroscopic capsular plication
Arthroscopic thermal shift
Arthroscopic subacromial decompression
Posterior capsular stretching
Selective external rotation stretching

Correct Answer: Posterior capsular stretching

Explanation:

DISCUSSION
: The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient’s symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.
REFERENCES
: Meister K: Injuries to the shoulder in the throwing athlete. Part two: evaluation/ treatment. Am J Sports Med 2000;28:587-601.
Liu SH, Boynton E: Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete. Arthroscopy 1993;9:697-699.
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement. Am J Sports Med 2000;28:668-673.
2010 Sports Medicine Examination Answer Book • 21

Question 78:

Where is the underlying defect in a rhizomelic dwarf with the findings shown in Figure 5?

Options:

Type I collagen
Type II collagen
Collagen oligomeric protein (COMP)
Sulfate transport
Fibroblast growth factor receptor 3

Correct Answer: Fibroblast growth factor receptor 3

Explanation:

DISCUSSION: The radiograph shows the typical findings of achondroplasia. The defect is in fibroblast growth factor receptor 3. The pedicles narrow distally in the lumbar spine. The pelvis is low and broad with narrow sciatic notches and ping-pong paddle-shaped iliac wings. This is often called a champagne glass pelvis. Type I collagen abnormalities are typically found in osteogenesis imperfecta, and type II collagen defects are found in spondyloepiphyseal dysplasia and Kneist syndrome. COMP is defective in multiple epiphyseal dysplasia. Sulfate transport defects are seen in diastrophic dysplasia.
REFERENCES: Johnson TR, Steinbach LS: Essentials of Musculoskeletal Imaging. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 809-812.
Caffey J: Achondroplasia of the pelvis and lumbosacral spine: Some roentgenographic features. Am J Roentgenol 1958;80:449.

Question 79:

What is the most common pediatric soft-tissue sarcoma?

Options:

Ewing’s sarcoma
Liposarcoma
Rhabdomyosarcoma
Malignant fibrous histiocytoma
Fibrosarcoma

Correct Answer: Rhabdomyosarcoma

Explanation:

Question 80:

Options:

an increased risk of chondrolysis.
an increased risk of osteonecrosis.
an increased risk of stiffness.
an increased time to closure of the physis.
no deleterious effect.

Correct Answer: no deleterious effect.

Explanation:

Question 81:

Options:

Ceramic-on-ceramic
Large diameter metal head on highly cross-linked polyethylene liner
Ceramic head on metal liner
Large diameter metal-on-metal total hip arthroplasty
Metal on conventional polyethylene liner (noncross-linked)

Correct Answer: Large diameter metal head on highly cross-linked polyethylene liner

Explanation:

Question 82:

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Options:

Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution

Correct Answer: Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty

Explanation:

Question 83:

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

Options:

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

Correct Answer: Fracture of the proximal third of the forearm

Explanation:

Question 84:

Options:

loss of active thumb interphalangeal (IP) flexion.
distal radioulnar joint instability.
avascular necrosis of the capitate.
ulnar carpal translocation.

Correct Answer: ulnar carpal translocation.

Explanation:

Question 85:

Options:

external beam radiation.
curetting and cementation.
radiofrequency ablation.
wide local resection. DISCUSSION.. The imaging shows a cartilaginous lesion with destruction and a malignant extraosseous mass most consistent with a dedifferentiated chondrosarcoma. The histology demonstrates a high-grade spindle-cell sarcoma abutting a cartilaginous tumor, confirming this diagnosis. Treatment in this patient would be wide resection. The role of chemotherapy in this tumor is unproven, and an 85-year-old patient is an unlikely candidate for such treatment. Radiofrequency ablation, curettage, and radiation do not play a role in the treatment of this tumor.

Correct Answer: wide local resection. DISCUSSION.. The imaging shows a cartilaginous lesion with destruction and a malignant extraosseous mass most consistent with a dedifferentiated chondrosarcoma. The histology demonstrates a high-grade spindle-cell sarcoma abutting a cartilaginous tumor, confirming this diagnosis. Treatment in this patient would be wide resection. The role of chemotherapy in this tumor is unproven, and an 85-year-old patient is an unlikely candidate for such treatment. Radiofrequency ablation, curettage, and radiation do not play a role in the treatment of this tumor.

Explanation:

Question 86:

03 A 28-year-old man who sustained the injury shown in Figure 31 is hemodynamically unstable. In addition to fluid resuscitation, the next most appropriate step in management should include

Options:

angiography and embolization.
an emergent exploratory laparotomy.
external pelvic stabilization.
open reduction and internal fixation.
closed reduction and percutaneous screw fixation. backanswer Question 112.03

Correct Answer: external pelvic stabilization.

Explanation:

Question 87:

Options:

Unloader brace
Distal femoral osteotomy
Open arthrofibrosis debridement with lateral ligament balancing and polyethylene exchange
Revision TKA of both the femoral and tibial components

Correct Answer: Revision TKA of both the femoral and tibial components

Explanation:

Question 88:

Options:

higher than previous reports because of the use of the wound VAC.
related mainly to the location of the soft-tissue defect.
related mainly to the timing of soft-tissue coverage.
lower than previous reports because of the use of the wound VAC.
lower than previous reports because of the intramedullary nailing.

Correct Answer: related mainly to the timing of soft-tissue coverage.

Explanation:

DISCUSSION: The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures.
REFERENCES: Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292.
Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.
Herscovici D Jr, Sanders RW, Scaduto JM, et al: Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 2003;17:683-688.

Question 89:

Options:

Subacromial corticosteroid injection
Use of a sling until the pain resolves
Posterior capsular stretching
Arthroscopic SLAP repair
Arthroscopic anterior-inferior capsulolabral plication with posterior capsular release

Correct Answer: Posterior capsular stretching

Explanation:

Question 90:

Within the intervertebral disk, aggrecan is primarily responsible for: Review Topic

Options:

Tensile strength of the nucleus pulposis
Tensile strength of the annulus fibrosis
Sensory transmission
Maintaining water content
Intermolecular cross-linking of collagen

Correct Answer: Intermolecular cross-linking of collagen

Explanation:

Question 91:

Options:

Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension
Immobilization of the hand with the MCP joints in extension and the IP joints in extension
Percutaneous pinning of the proximal phalanx
Open reduction and internal fixation of the proximal phalanx
Early motion and pain management

Correct Answer: Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension

Explanation:

DISCUSSION: Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Kozin SH, Thoder JJ, Lieberman G: Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg 2000;8:111-121.

Question 92:

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 93:

A 20-year-old professional female jockey who is wearing a helmet is thrown from her horse. What is the most likely location of her injury?

Options:

Face
Head
Neck
Lower back
Leg

Correct Answer: Leg

Explanation:

Question 94:

Options:

Neutral rotation
External rotation
Internal rotation
Hyperflexion
Midstance phase of gait

Correct Answer: External rotation

Explanation:

Question 95:

A patient sustains an injury to the pelvis as a result of high-energy trauma. A radiographic and clinical assessment is performed. A lateral view of the pelvis will best identify

Options:

pubic symphysis diastasis.
sagittal plane pelvic rotation.
sacroiliac diastasis.
spinopelvic dissociation.
a vertical transforaminal sacral fracture.

Correct Answer: spinopelvic dissociation.

Explanation:

Question 96:

Options:

1,700 mg of calcium
1,200 mg of calcium
1,700 mg of vitamin D
1,200 mg of iron
1,700 mg of PTH

Correct Answer: 1,200 mg of calcium

Explanation:

Question 97:

Options:

Self-directed exercise therapy
Supervised exercise therapy
Supervised exercise therapy with static progressive elbow splinting
Continuous passive motion device
Closed manipulation under anesthesia

Correct Answer: Continuous passive motion device

Explanation:

Question 98:

In children between the ages of 4 and 8 years, the major blood supply to the femoral head comes from the

Options:

posterosuperior and posteroinferior branches of the medial femoral circumflex artery.
anterior branch of the lateral femoral circumflex artery.
anterior branch of the medial femoral circumflex artery.
ascending branch of the lateral femoral circumflex artery.
artery of the ligamentum teres.

Correct Answer: posterosuperior and posteroinferior branches of the medial femoral circumflex artery.

Explanation:

Question 99:

Options:

mechanical alignment radiographs.
stress radiographs of the knee.
comparison radiographs of both knees.
an erythrocyte sedimentation rate and a C-reactive protein.
examination of the hip.

Correct Answer: examination of the hip.

Explanation:

While all of the answers may be appropriate, radiating pain from hip pathology must be excluded. At this age, a slipped capital femoral epiphysis is likely. Therefore, the hip must be examined.

Question 100:

Options:

bone scan results returning to normal.
a decline in intensity on serial bone scans.
the serum levels of alkaline phosphatase measured over time.
the level of serum calcium-phosphorus product.
the time since injury and evidence of bone maturation on plain radiographs.

Correct Answer: the time since injury and evidence of bone maturation on plain radiographs.

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

Orthopedic Surgery Board Review MCQs: Spine, Trauma & Sports Medicine | Part 49

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 49

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index