Orthopedic Board Review MCQs: OITE & AAOS Prep Part 51

About This Board Review Set

This is Part 51 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.
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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 51

This module focuses heavily on: Ankle, Elbow, Fracture, Ligament, Nerve, Trauma.

Sample Questions from This Set

Sample Question 1: The arthroscopic views shown in Figures 31a and 31b reveal extensive synovitis in the anterolateral corner of the ankle overlying a band of tissue sometimes implicated in soft-tissue impingement of the ankle following a chronic sprain injur...

Sample Question 2: An axillary nerve lesion may cause weakness in the deltoid and the...

Sample Question 3: A 12-year-old gymnast has had elbow pain for 4 weeks. She denies any specific trauma to the elbow. Examination reveals lateral pain and no instability on testing. Range of motion is as follows: 15 degrees, loss of elbow extension, normal fl...

Sample Question 4: Longitudinal radioulnar dissociation, including Essex Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT?...

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

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

The arthroscopic views shown in Figures 31a and 31b reveal extensive synovitis in the anterolateral corner of the ankle overlying a band of tissue sometimes implicated in soft-tissue impingement of the ankle following a chronic sprain injury. This band is a portion of the

Explanation

DISCUSSION: The arthroscopic views show the lateral side of the ankle as demonstrated by the presence of the tibiofibular articulation. As is typical in chronic anterolateral impingement, synovitis overlies the anteroinferior band of the tibiofibular ligament, the most distal portion of the anterior syndesmosis. Hypertrophic scar formed on or in this ligament can impinge on the lateral margin of the talar dome and has been associated with chronic anterolateral ankle pain.
REFERENCES: Bassett FH III, Gates HS III, Billys JB, et al: Talar impingement by the anteroinferior tibiofibular ligament: A cause of chronic pain in the ankle after inversion sprain.

J Bone Joint Surg Am 1990;72:55-59.
DiGiovanni BF, Fraga CJ, Cohen BE, et al: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 2000;21:809-815.

Question 2

An axillary nerve lesion may cause weakness in the deltoid and the

Explanation

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 3

A 12-year-old gymnast has had elbow pain for 4 weeks. She denies any specific trauma to the elbow. Examination reveals lateral pain and no instability on testing. Range of motion is as follows: 15 degrees, loss of elbow extension, normal flexion, and normal pronation and supination. Radiographs reveal a 3- x 7-mm radiolucency of the capitellum. A T1-weighted MRI scan reveals a single solitary lesion, and T2-weighted images show no signal around the lesion. There are no intra-articular loose bodies. Appropriate management should include which of the following? Review Topic

Explanation

This is a typical presentation for an osteochondral lesion of the capitellum. This patient is young and has, by definition, a stable lesion and has excellent potential to heal this lesion with nonsurgical management. However, the patient should stop her activities (gymnastics) to prevent further damage and the possible development of an unstable lesion that might then necessitate surgery. Surgical procedures are generally not necessary for the treatment of these lesions.

Question 4

Longitudinal radioulnar dissociation, including Essex Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT?

Explanation

DISCUSSION: The IOM includes 5 types of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The annular ligament is not a part of the IOM.
The IOM bridges the radius and ulna and acts as a hinge for rotation of radius about ulna. The central portion is thickened, and forms the central band which is the most important ligament for IOM load distribution characteristics.
Noda et al, in a cadaver study, identified the precise anatomical insertions and attachment points of each of the 5 IOM components. They found the most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head.
Pfaeffle et al also performed a cadaveric biomechanical study applying compressive loads to specimens with IOMs that are intact, cut, or cut/reconstructed with flexor carpi radialis allografts. They found that reconstruction of the IOM can restore the normal load transfer chararcteristics and that the central band of the IOM is the most important portion of the IOM to be reconstructed.

Question 5

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

Explanation

DISCUSSION: When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.
REFERENCES: Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study. J Bone Joint Surg Am 2003;85:773-781.
Shen WJ, Liu TJ, Shen YS: Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001;26:1038-1045.

Question 6

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment?

Explanation

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.
REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures:

A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 7

Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?

Explanation

DISCUSSION: When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable.
REFERENCES: Phillips FM, Pfeifer BA, Leiberman IH, et al: Minimally invasive treatment of osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty. Instr Course Lect 2003;52:559-567.
Truumees E, Hilibrand A, Vaccaro AR: Percutaneous vertebral augmentation. Spine J 2004;4:218-229.
Rao RD, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 8

A 23-year-old man was a restrained backseat passenger in a head-on motor vehicle collision. Examination revealed extensive bruising diagonally across his chest and abdominal areas and extreme pain at the thoracolumbar junction posteriorly. The lateral chest radiograph showed splaying of the spinous processes and increased disk height at the level of the injury, but no fracture of the vertebral bodies. He underwent a posterior spine fusion with instrumentation to stabilize the spine after a full trauma workup revealed the spine to be his only injury. Where is the center of rotation for this injury? Review Topic

Explanation

The injury described is termed a "chance fracture" of the spine, and the radiograph suggests significant soft-tissue disruption of the spine without bony involvement anteriorly. The question asks the examinee to infer that the injury is an all-soft-tissue injury, continuing through the disk space, and that the forces acting on the spine are almost completely distractive and on the same side of the center of rotation. A chance fracture of the spine is classically regarded as a flexion-distraction injury resulting in variable bony/soft-tissue injury to the spine, classically associated with a center of rotation anterior to the spine (frequently being associated with bowel or other abdominal organ injury).

Question 9

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

Explanation

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

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

Question 10

A 55-year-old male is involved in a motorcycle crash and sustains a closed, right-sided, midshaft femur fracture. This is an isolated injury. He is treated with retrograde femoral nailing, and postoperatively is noted to have 30 degrees of internal rotation of the operative extremity, when compared with his nonsurgical side. Which of the following is the most likely cause of this malrotation deformity?

Explanation

Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing can cause a malrotation deformity.
Postsurgical internal malrotation after treatment for a diaphyseal femur fracture typically occurs either via internal rotation of the distal segment relative to the proximal or external rotation of the proximal segment relative to the distal. These clinical findings are consistent with an iatrogenic increase in femoral anteversion.
Dimitriou et al. performed a study to quantify the side-to-side anatomic variation in the proximal femur and the implications for preoperative planning and leg length discrepancy following hip arthroplasty. CT-based 3D femoral models were reconstructed for 122 paired femurs in 61 young healthy subjects with no history of hip pathology. Significant side-to-side differences were found in femoral anteversion, horizontal offset, and femoral head center location.
They concluded that relying on the anatomic landmarks of the contralateral femur during hip arthroplasty may not necessarily result in restoration of native anatomy and leg-length.
Karaman et al. conducted a study which saught to clarify the influence of a femoral rotational malalignment of ≥10° after intramedullary nailing on daily activities. They evaluated twenty-four femoral shaft fracture patients treated with closed antegrade IMN, and determined the presence of malrotation with post-operative CT scans. Ten of the 24 patients had a CT-detected true rotational malalignment of ≥10° compared with the unaffected side, and were noted to have significantly worse functional outcome scores compared with normally rotated femoral shaft patients.
Espinoza et al. present a technique using intraoperative fluoroscopy and the anteversion inherent to the IM nail for obtaining appropriate femoral rotational alignment during surgery. The authors state that their technique reliably sets the femoral anteversion within a normal physiologic range with minimal additional intraoperative steps and without preoperative measurements.
Illustration A shows a CT evaluation of femoral malrotation. The angle on the uninjured side measures 30°, while the malrotated fractured side measures only 3°, indicating a 27° external rotation deformity.
Incorrect Answers:

OrthoCash 2020

Question 11

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

Explanation

DISCUSSION: V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of

the thumb.
REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

Question 12

A right-handed 44-year-old construction worker reports pain and limited range of motion in his right elbow that has limited his ability to work for the past year. Examination reveals range of motion from 60 to 90 degrees, and he has pain at the extremes of flexion and extension. Pronation and supination are minimally restricted. Anti-inflammatory drugs have failed to provide relief. A radiograph is shown in Figure 8. Management should now consist of

Explanation

DISCUSSION: The radiograph reveals primary osteoarthritis of the elbow; therefore, ulnohumeral arthroplasty is the preferred procedure. Patients with severely limited preoperative elbow extension of more than 60 degrees and flexion of less than 100 degrees are at risk for ulnar nerve dysfunction postoperatively and should undergo a concomitant ulnar nerve decompression. Nonsurgical methods are unlikely to improve his chronic condition. Elbow arthroplasty is contraindicated for patients in this age group and with this diagnosis.
REFERENCES: Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: Long-term outcome and complications. J Bone Joint Surg Am 2002;84:2168-2173.
Phillips NJ, Ali A, Stanley D: Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty: A long-term follow-up. J Bone Joint Surg Br 2003;85:347-350.

Question 13

Based on the radiograph shown in Figure 4, the innervation of what muscle is most at risk with total hip arthroplasty?

Explanation

DISCUSSION: The radiograph reveals a Crowe IV deformity in a patient with developmental dysplasia of the hip. If hip arthroplasty is performed, then some degree of limb lengthening is anticipated. Excessive limb lengthening can result in sciatic nerve palsy in these patients. The peroneal branch of the sciatic nerve is most often affected. Of the muscles listed, only the extensor hallucis longus is innervated by the peroneal branch of the sciatic nerve.
REFERENCES: Eggli S, Hankemayer S, Muller ME: Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br 1999;81:843-845.
Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip replacement:

Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.

Question 14

Figures A and B are radiographic images of an 85-year-old woman with isolated left hip pain. She describes a non-syncopal fall from standing 4 hours ago. Physical examination reveals pain with log-rolling the left thigh and the inability to bear weight on the affected leg. The radiologist reports no fracture in the left hip. What would be the next best step? Review Topic

Explanation

Absent plantar sensation at presentation
Depression at 3 months post-injury
Use of an intramedullary nail
Free tissue transfer instead of rotational flap
Need for multiple debridements
The presence of depression at the 3 months post-injury is a significant predictor of worse long term outcome as well as lower return to work rates in patients that present with limb threatening lower extremity trauma.
The findings of the Lower Extremity Assessment Project (LEAP study) has challenged many of the long-held beliefs of lower extremity trauma surgery, including the concept that patients with absent plantar sensation should undergo immediate amputation . The LEAP study has also brought to light the importance of socioeconomic and psychosocial factors in patient outcomes following these injuries.
Bosse et al analyzed a subgroup of 55 patients from the LEAP study with absent plantar sensation at presentation. Those patients that underwent limb salvage despite absent sensation (n=26) had no significant difference in functional outcome when compared with either insensate patients who underwent amputation or a matched control group of sensate patients with similar injuries. All but one patient in the salvage group had return of some sensation at 2-year follow up and the authors concluded that an insensate plantar foot at presentation should not be included in the algorithm for amputation.
Mackenzie and Bosse reviewed the results of the LEAP study with particular emphasis on the social and economic variables that influence outcomes in severe lower extremity. The authors note that 19% of patients screened positive for severe depression. The presence of anxiety, pain and depression at 3 months post-injury were significant predictors of poor outcome
Incorrect Answers:
tissue for type IIIB tibia fractures. Answer 5: The number of debridements has not been shown to influence outcome.

Question 15

An 82-year-old woman reports right buttock pain after a car trip. Laboratory studies show an erythrocyte sedimentation rate of 30 mm/h and WBC of 4,600/mm 3 . Figure 34a shows a plain AP radiograph of the pelvis, and Figure 34b shows a delayed technetium Tc 99m bone scan. Management should consist of

Explanation

DISCUSSION: The radiograph shows bilateral cemented total hip arthroplasties. The acetabular components are loose bilaterally, but there has been no acute change. Therefore, it is unlikely that the acetabular loosening is contributing to the patient’s pain. The bone scan is consistent with a sacral insufficiency fracture. This is best treated with bed rest and pain medication. Activity can be increased as the pain allows. Revision will not address the pain.
REFERENCES: Newhouse KE, el-Khoury GY, Buckwalter JA: Occult sacral fractures in osteopenic patients. J Bone Joint Surg Am 1992;74:1472-1477.
Marmor L: Stress fracture of the pubic ramus simulating a loose total hip replacement. Clin Orthop 1976;121:103-104.

Question 16

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

Explanation

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

Figure 29a Figure 29b

Question 17

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Explanation

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child. Taping techniques result in no change or only a temporary decrease in deformity. Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer. Arthrodesis is rarely indicated.
REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: A

double-blind, randomized, prospective trial. J Bone Joint Surg Br 1993;75:662-663.
Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.

J Bone Joint Surg Br 1984;66:770-771.

Question 18

A 46-year-old woman has bilateral groin pain, with more severe pain on the left side than on the right side. Figures 44a and 44b show a radiograph and a T 1 -weighted MRI scan. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals bilateral patchy sclerosis of the femoral heads without evidence of collapse. The MRI scan shows bilateral head involvement with a common serpentine-like low-intensity signal of the superior femoral head that is common to osteonecrosis. Changes confined to the femoral head effectively exclude rheumatoid arthritis and osteoarthritis.
REFERENCES: Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 4. Philadelphia, PA, WB Saunders, 2002, vol 4, pp 3160-3162.
Epstein RE, Dalinka MK: Ischemic necrosis, in Stark DD, Bradley WG (eds): Magnetic Resonance Imaging, ed 3. St Louis, MO, Mosby, 1999, vol 2, pp 1023-1027.

Question 19

Figure 24 shows the radiograph of a 4-year-old girl with spina bifida. Examination reveals an L3 motor level, excellent sitting and standing balance, and satisfactory range of motion at the hips. Management should consist of

Explanation

DISCUSSION: Children with spina bifida and bilateral symmetrical dislocation of the hips usually do not require treatment. A level pelvis and good range of motion of the hips are more important for ambulation than reduction of bilateral hip dislocations. Because the patient has good sitting and standing balance and good range of motion, maintenance of that range of motion and symmetry is more important than reduction. Surgery is not recommended.
REFERENCE: Heeg M, Broughton NS, Menelaus MB: Bilateral dislocation of the hip in spina bifida: A long-term follow-up study. J Pediatr Orthop 1998;18:434-436.

Question 20

With increasing abduction in the scapular plane, maintaining neutral rotation, contact area, and contact pressure per unit area between the humeral head and glenoid follows what pattern if the total load across the joint is held constant?

Explanation

DISCUSSION: The glenohumeral joint becomes more congruent at higher levels of abduction. As a consequence, contact area increases. As the load is spread more evenly across the joint, contact pressure per unit area decreases as long as the total load across the joint is held constant.
REFERENCES: Warner JJP, Bowen MK, Deng XH, et al: Articular contact patterns of the normal glenohumeral joint. J Shoulder Elbow Surg 1998;7:381-388.
Greis PE, Scuderi MG, Mohr A, et al: Glenohumeral articular contact areas and pressures following labral and osseous injury to the anteroinferior quadrant of the glenoid. J Shoulder Elbow Surg 2002;11:442-451.

Question 21

An 80-year-old man who was involved in a fall from ground height is evaluated in the emergency department for head lacerations and mild neck pain. Examination reveals only mild tenderness of the posterior neck region with some limitation of motion. Neurologic examination is normal. Radiographs of the cervical spine are shown in Figures 58a and 58b. What is the next most appropriate step in management for this patient? Review Topic

Explanation

The patient has radiographic findings compatible with diffuse idiopathic skeletal hyperostosis (DISH) of the cervical spine. Characteristics of DISH include flowing, non-marginal osteophytes at four or more levels. Patients with DISH develop a significant loss of flexibility of the spine. The spine acts more as a long bone with minimal force needed to create unstable fractures. Any minor trauma in patients with DISH should be worked up aggressively to rule out occult fracture. In this patient, radiographs fail to clearly rule out a fracture; therefore, CT of the cervical spine is indicated. Without a suspicion of history of a head injury, admission specifically for a possible intracranial hematoma is not warranted. The more concerning injury in a patient with DISH is occult neck fracture. Treatment with a soft or hard collar is not advised until a fracture is ruled out. Repeat radiographs are unlikely to show any occult fractures, and flexion and extension views would not be advised in a patient with a suspected vertebral fracture.

Question 22

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Explanation

DISCUSSION:
Vascular complications during TKA are rare but do occur. Traditionally, it was taught that the popliteal artery was situated posterior to the PCL; however, more recent anatomic dissections have demonstrated that this artery is usually located posterolateral to the PCL.

Question 23

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

Explanation

Question 24

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Explanation

DISCUSSION: The union rate for minimally displaced midthird scaphoid fractures is quite high with cast immobilization while allowing a return to sports. Inadequate immobilization results in a much higher nonunion rate. Early fixation and rehabilitation have been proposed for sports or positions that are not amenable to cast immobilization. While immobilization of a nondisplaced fracture results in an acceptably high union rate, there is no advantage to fixation in conjunction with immobilization in the course of healing. With adequate immobilization and protection, play restrictions until healing has occurred are unnecessary.
REFERENCES: Rettig AC, Kollias SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med 1996;24:182-186.
Rettig AC, Weidenbener EJ, Gloyeske R: Alternative management in midthird scaphoid fractures in the athlete. Am J Sports Med 1994;22:711-714.
Riester JN, Baker BE, Mosher JF, Lowe D: A review of scaphoid fracture healing in competitive athletes. Am J Sports Med 1985;13:159-161.

Question 25

Figures 28a and 28b show AP and lateral radiographs of the knee. Based on these findings, which of the following structures has most likely been injured?

Explanation

DISCUSSION: The radiographs show a posterior knee dislocation. Knee dislocations almost always involve rupture of both the anterior and posterior cruciate ligaments. Collateral ligament injuries also are common. Arterial, nerve, and tendon injuries each occur in less than half of knee dislocations.
REFERENCES: Schenck RC Jr, Hunter RE, Ostrum RF, et al: Knee dislocations. Instr Course Lect 1999;48:515-522.
Wascher DC, Dvirnak PC, DeCoster TA: Knee dislocation: Initial assessment and implications for treatment. J Orthop Trauma 1997;11:525-529.

Question 26

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

Explanation

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

Question 27

A 36-year-old woman with familial neurofibromatosis has an enlarging mass in the posterior thigh. The lesion has slowly increased in size and is now constantly painful. Pressure on the mass causes dysesthesias in the foot. Figures 44a through 44c show T 1 -weighted, STIR, and T 1 -weighted fat-saturated gadolinium scans, respectively. Figure 44d shows a PET scan. What does this lesion most likely represent?

Explanation

DISCUSSION: The images reveal a large mass in the posterior thigh arising from the sciatic nerve. The lesion is edematous, and the gadolinium image reveals rim enhancement, suggesting necrosis, given that the STIR image is not uniformly bright as would be seen in a cystic lesion. The PET scan has increased uptake, in this case a standard unit value (SUV) of greater than 2.0. These findings are all very suggestive of a malignant process. The history of neurofibromatosis makes a malignant peripheral nerve sheath tumor, or neurofibrosarcoma, the most likely diagnosis. The term “peripheral nerve sheath tumor” has replaced neurolemmoma and schwannoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 225-230.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4218-4235.

Question 28

CLINICAL SITUATION Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. What is the best next step in the patient’s evaluation?

Explanation

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome,
but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-union, especially in the femur.

Question 29

A 14-year-old boy sustained a femoral neck fracture in a fall from a tree and underwent open reduction and internal fixation 6 months ago. Follow-up examination now reveals an antalgic Trendelenburg gait and painful range of motion. A radiograph is shown in Figure 23, and a CT scan shows a nonunion. Treatment should consist of

Explanation

DISCUSSION: The coxa vara deformity and fracture nonunion should be treated simultaneously; therefore, the treatment of choice is curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation. In addition, valgus osteotomy will convert the shear forces across the nonunion to compression, aiding in healing of the nonunion. None of the other procedures addresses both issues, and hip fusion is inappropriate under these conditions.
REFERENCES: Lam SF: Fractures of the neck of the femur in children. J Bone Joint Surg Am 1971;53:1165-1179.
Canale ST, Beaty JH: Pelvic and hip fractures, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1109-1193.

Question 30

A 26-year-old man is involved in a high-speed motorcycle accident. He sustains a grade IIIB open tibia fracture. Examination reveals a large soft-tissue defect and an insensate foot. What is the expected outcome in this scenario? Review Topic

Explanation

The Lower Extremity Assessment Project data have shown that absent plantar sensation is not an indication for primary amputation. When looking at a comparison between an insensate salvage group and a sensate salvage group at 2 years follow-up, both groups had an equal proportion (55%) of normal plantar sensation and functionally both groups were equivalent. Absent plantar sensation at initial evaluation is not prognostic for long-term plantar sensory status or functional outcome.

Question 31

The arrow in the axial T 1 -weighted MRI scan shown in Figure 18 is pointing to which of the following structures?

Explanation

DISCUSSION: The arrow is pointing to the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long, beginning at the proximal extent of the transverse carpal ligament and ending at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches, with the deep branch of the ulnar nerve persisting distal to the canal. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel. The radial artery is on the radial side of the wrist. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist.
REFERENCES: Goss MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop 1985;196:238-247.
Denman EE: The anatomy of the space of Guyon. Hand 1978;10:69-76.

Question 32

What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery?

Explanation

The current recommendation for antibiotic prophylaxis for major orthopaedic surgical procedures is to administer intravenous antibiotics within 1 hour of surgical incision. Redosing of antibiotics should occur 3 to 4 hours after the initial dose for procedures that extend beyond 3 to 4 hours. Little evidence supports postsurgical antibiotic use beyond 24 hours. As you move beyond 1 hour from time of administration of antibiotics, risk for infection increases and rates of bacterial cell death decline. It is not acceptable to administer presurgical antibiotics after incision.

Question 33

A B Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

Explanation

DISCUSSION
This injury pattern represents a flexion distraction injury, or a Chance fracture. The imaging hallmark of this injury is the axial split of the pedicle seen on the sagittal CT scan. This injury necessitates surgical intervention to prevent progressive deformity and pain. A rotation mechanism results in a dislocation with a rotational deformity at the level of injury. An extension force causes failure of the anterior column in tension with compression of the posterior column. An axial load force would result in a burst fracture.
RECOMMENDED READINGS
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.
Vaccaro AR, Baron EM, Sanfilippo J, Jacoby S, Steuve J, Grossman E, DiPaola M, Ranier P, Austin L, Ropiak R, Ciminello M, Okafor C, Eichenbaum M, Rapuri V, Smith E, Orozco F, Ugolini P, Fletcher M, Minnich J, Goldberg G, Wilsey J, Lee JY, Lim MR, Burns A, Marino R, DiPaola C, Zeiller L, Zeiler SC, Harrop J, Anderson DG, Albert TJ, Hilibrand AS. Reliability of a novel classification system for thoracolumbar injuries: the Thoracolumbar Injury Severity Score. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S62-9; discussion S104. PubMed PMID:16685239.View Abstract at PubMed

Question 34

What is the most appropriate treatment for a 17-year-old boy who sustained a gunshot wound to his forearm from a handgun with a muzzle-velocity of 1000 feet/second if he is neurovascularly intact and radiographs reveal no fracture?

Explanation

DISCUSSION: The question refers to appropriate management of a gunshot wound to the forearm. The first question that must be answered when evaluating gun shot injuries is whether the gunshot is low velocity or high velocity. Low-velocity wounds are less severe, are more common in the civilian population, and are typically attributed to bullets with muzzle velocities below 1,000 to 2,000 feet per second. Tissue damage is usually more substantial with higher-velocity (greater than 2,000 to 3,000 fps) military and hunting weapons. In this question, a muzzle velocity of 1,000 ft/sec is provided. Low velocity injuries with stable, non-operative fractures can be treated with local wound care and oral antibiotics.
The two referenced articles offer guidance for treating low-velocity gunshot injuries with stable, non-operative fracture patterns. The first article by Geissler et al is a retrospective study comparing 25 patients that prospectively received local irrigation and debridement, tetanus prophylaxis and a long acting cephalosporin intramuscularly to a random retrospective sample of 25 patients with similar ballistic-induced fractures and wounds managed by local debridement and 48h of intravenous antibiotics. One infection occurred in each group, requiring further therapy. It was concluded that patients with low-velocity gunshot induced fractures can be managed without the use of short-term intravenous antibiotics with no increased risk of infection.
In the second study, Dickey et al evaluated the efficacy of an outpatient management protocol for patients with a gunshot-induced fracture with a stable, non-operative configuration. 41 patients with a grade I or II open, nonoperative fracture secondary to a low-velocity bullet were treated with 1gm of cefazolin administered in the emergency room and a 7-day course of oral cephalexin. No patient developed a deep infection. Thus, local I&D, tetanus, and oral antibiotics for 2-3 days is adequate for low velocity gunshot wounds

Question 35

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Explanation

DISCUSSION: Unlike malignant bone tumors, malignant soft-tissue tumors usually are asymptomatic and present with the presence of a mass. Malignant soft-tissue tumors enlarge by centrifugal growth, creating a mass while compressing surrounding tissue. Symptoms may develop as the result of direct compression on neurovascular structures as the tumor enlarges. This is especially true in the pelvis where the tumor can enlarge appreciably without being noticed. However, in the extremities, the tumor is most often apparent before neurologic symptoms develop. An asymptomatic mass is not necessarily benign; therefore, biopsy should not be delayed. It is uncommon for a malignant soft-tissue mass to be discovered incidentally. Soft-tissue tumors are not typically apparent on radiographs; they are best identified with MRI.
REFERENCES: Brouns F, Stas M, De Wever I: Delay in diagnosis of soft tissue sarcomas. Eur J Surg Oncol 2003;29:440-445.
Rougraff B: The diagnosis and management of soft tissue sarcomas of the extremities in the adult. Curr Probl Cancer 1999;23:1-50.
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 36

-Images from an MRI scan of this patient’s left hip are shown in Figure 30c through 30e. What is the most likely cause of his acute pain?

Explanation

DISCUSSION FOR QUESTIONS 30 THROUGH 32
This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.Surgical treatment for cam impingement can be effective for symptomatic patients. Even among highlevel athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable to those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.Byrd and Jones described 5 patients who developed transient neurapraxias that resolved uneventfully.The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 37

A 12-year-old girl has had progressive left knee pain for the past 4 months. She reports that the pain is unrelated to activity, and she has no history of fever or recent infections. Examination reveals full range of motion of the knee but tenderness along the medial joint line. Plain radiographs and MRI scans are shown in Figures 39a through 39d. A biopsy specimen of the lesion is shown in Figure 39e. Treatment should include

Explanation

DISCUSSION: The lesion is a chondroblastoma. The plain radiographs show a well-defined radiolucent lesion in the distal femoral epiphysis of a skeletally immature patient. The margins are well defined, suggesting a benign growth. The epiphysis is an unusual location for bone tumors, except for chondroblastomas. Of all chondroblastomas, 95% are located within the epiphysis. The MRI scans show a punctate appearance that is commonly seen in cartilage lesions. The biopsy specimen shows a chondroid lesion with polygonal chondrocytes. These findings are consistent with a chondroblastoma. The natural history of chondroblastomas is for continued growth and bone destruction if left untreated. Treatment should consist of curettage, with or without the use of physical or chemical adjuvants, and bone grafting.
REFERENCE: Springfield DS, Capanna R, Gherlinzoni F, Picci P, Campanacci M: Chondroblastoma: A review of seventy cases. J Bone Joint Surg Am 1985;67:748-755.

Question 38

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 39

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

Explanation

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

Question 40

Figures 1 through 3 are the weight-bearing radiograph and MRI scans of a 27-year-old man who twisted his knee coming down awkwardly from a lay-up during a basketball game. He felt a sharp stabbing pain in the posterior aspect of his knee at the time of the injury. Physical examination reveals a trace effusion, full range of motion but pain with hyperflexion >90° degrees and tenderness over the affected joint line. What is the most appropriate treatment at this time?

Explanation

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more appropriate in the older patient with pre-existing advanced degenerative changes.

Question 41

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. Radiographs of the player’s right ankle confirm there are no fractures. With a lateral talar tilt test result of 19°, which additional structure is most likely damaged?

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 42

Figure 11 shows the radiograph of a 26-year-old man with type I diabetes mellitus who was struck by a motor vehicle. What is the most common complication associated with this pelvic fracture?

Explanation

DISCUSSION: The most common complication following acetabular or pelvic ring injury is deep venous thrombosis (DVT). Without prophylaxis, rates of DVT are as high as 70% to 80%. With prophylaxis, the rates are around 10%. Infection rates in surgical repair of acetabular fractures are relatively low but a history of diabetes mellitus and a significant Morel-Lavalle lesion certainly increase the risk. However, even with these two complicating factors, the rates of infection are still lower than 10%. Sciatic nerve palsy rates from the injury alone approach 20% and iatrogenic injury is usually less than 2%. Degenerative changes to the hip following this injury approach 20% to 25%, even with an anatomic reduction.
REFERENCES: Geerts WH, Code KI, Jay RM, et al: A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601-1606.
Steele N, Dodenhoff RM, Ward AJ, et al: Thromboprophylaxis in pelvic and acetabular trauma surgery: The role of early treatment with low-molecular-weight heparin. J Bone Joint Surg Br 2005;87:209-212.

Question 43

…What is the etiology of the pain associated with this lesion?

Explanation

Question 44

It has been shown that bisphosphonate-based supportive therapy (pamidronate or zoledronate) reduces skeletal events (onset or progression of osteolytic lesions) both in patients with multiple myeloma and in cancer patients with bone metastasis. The use of biphosphonate therapy has been associated with Review Topic

Explanation

The use of bisphosphonates has been recently associated with the development of osteonecrosis of the jaw. Length of exposure seems to be the most important risk factor for this complication. The type of bisphosphonate may play a role and previous dental procedures may be a precipitating factor. Bisphosphonates are a class of therapeutic agents originally designed to treat loss of bone density (ie, alendronate). The primary mechanism of action of these drugs is inhibition of osteoclastic activity, and it has been shown that these drugs are useful in diseases with propensities toward osseous metastases. In particular, they are effective in diseases in which there is clear upregulation of osteoclastic or osteolytic activity, such as breast cancer and multiple myeloma, and have developed into a mainstay of treatment for individuals with these diseases. Although shown to reduce skeletal events, there has been no improvement in patient survival.

Question 45

Figures 87a and 87b are the radiographs of an 18-year-old pedestrian who was struck by a car. During intramedullary nailing, it is difficult to maintain proper alignment. Poller blocking screws placed in the proximal fragment at which position(s) relative to the nail can help prevent the typical deformity?

Explanation

This is a proximal one third tibial shaft fracture. Typically nailing of this fracture creates a valgus and procurvatum malalignment that must be addressed. This can be difficult when using an intramedullary nail in the wide metaphyseal bone of the proximal tibia. To help direct and center the nail in the metaphysis, blocking screws can be used. Blocking screws should be placed where the nail should not travel. If the nail was passed with the proximal fragment in this position, it would occupy the lateral and posterior aspects of the metaphyseal fragment. To prevent this, blocking screws should be placed in the lateral and posterior aspects of the proximal fragment.

Question 46

During anatomic medial patellofemoral ligament (MPFL) reconstruction, the surgeon notes that the graft is becoming too tight with greater knee flexion. What is the most likely cause?

Explanation

If the graft becomes tighter with knee flexion, the femoral attachment is too proximal. This error is referred to as “high and tight,” meaning that a high or proximal femoral attachment produces a graft that is too tight with knee flexion. If graft tension increases with increasing knee flexion, the result is loss of knee flexion or graft failure, increased contact forces resulting in patella femoral chondrosis, and possibly medial subluxation.

Question 47

What is the most frequent late complication of cementless fixation in total knee arthroplasty?

Explanation

DISCUSSION: The incidence of osteolysis, particularly around fixation screws in the tibia, can be as high as 30%. Stable femoral component fixation is generally maintained. Infection, subluxation of the patella, and stiffness can occur with either cemented or cementless fixation.
REFERENCES: Peters PC, Engh GA, Dwyer KA, Vinh TN: Osteolysis after total knee arthroplasty without cement. J Bone Joint Surg Am 1992;74:864-876.
Parks NL, Engh GA, Topoleski LDT, Emperado J: Modular tibial insert micromotion: A concern with contemporary knee implants. Clin Orthop 1998;356:10-15.

Question 48

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Explanation

DISCUSSION: The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.
REFERENCES: Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225.
Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Kerr CD, Sybert DR, Albarracin NS: An analysis of the flexor synovium in idiopathic carpal tunnel syndrome: Report of 625 cases. J Hand Surg Am 1992;17:1028-1030.

Question 49

A polytrauma patient underwent the following procedures: (1) statically locked intramedullary nailing for a right femoral shaft fracture; (2) open reduction with plate-and-screw fixation [ORIF] for a right simple distal fibula fracture; (3) ORIF right middle third radius and ulna fracture; and (4) ORIF left humeral shaft fracture. What is the appropriate weightbearing status for this patient? Review Topic

Explanation

The standard postoperative weightbearing for locked medullary nailing for femoral shaft fractures and humeral shaft fractures is weight bearing as tolerated (WBAT). Simple ORIF ankle fractures may be managed with early protected weight bearing. ORIF right middle third radius and ulna fracture should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture.
Tingstad et al. examined the effect of immediate weightbearing on plated fractures of the humeral shaft. They reported that immediate weightbearing on humeral shaft fractures, treated with plating and full weightbearing, did not have any negative effect on the union or malunion rates.
Brumback et al. evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. Using biomechanical and clinical data, they showed that all fractures united with no loss of fixation or hardware failure.
Starkweather et al. retrospectively assessed the complications and loss of reduction in patients who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures. Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. These results suggest early protected weightbearing may be safe.
Incorrect Answers:

Question 50

Figure 54 is the lateral radiograph of a 55-year-old man who is evaluated for a 2-year history of pain and stiffness of his right metatarsophalangeal (MTP) joint. Upon examination he has dorsal bossing, severe crepitation, and pain with passive range of motion. There is pain with the "grind" test. Dorsiflexion is limited to 0 degrees. No sesamoid tenderness is present. What is the most appropriate surgical treatment?

Explanation

DISCUSSION
The radiograph reveals end-stage degenerative changes of the first MTP joint with a dorsal loose body. MTP arthritis and decreased joint dorsiflexion is referred to as hallux rigidus. A chevron bunionectomy is used to correct hallux valgus deformity without arthritis. The cheilectomy is used in lesser degrees of joint destruction. Resection of the proximal phalanx results in a floppy toe and is generally not recommended.
RECOMMENDED READINGS
McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int. 2013 Jan;34(1):15-32. doi: 10.1177/1071100712460220. Review. PubMed PMID: 23386758.
View Abstract at PubMed
Deland JT, Williams BR. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012 Jun;20(6):347-58. doi: 10.5435/JAAOS-20-06-347. Review. PubMed PMID: 22661564.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 55 THROUGH 58
Figures 55a and 55b are the anteroposterior and lateral radiographs of a 57-year-old man who fell off of a ladder 10 days ago and landed on his left foot. He is now unable to weight bear on the left. He has no history of trauma to this foot, and his medical history is unremarkable. Upon examination his left foot is swollen and tender. Pulses and sensation are intact.

A B

Question 51

A 12-year-old boy with hemophilia A and no known inhibitors sustains a tibia fracture and has pain with passive motion of the deep toe flexors. Appropriate management should consist of

Explanation

DISCUSSION: In a patient with hemophilia, factor replacement followed by assessment of compartment pressures is essential. If the patient has inhibitors, the problem is more difficult. Porcine factor has been helpful in patients with inhibitory antibodies. Recent evidence points to using activated factor VII and bypassing the intrinsic pathway. Desmopressin is an adjunct to therapy but is not as effective as factor VII.
REFERENCES: Dumontier C, Sautet A, Man M, Bennani M, Apoil A: Entrapment and compartment syndromes of the upper limb in haemophilia. J Hand Surg Br 1994;19:427-429.
Carr ME Jr, Loughran TP, Cardea JA, Smith WK, Kuhn JG, Dottore MV: Successful use of recombinant factor VIIa for hemostasis during total knee replacement in a severe hemophiliac with high-titer factor VIII inhibitor. Int J Hematol 2002;75:95-99.
Chuansumrit A, Isarangkura P, Angchaisuksiri P, et al: Controlling acute bleeding episodes with recombinant factor VIIa in haemophiliacs with inhibitor: Continuous infusion and bolus injection. Haemophilia 2000;6:61-65.

Question 52

1 and 2 show the radiograph and CT obtained from a year-old woman who underwent right total hip replacement in She initially did well with no pain. She was last seen 7 years ago and was having mild hip pain at that time. She was found to have a supra-acetabular cyst on radiographs. She has had severe right hip pain for the past 9 months while using a walker for ambulation. The initial blood work reveals an estimated erythrocyte sedimentation rate of 32 mm/hr, a C-reactive protein level of 5 mg/L, a serum cobalt level of 4 µg/L, and a serum chromium level of 6 µg/L. Right hip aspiration is performed, revealing a white blood cell count of 139, 52% neutrophils, and a negative leukocyte esterase test. What is the best next step?

Explanation

DISCUSSION:
The hip replacement was performed in 1995, during the period when the previous generation of polyethylene was utilized. This polyethylene was subjected to irradiation in air, with subsequent oxidation and consequent osteolysis after implantation. The mechanism of osteolysis begins with the uptake of polyethylene particles by macrophages, which then initiate an inflammatory cascade and the release of osteolytic factors. This cycle continues, with eventual implant loosening and failure. The imaging shows significant osteolysis and raises concern for pelvic discontinuity and acetabular implant failure. The surgical treatment consists of acetabular reconstruction. In this patient, concern exists for discontinuity based on the substantial amount of bone loss and nonsupportive anterior and posterior columns. This scenario requires complex acetabular revision using a custom triflange device, distraction with a jumbo acetabular component, or placement of a porous metal cup/cage construct with augmentation. The laboratory values are not consistent with infection or failure due to metal debris.

Question 53

A 3-year-old boy sustains a complete paralysis following a high thoracic spinal cord injury consistent with a SCIWORA-type injury (spinal cord injury without radiographic abnormality). Subsequent progressive spinal deformity will develop in what percent of patients with this injury?

Explanation

DISCUSSION: Spinal cord injury in skeletally immature patients almost always leads to the development of paralytic spinal deformity. The age at injury is the most important factor affecting the development of scoliosis. Spinal cord injury that occurs more than 1 year prior to skeletal maturity is almost always followed by the development of scoliosis. In one study, scoliosis developed in 100% of children who were younger than age 10 years at the time of spinal cord injury. Scoliosis can occur after injury at any level. Spasticity is often a contributing factor. Up to two thirds of patients who have paralytic scoliosis prior to skeletal maturity will eventually require surgery for curve control.
REFERENCES: Mayfield JK, Erkkila JC, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg Am 1981;63:1401-1411.
Lancourt JE, Dickson JH, Carter RE: Paralytic spinal deformity following traumatic spinal cord injury in children and adolescents. J Bone Joint Surg Am 1981;63:47-53.
Dearolf WW III, Betz RR, Vogel LC, Levin J, Clancy M, Steel HH: Scoliosis in pediatric spinal cord injured patients. J Pediatr Orthop 1990;10:214-218.

Question 54

A 13-year-old girl who is 2 years postmenarche has been referred for management of scoliosis. She denies any history of back pain. Radiographs show a right thoracic curve of 35°. She has a Risser sign of 4 and a bone age of 15.5 years. Management should consist of

Explanation

DISCUSSION: Because the patient is skeletally mature with a curve of less than 40°, there is no benefit to bracing and surgery is not indicated. Management should consist of observation and follow-up radiographs in 6 months.
REFERENCES: Lonstein JE, Carlson JM: The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 1984;66:1061-1071.
Frymoyer JW (ed): Orthopaedic Knowledge Update 4. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1993, pp 447-459.

Question 55

Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque?

Explanation

DISCUSSION: Computer-assisted navigation has been shown to reduce radiation exposure for surgeons when performing interlocking of medullary nails compared to free-hand technique.
Ricci et al compared two fluoroscopic navigation tracking technologies, optical and electromagnetic versus standard freehand fluoroscopic targeting, in a standardized foam block model for placement of interlocking screws. They found that fluoroscopy time (seconds) and number of fluoroscopy images were significantly less when using the computer-guided systems than for freehand-unguided insertion. Average distance of pin placement from the target in the foam blocks was significantly greater for controls than for each of the navigated systems.
Suhm et al performed a prospective controlled clinical study to compare fluoroscopic guidance with fluoroscopy-based surgical navigation for distal locking of intramedullary implants. The surgical navigation group showed increased procedure time, but equivalent precision with reduced radiation exposure. There was no significant difference in the technical reliability between both groups.

Question 56

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 57

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

Explanation

DISCUSSION: The radial nerve is only 4 mm from the anterolateral portal, while the median nerve is 11 mm away from the anteromedial portal. The ulnar nerve is only at risk on the medial side of the elbow. Anterior and posterior interosseous nerves are more distal within the forearm and are not in danger during portal placement.
REFERENCES: O’Driscoll SW, Morrey BF: Elbow arthroscopy, in Morrey BF (ed): The Elbow. Philadelphia, PA, Lippincott, Williams and Wilkins, 1994, pp 21-34.
Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.

Question 58

A 44-year-old patient who has had a proximal first metatarsal osteotomy has recurrent pain and difficulty wearing many types of shoes. Radiographs show a large 1-2 intermetatarsal angle (IMA).

Explanation

Question 59

Figure 31 shows the AP and lateral radiographs of the elbow of a 56-year-old man with chronic polyarticular rheumatoid arthritis. His function continues to be limited by pain with activities of daily living. Examination shows that his total arc of motion is 110 degrees. Nonsurgical management has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: A semiconstrained prosthesis can provide excellent results in carefully selected patients. Because the radiographs show extensive joint destruction with loss of the capitellum and trochlea, a capitellocondylar total elbow (unconstrained) prosthesis is contraindicated. Elbow fusion is poorly accepted, and the radiographs show too much articular destruction for a radial head excision, synovectomy, or interposition arthroplasty to be effective.
REFERENCES: Ewald FC, Simmons ED Jr, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis: Long-term results. J Bone Joint Surg Am 1993;75:498-507.
Morrey BF, Adams RA: Capitellocondylar total elbow replacement in rheumatoid arthritis. J Bone Joint Surg Am 1992;74:479-490.

Question 60

The wear resistance of ultra-high molecular weight polyethylene can be improved by exposing the polymer to high-energy radiation (eg, gamma or electron beam), followed by a thermal treatment. What is one detrimental side effect of this process?

Explanation

DISCUSSION: Highly cross-linked polyethylene has gained widespread acceptance for joint arthroplasty components because of reported experimental and early clinical accounts of significant reductions in wear. Cross-linking is increased by imparting additional energy into the polymer (above that conventionally used for sterilization). The thermal treatments after cross-linking stabilize the material against oxidative degradation by quenching free radicals and also reduce the elastic modulus. One disadvantage of the increased cross-linking is a reduction in toughness that makes the polyethylene more susceptible to crack initiation and propagation. The reduced toughness raises concerns for gross component fracture and fracture at stress concentrations that can arise with the locking mechanisms used to secure polyethylene inserts into metallic backings. Nonconsolidated polyethylene particles have been associated with increased subsurface density secondary to oxidative degradation in conventional polyethylene implants. The quenching of free radicals by thermal treatment in highly cross-linked polyethylene should prevent this problem.
REFERENCES: Collier JP, Currier BH, Kennedy FE, et al: Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop 2003;414:289-304.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 203-208.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 61

…Giant-cell tumor of bone usually involves the epiphysis of long bones. What is the next most common type of tumor involving this anatomical location?

Explanation

CLINICAL SITUATION FOR QUESTIONS 71 THROUGH 73
Figures 71a through 71e are the radiographs, MRI scan, and CT scans of a 14-year-old-boy who has cyclical pain in his thigh. His symptoms began approximately 6 months ago. He complains of increased pain when he runs and also of pain that wakes him at night. This pain is relieved by nonsteroidal anti-inflammatory drugs (NSAIDs).

Question 62

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Explanation

Several studies have shown worse functional results in patients older than 40 or 50 years of age compared to younger patients after open reduction and internal fixation of tibial plateau fractures. Two studies showed that older patients with less severe fractures performed less favorably than younger patients with more severe injuries. Only 35% of patients older than 50 years were satisfied with their results independent of fracture type.

Question 63

Flow cytometry of tumors measures the

Explanation

Flow cytometry is a method of quantitating components or structural features of cells primarily by optical means. Ploidy and cell cycle analysis of cancers is the major diagnostic use. Cells are passed single file through a laser beam by continuous flow and several parameters are measured including Cell Diameter, proportional quantity of granular (DNA) within the cell, and using fluorescent probes the total DNA or a specific DNA/mRNA sequence can be counted. In examining tumors the amount of DNA in each cell is important for determining neoplasia.

Question 64

Figure 4 shows the AP radiograph of a 28-year-old woman who has had moderate pain in the left hip for the past year. Nonsurgical management has failed to provide relief. She denies any history of hip pain, pathology, or trauma. Management should consist of

Explanation

DISCUSSION: The radiograph shows developmental dysplasia of the hip with the hip reduced and congruent. The treatment of choice is a periacetabular osteotomy because it can improve hip biomechanics and prolong the function of the hip joint. This procedure should be performed prior to the development of severe degenerative changes. Observation will not alter the patient’s natural history or the biomechanics of the hip. A total hip arthroplasty should be delayed until severe degenerative changes are present. A Chiari osteotomy is a salvage osteotomy used for a noncongruent subluxated hip. A Pemberton osteotomy requires an open triradiate cartilage; therefore, it is not an option in an adult.
REFERENCES: Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.
Pemberton PA: Pericapsular osteotomy of the ilium for the treatment of congenital subluxation and dislocation of the hip. J Bone Joint Surg Am 1965;47:65-86.

Question 65

Figure A is a pelvic radiograph of a healthy 20-month old girl with a limb leg discrepancy. A hip arthrogram under general anesthesia reveals concentric reduction of the left hip ONLY when the hip is positioned in 70 to 80 degrees of abduction. The next best step in treatment would be: Review Topic

Explanation

Figure A shows left hip subluxation consistent with late presenting developmental hip dysplasia (DDH). The most appropriate treatment at this stage would be open hip
capsulorrhaphy, +/- femoral osteotomy +/- pelvic osteotomy
In children older than 18 months, open reduction is the preferred treatment for hip dysplasia. Open reduction is also considered when concentric closed reduction cannot be achieved or when excessive abduction (>60 degrees) is required to maintain reduction (due to increasing risk of avascular necrosis). The goal of open reduction is to remove the blocks to reduction and to increase stability by preforming soft-tissue or bone procedures.
Wenger et al. reviewed the surgical treatment of DDH. They say that the impediment to congruent reduction are the iliopsoas muscle, joint capsule, ligamentum teres, pulvinar, labrum, and transverse acetabular ligament. The most commonly used approaches are anterior and medial/anteromedial to the hip.
Gholve et al. reviewed DDH and the factors that contribute to secondary procedures. In their study, neither age nor unilateral vs bilateral dislocation had a direct influence on the outcome or the need for secondary procedures. The variable that significantly influenced the need for a secondary procedure was the concomitant use of a femoral osteotomy during initial surgical treatment. Of the 27 patients who did not have concurrent femoral osteotomy at index surgery, 19/27 (73%) required a secondary procedure (P<0.001).
Figure A shows an AP pelvic radiograph of an infant. Focusing on the left hip, there is lateral and superior subluxation of the femoral head, with the femoral head lateral to Perkin's line. The medial joint space is increased. The acetabular index is increased
>30 degrees. Shenton's line is disrupted. These are all features of DDH.
Incorrect Answers:

Question 66

Mutations of what gene are associated with subsequent development of osteosarcoma?

Explanation

DISCUSSION: The mutation of the retinoblastoma gene has been associated with an increased prevalence of osteosarcoma. The mutation resulting in EWS-FLI1 is associated with Ewing’s sarcoma. The other mutations are associated with tumor formation and proliferation but not necessarily with osteosarcoma formation.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 4.
Scholz R, Kabisch H, Delling G, Winkler K: Homozygous deletion within the retinoblastoma gene in a native osteosarcoma specimen of a patient cured of a retinoblastoma of both eyes. Pediatr Hematol Oncol 1990;72:65.
Hovig E, Lothe R, Farrants G, et al: Chromosome thirteen alterations in osteosarcoma cell lines derived from a patient with previous retinoblastoma. Cancer Genet Cytogenet 1991;57:31-40.

Question 67

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 68

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Explanation

DISCUSSION: A positive margin is most closely related to subsequent local recurrence. The other factors cited, including the size and site of the tumor, may be related to local recurrence; however, they are more commonly prognostic because of the difficulty in obtaining wide surgical margins about large or proximal tumors. Radiation therapy has been noted to decrease the incidence of recurrence but is not felt to be as important as the surgical margin. The grade of the tumor has more influence on the prevalence of metastatic disease than the incidence of local recurrence.
REFERENCES: Lewis JJ, Leung D, Heslin M, Woodruff JM, Brennan MF: Association of local recurrence with subsequent survival in extremity soft tissue sarcoma. J Clin Oncol 1997;15:646-652.
Meterissian SH, Reilly JA Jr, Murphy A, Romsdahl MM, Pollock RE: Soft-tissue sarcomas of the shoulder girdle: Factors influencing local recurrence. Distant metastases and survival. Ann Surg Oncol 1995;2:530-536.

Question 69

Figures 1 and 2 show the intraoperative photographs obtained from a man who is undergoing open reduction and internal fixation of a fifth carpometacarpal joint fracture dislocation. If the structure marked with an arrow in Figure 2 is cut, the patient can expect to experience

Explanation

EXPLANATION:
The arrow in Figure 2 marks the dorsal sensory branch of the ulnar nerve. Injury to this nerve results in sensory loss of the dorsal ulnar palm and the dorsal small and ring finger digits. The dorsal sensory branch of the ulnar nerve exits the main ulnar nerve at an average distance of 8.3 cm from the proximal border of the pisiform. It becomes subcutaneous on the ulnar aspect of the forearm at an average distance of 5
cm from the proximal edge of the pisiform. It then travels dorsal to the extensor carpi ulnaris tendon to innervate the dorsal ulnar hand and the dorsal ring and small digits. Injuries to this nerve can occur from open and arthroscopic procedures (such as triangular fibrocartilage complex repair) as well as from procedures requiring percutaneous pinning. Care must be taken to identify and protect this nerve to avoid the complications of numbness and possible neuroma formation. The inability to extend the small finger would be caused by an injury to the extensor tendon(s) in this area, and the inability to abduct the small finger would require an injury to the abductor digiti minimi muscle/tendon unit or the ulnar nerve motor branch, which is located on the volar aspect of the proximal palm. Clawing of the small and ring fingers would be caused by absent intrinsic function due to an injury to the ulnar motor nerve branch located on the volar proximal palm.

Question 70

A 55 year-old man has multiple lytic lesions in the humeri, clavicles, and scapulae. Which of the following diagnostic studies best confirms a diagnosis of multiple myeloma?

Explanation

Myeloma is a malignant bone tumor derived from plasma cells. It is associated with abnormalities of protein synthesis. It is the most common primary malignant tumor of bone. The disease is most common between the ages of 50 and 80. Patients most commonly present with bone pain, usually in the spine and ribs. Biopsy is necessary to establish the diagnosis in a solitary lesion and is still the gold standard for diagnosis of any lesion. Definitive diagnosis of multiple myeloma is established by bone marrow aspiration. However, multiple myeloma may also be diagnosed with considerable confidence based on radiographs and lab data. Bence Jones proteins may be found in the urine. Serum protein abnormalities may cause formation of a rouleaux in the peripheral blood smear. Serum and urine protein electrophoresis are usually abnormal. Answers #3, #4, and #5 may provide some information but the definitive diagnosis is based on bone marrow aspiration. Answer #1 provides little information.

Question 71

A 53-year-old man reports acute, severe left shoulder pain after undergoing abdominal surgery 10 days ago. Initial management, consisting of anti-inflammatory drugs, physical therapy, and a subacromial injection of corticosteroid, fails to provide relief. Reexamination of the shoulder 2 months after the onset of symptoms reveals atrophy of the infraspinous and supraspinous fossa and profound weakness of active abduction and external rotation. His neck is supple with a full range of motion. Plain radiographs and an MRI scan of the shoulder are normal. What diagnostic study should be performed next in the evaluation of this patient?

Explanation

DISCUSSION: Suprascapular nerve palsy is a fairly uncommon yet well-known cause of shoulder pain and weakness. A variety of causes have been described, including compression by a ganglion cyst, an anomalous or thickened superior transverse scapular ligament, a humeral and scapular fracture, and traction or kinking of the nerve in the suprascapular notch.
In this patient, the injury is most likely caused by traction or compression of the nerve in the suprascapular notch as the result of positioning during abdominal surgery; therefore, the studies of choice are electromyography and nerve conduction velocity studies. While MRI of the cervical spine may be of some value in ruling out a radiculopathy, the clinical history does not support such a cause for this condition.
REFERENCES: Rengachary SS, Neff JP, Singer PA, Brackett CE: Suprascapular entrapment neuropathy: A clinical, anatomical, and comparative study. Part 1: Clinical study. Neurosurgery 1979;5:441-446.
Rengachary SS, Burr D, Lucas S, Hassanein KM, Mohn MP, Matzke H: Suprascapular entrapment neuropathy: A clinical, anatomical and comparative study. Part 2: Anatomical study. Neurosurgery 1979;5:447-451.
Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthoscopy 1990;6:301-305.

Question 72

Figure 3 is the clinical photograph of a 20-year-old college soccer player who has a 7-day history of worsening left ankle pain and swelling after being slide-tackled in a game. Radiograph findings of his ankle and foot are normal. He complains of malaise. His history includes a severe ankle sprain 3 months ago. The sprain caused him to miss half the season, but he was able to play in the last 2 games. What is the most appropriate treatment? Review Topic

Explanation

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant Staphylococcus aureus. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 73

A 67-year-old woman has a painful, arthritic proximal interphalangeal (PIP) joint, and nonsurgical measures have failed to improve the pain. What implant and joint replacement approach combination has been demonstrated to have the lowest rate of revision surgery?

Explanation

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate, the worst gain in arc of motion, and the greatest extension lag. However, substantial pain relief and higher satisfaction still were reported after surface replacement arthroplasty, regardless of the complications.

Question 74

A 45-year-old woman has severe anterior knee pain. Her radiographs indicate end-stage patellofemoral compartment osteoarthritis. The tibiofemoral compartments are preserved. Extensive nonsurgical treatment has failed to provide relief, and she is offered patellofemoral arthroplasty (PFA). What is the most common long-term mode of failure for PFA using an implant with an onlay prosthesis design?

Explanation

DISCUSSION:
Contemporary onlay-design trochlear prostheses in PFA replace the entire anterior trochlear surface. Previous inlay designs were inset within the native trochlea and carried a higher risk of catching and patellar instability, particularly in patients with trochlear dysplasia; they also generally have higher failure rates. The current most common mode of failure is progression of arthritis throughout the knee, in some series as high as 25% at 15 years. Aseptic loosening, particularly of cemented implants, is less common. Infection is an uncommon long-term complication. Patients considering PFA should be advised of the risk of arthritis progression. Many authors routinely obtain a preoperative MRI to assess the status of the tibiofemoral compartments.

Question 75

Figures 48a and 48b are the initial radiograph and clinical photograph of a 21-year-old woman who sustained a severe mangling injury to her left foot in a rollover ATV crash. After multiple dTbridements, she underwent definitive transmetatarsal amputation with split-thickness skin graft. She did have intact plantar sensation. Figure 48c shows the clinical photograph 10 days after amputation. Her wounds healed without infection and she did not require further surgery. At 2 years after injury, which of these factors is most likely to be associated with improved level of satisfaction? Review Topic

Explanation

Anterior pelvic external fixation with pins placed in the AIIS and a posterior sacroiliac screw
Open reduction and internal fixation of the pubic symphysis with a two hole plate and posterior fixation with a iliosacral screw
Open reduction and internal fixation of the pubic symphysis with a non-locking multi-hole plate and posterior fixation with a iliosacral screw
Anterior pelvic external fixation and posterior triangular osteosynthesis
Open reduction and internal fixation of the pubic symphysis with a locked multi-hole plate and posterior sacral plate fixation
The radiographs and CT scan show a fracture pattern consistent with an APC-III injury. This is most appropriately treated with pubic symphysis ORIF with a multi-hole plate and posterior iliosacral screw fixation.
APC-III pelvic ring injuries are associated with with disruption of the anterior and posterior SI ligaments (SI dislocation) as well as disruption of sacrospinous and sacrotuberous ligaments. They are commonly associated with vascular injury and retroperitoneal bleeding.
Sagi et al studied the radiographic and clinical outcome of symphyseal plating techniques, specifically comparing two hole (THP) vs multi-hole plating (MHP). Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. When comparing the 2 different methods of anterior fixation, they found that the rate of fixation failure was greater in group THP (33%) than group MHP (12%). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (57%) than in the MHP group (15%). On the basis of these findings, the authors recommended multi-hole plating of unstable pubic symphyseal disruptions.
Grimshaw et al performed a biomechanical study to determine the failure risk and potential benefit to use of locked fixation constructs in simulated pelvic ring injuries. The authors used a six-hole 3.5-mm plate specifically designed for the symphysis pubis with the capability of fixation in locked or unlocked mode, six pelves were fixed with locked screws and six pelves were fixed standard unlocked bicortical screws. Biomechanical testing was performed, and no abrupt failures were noted. However, locked plating of the pubic symphysis did not appear to offer any advantage over the standard unlocked technique
Illustrations A, B, and C show the AP, outlet, and inlet postoperative radiographs. Incorrect Answers:
1,4-Anterior pelvic fixation is typically not used as definitive treatment of these
injuries unless performed in a damage-control setting. The patient in this case is stable.
2-Multi-hole plate fixation of the pubic symphysis is preferred over 2-hole plate fixation.
5-Posterior sacral plating is not indicated in this fracture pattern, as there is no significant sacral comminution of vertical shear component. Furthermore, no distinct advantage has been found with locked symphyseal plating.

Question 76

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Explanation

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837. View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983. View Abstract at PubMed Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709. View Abstract at PubMed

Question 77

A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?

Explanation

Osteoarthrosis of the glenohumeral joint is a potential late complication of the anterior Putti-Platt capsulorrhaphy. Disabling pain in the shoulder began an average of 13.2 after a Putti-Platt repair that had been done for recurrent anterior unidirectional instability. Osteoarthrosis of the glenohumeral joint resulted in substantial limitation of motion. Complications of the Putti-Platt surgery include persistent pain, recurrent subluxation or dislocation, or residual weakness of the shoulder; paresthesias of the musculocutaneous nerve, and infection. This late complication develops when the repair is excessively tight, a 20-25 degree limitation of full external rotation is desired and expected after rehabilitation. The most direct correlation with the severity of osteoarthrosis was the degree of limitation of external rotation.

Question 78

What percent of adult patients with rheumatoid arthritis test positive for rheumatoid factor?

Explanation

Rheumatoid factor is present in 80% to 90% of adult patients with rheumatoid arthritis. Although rheumatoid factor is very sensitive, it is not very specific. Antinuclear antibodies (ANA) can be detected in 30% to 40% of patients with rheumatoid arthritis.

Question 79

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

Explanation

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

Question 80

Figures 24a and 24b are the radiographs of a 7-year-old boy who fell off the monkey bars and has a closed injury. His hand appears warm and well perfused with an absent radial pulse. What is the best initial treatment?

Explanation

DISCUSSION
In displaced extension-type supracondylar fractures, the neurovascular structures get kinked anteriorly or anteromedially related to the displacement. In almost all cases, there is a spontaneous resolution of this kink following closed fracture reduction.

Question 81

A 13-year-old gymnast presents with ongoing knee pain for the past few months. She tried conservative measures including kinesiotaping, physical therapy and rest. On physical exam, she has normal valgus alignment, negative patellar tilt and discomfort with resisted open chain knee extension. A representative radiographs are shown in Figure A-C. What is the most likely clinical diagnosis? Review Topic

Explanation

Based on history, physical examination and radiographic findings this patient has patellofemoral syndrome
Evaluation of a patient with patellofemoral pain requires a physical examination and plain radiographs. Appropriate examination of all structures around the knee is critical to rule out other diagnoses. An MRI is useful for evaluating intra-articular or intra-osseous lesions, if clinical suspicion is suggestive of this. Treatment is predominantly conservative, with focus on low impact exercises that maximize aerobic conditioning.
Earl et al. review the epidemiology, etiology and management of patellofemoral syndrome. They note that there is no clear cause of this issue, although issues related to the quadriceps and dynamic malalignment may be contributory.
Outerbridge et al. describe overuse injuries in the young athletic patient. They provide an overview of diagnosis and management specific to this patient population.
Figures A, B and C show AP, lateral and merchant radiographs of a normal knee in a skeletally immature individual. No osseous abnormalities are identified.
Incorrect

Question 82

Figures 12a and 12b show the radiographs of a 56-year-old man with diabetes mellitus who has had left foot swelling with no pain for the past several weeks. He denies any history of trauma. Examination reveals warmth, moderate swelling, no tenderness, and mild pes planus with standing. Pulses are palpable, and his sensory examination is grossly intact to light touch. Standing radiographs are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show tarsometatarsal joint subluxation without fragmentation. The clinical history and delay in presentation with the radiographic findings suggest a neuropathic or Charcot arthropathy involving the midfoot area. Intact sensory examination to light touch is not diagnostic for an intact peripheral neurologic system; monofilament testing is a more accurate office baseline examination for the presence of sensory peripheral neuropathy. With an acute traumatic Lisfranc fracture-dislocation, a history of a traumatic event is necessary, and radiographic abnormalities are expected, although nonstanding radiographs still may be misleading. Acquired pes planus due to posterior tibial tendon rupture may have negative nonstanding radiographs. Standing radiographs may reveal pes planus. However, intermetatarsal disruption is not expected as seen in a Lisfranc abnormality. Localized osteomyelitis of the foot without a penetrating injury or cutaneous ulceration is extremely unlikely and does not fit with the clinical picture described. An isolated metatarsal stress fracture would show osseous irregularity without the instability pattern pictured.
REFERENCES: Brodsky JW: The diabetic foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 895-969.
Myerson MS: Diabetic neuroarthropathy, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 439-465.

Question 83

Which of the following best describes heat stroke? Review Topic

Explanation

Heat stroke consists of hyperthermia (greater than 105.8 degrees F [41 degrees C]), central nervous system dysfunction, and cessation of sweating with hot, dry skin. It is a medical emergency that results from failure of the thermoregulatory mechanisms of the body. It has a high death rate and requires rapid reduction in body core temperature. Heat syncope is characterized by a transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature. Heat cramps involve painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride. Heat exhaustion is distinguished by a core temperature of less than 102.2 degrees F (39 degrees C) and an absence of central nervous system dysfunction. Hypernatremic heat exhaustion results from inadequate water replacement.

Question 84

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?
A. Improved longevity in comparison to the linked prosthesis
B. A significantly larger flexion-extension arc
C. A higher incidence of postsurgical instability
D. Lower frequency of ulnar nerve dysfunction
TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 85

When performing a long fusion to the sacrum in an osteopenic patient in whom optimal sagittal balance is restored, which of the following is a benefit of extending the distal fixation to the pelvis, rather than the sacrum alone? Review Topic

Explanation

In osteopenic individuals, even those with excellent obtained or maintained balance, long instrumented fusions to the sacrum impart a high degree of strain, and the sacrum may fail in a transverse fracture or fracture-dislocation pattern. The risk of proximal functional kyphosis is unrelated to distal fixation as are coronal plane correction and rod contouring. Pubic ramus fractures have been shown to be associated with both fixation to the sacrum alone as well as to the ilium.

Question 86

The mother of a 2-year-old boy reports that he had pain in the right hip all night and refuses to walk on the leg this morning. He is afebrile. Examination reveals pain on hip extension and adduction, but he is able to internally and externally rotate the hip approximately 20 degrees in each direction without pain. Laboratory studies reveal a WBC count of 7,400/mm 3 , with 62% polymorphonuclear neutrophil leukocytes. The AP radiograph shown in Figure 15 reveals a left teardrop distance of 8 mm, while the right side measures 10 mm. Which of the following diagnostic studies will best help confirm the diagnosis?

Explanation

DISCUSSION: The differential diagnosis includes septic hip and transient synovitis. Both disorders may present with a joint effusion. The increased teardrop distance and loss of range of motion implies that there is excess fluid in the joint. While the other tests can confirm this, only aspiration can characterize the fluid further, thereby indicating the etiology of the effusion. Provided there is enough fluid obtained at aspiration, the joint fluid should be sent for Gram stain, culture, cell count, glucose, and protein studies.
REFERENCE: Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990, pp 1415-1435.

Question 87

A 22-year-old javelin thrower reports that he has had increasing discomfort in his right elbow and loss of distance from his throws for the past 3 months. Examination reveals tenderness over the medial elbow. Application of valgus torque to the elbow through a passive range of motion elicits pain from 70 degrees to 120 degrees of flexion, with no pain at the limits of extension. What structure is primarily responsible for the patient's symptoms? Review Topic

Explanation

The MCL is divided into anterior and posterior bundles; the anterior bundle is subdivided into anterior and posterior bands. Sectioning studies showed that the anterior band of the anterior bundle is the primary restraint to valgus stress at 30 degrees, 60 degrees, and 90 degrees; the posterior band of the anterior bundle is the primary restraint at 120 degrees. Medial elbow pathology in a throwing athlete can present with pain, instability, loss of velocity or control, or with ulnar nerve symptoms. Differentiating between different causes of disability can be largely accomplished through physical examination. The moving valgus stress test is performed by applying a valgus stress to a maximally flexed elbow, then passively extending the elbow. Reproduction of the patient's symptoms in the mid arc of flexion suggests MCL insufficiency. Pain at the end point of extension suggests posterior compartment symptoms, which were not present in this patient. The posterior bundle
is a secondary stabilizer at 30 degrees of flexion, and not susceptible to valgus load when the anterior bundle is intact. The annular ligament and triceps insertion are not involved with medial instability of the elbow. Olecranon osteophytes likely cause pain in terminal extension of the elbow.

Question 88

A 12-year-old girl with juvenile rheumatoid arthritis (JRA) has had chronic pain and synovitis about the knee that is now well-controlled medically. Examination reveals 20° of valgus at the knee. Knee range of motion shows 10° to 90° of flexion. Treatment should consist of

Explanation

DISCUSSION: Children with JRA frequently have valgus in association with hypervascularity because of chronic inflammation. This is normally caused by overgrowth of the medial femoral epiphysis. Staple hemiepiphyseodesis, if done early, can reverse the deformity. Osteotomy is usually unnecessary at this age, and there is a risk of stiffness of the knee following the procedure. Synovectomy may be helpful but will not prevent or correct a deformity.
REFERENCE: Rydholm U, Brattstrom H, Bylander B, Lidgren L: Stapling of the knee in juvenile chronic arthritis. J Pediatr Orthop 1987;7:63-68.

Question 89

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain is elicited with valgus stress. Initial radiographs were negative for abnormality. What is the most likely area of injury?

Explanation

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or long-leg cast.

Question 90

Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying

Explanation

DISCUSSION: During the late acceleration phase of throwing, the triceps forcibly contracts, extending the elbow as the ball is released. Normally, this force is absorbed by the anterior capsule and the brachialis and biceps muscles. However, if the ulnar collateral ligament is insufficient, the elbow will be in a subluxated position during extension and cause impaction of the olecranon and the olecranon fossa posteromedially. Over time, osteophyte formation is likely to occur.
REFERENCES: Conway JE, Jobe FW, Glousman RE, Pink M: Medial instability of the elbow in throwing athletes: Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74:67-83.
Wilson FD, Andrews, JR, Blackburn TA, McCluskey G: Valgus extension overload in the pitching elbow. Am J Sports Med 1983;11:83-88.

Question 91

An 8-year-old boy with moderate factor VIII hemophilia played kickball earlier in the day and now reports progressively severe groin pain and is unable to walk. Examination reveals marked paresthesias over the medial aspect of the distal tibia. What is the most likely diagnosis?

Explanation

DISCUSSION: The iliacus muscle is a frequent site of hemorrhage in patients with severe or moderate hemophilia. In patients with moderate hemophilia, hemorrhage into the iliacus muscle often follows play or sporting events that include forceful contraction of the hip flexor muscles. An expanding iliacus hematoma compresses the adjacent femoral nerve, with one study reporting 60% complete femoral nerve palsy in hemophiliacs with an iliacus or iliopsoas hemorrhage. Femoral nerve compression typically includes paresthesias in the distribution of the terminal saphenous nerve branch. Hip joint hemarthrosis may occur, but this condition is not as frequent in hemophiliacs as muscle hemorrhage into the iliacus muscle. More importantly, a hip joint hemarthrosis is not associated with significant compression of the femoral nerve. Avulsion fractures of the anterior superior iliac spine typically occur during adolescence and are not associated with saphenous nerve paresthesias. Slipped capital femoral epiphysis does not have an increased association with hemophilia and usually occurs during the adolescent years.
REFERENCES: Greene WB: Diseases related to the hematopoietic system, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 379-426.
Gilbert MS, Radomisli TE: Therapeutic options in the management of hemophilic synovitis. Clin Orthop 1997;343:88-92.

Question 92

The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them? Review Topic

Explanation

ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.

Question 93

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Explanation

Posterolateral disk herniations will generally compress the transversing nerve root. Therefore, a posterolateral disk herniation at the L4-5 level will typically compromise the L5 nerve root. Far lateral (extraforaminal) disk herniations generally compromise the exiting nerve root. Therefore, an extraforaminal herniation at the L4-5 level will typically compromise the exiting L4 nerve root.

Question 94

Figures 80a and 80b are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test result, trace effusion, and range of motion from 0 to 85 degrees of knee flexion. Which factor is most contributory to his examination findings?

Explanation

DISCUSSION
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

CLINICAL SITUATION FOR QUESTIONS 81 THROUGH 84
Figures 81a through 81d are the MR images of a 25-year-old man with left knee pain after a motorcycle collision. He has palpable pedal pulses with an ankle-brachial index of 0.95. Neurologic examination findings of the injured extremity are normal.

Question 95

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Explanation

DISCUSSION: Fluoroquinolones have been associated with increased rates of tendinitis, with special predilection for the Achilles tendon. Tenocytes in the Achilles tendon have exhibited degenerative changes when viewed microscopically after fluoroquinolone administration. Recent clinical studies have shown an increased relative risk of Achilles tendon rupture of 3.7. The other listed drugs have no known increase in tendon rupture rates nor tendinitis.
REFERENCES: van der Linden PD, van de Lei J, Nab HW, et al: Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999;48:433-437.
Bernard-Beaubois K, Hecquet C, Hayem G, et al: In vitro study of cytotoxicity of quinolones on rabbit tenocytes. Cell Biol Toxicol 1998;14:283-292.
Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036.

Question 96

A 20-year-old woman with spastic hemiplegia is evaluated for function and hygiene issues with her right wrist. Her wrist has a resting posture of 90° of flexion and can be passively extended to 65° of flexion. Her fingers are flexed into her palm but can be passively extended with the wrist at 95°. What treatment is likely to provide the most durable result for improved hygiene, function, and cosmesis?

Explanation

EXPLANATION:
The patient has a static deformity of the wrist with a fixed flexion deformity of more than 45°. Soft-tissue procedures such as those referenced in options A and B would not be sufficient to address the degree of contracture. Additionally, Botulinum toxin injections would not provide relief for capsular contractures. Wrist arthrodesis combined with a proximal row carpectomy has been shown to provide a functional and cosmetic alternative for patients with severe wrist flexion contractures.

Question 97

03 An 18 month old child has bilateral “corner fractures” of the distal femoral metaphyses of unknown origin. Following a skeletal survey, the first step in management should consist of

Explanation

The key to this question consists in realizing that corner fractures are highly diagnostic for battered children. Thus, the first step in management is to notify protective services. The cited references however remind us that any broken bone could be indicative of child abuse.
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Question 98

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Explanation

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip? Review Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 99

Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?

Explanation

DISCUSSION: Of the pelvic ring injuries, APC type III have the highest rate of mortality, blood loss, and need for transfusion. They also have a high rate of urogenital injury and abdominal organ injury. Lateral compression injuries (especially type III) have the highest rate of head injury. Vertical shear and combined injuries also have significant rates of concomitant injuries. The referenced article by Dalal et al is a review of Shock Trauma's pelvic ring injuries; they found significant increases in associated injuries as the grade of pelvic ring injury increased, regardless of mechanism/pattern. The aforementioned information was also found to be true with their patient review.

Question 100

Kinematic testing of patellofemoral motion demonstrates that malalignment that produces increased Q angle causes a shift of the patella laterally in the trochlear groove and is most pronounced during what phase of the flexion arc? Review Topic

Explanation

Dynamic patellofemoral joint contact measurements on cadaveric knees with simulated increased Q angle demonstrated that forces shifted to the lateral facet. The lateral shift in the patella was most pronounced from 40 to 90 degrees of flexion. At lower degrees of flexion, the lateral shift was significantly less. At higher degrees of flexion, the continued shift of the patella was not as pronounced.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

anteroinferior tibiofibular ligament.
anterior talofibular ligament.
calcaneofibular ligament.
deltoid ligament.
extensor retinaculum.

Correct Answer: anteroinferior tibiofibular ligament.

Explanation:

DISCUSSION: The arthroscopic views show the lateral side of the ankle as demonstrated by the presence of the tibiofibular articulation. As is typical in chronic anterolateral impingement, synovitis overlies the anteroinferior band of the tibiofibular ligament, the most distal portion of the anterior syndesmosis. Hypertrophic scar formed on or in this ligament can impinge on the lateral margin of the talar dome and has been associated with chronic anterolateral ankle pain.
REFERENCES: Bassett FH III, Gates HS III, Billys JB, et al: Talar impingement by the anteroinferior tibiofibular ligament: A cause of chronic pain in the ankle after inversion sprain.
J Bone Joint Surg Am 1990;72:55-59.
DiGiovanni BF, Fraga CJ, Cohen BE, et al: Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 2000;21:809-815.

Question 2:

An axillary nerve lesion may cause weakness in the deltoid and the

Options:

teres major.
teres minor.
teres major and teres minor.
latissimus dorsi.
latissimus dorsi and teres major.

Correct Answer: teres minor.

Explanation:

DISCUSSION: While the most prominent functional deficit from axillary nerve lesions occurs from denervation of the deltoid, denervation of the teres minor also occurs.
REFERENCE: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs. New York, NY, Harper & Row, 1969.

Question 3:

Options:

Arthroscopic debridement of the elbow
Open repair of the lesion
Open biopsy of the lesion
Continued participation in gymnastics until symptoms worsen
No participation in gymnastics until symptoms resolve and motion recovers

Correct Answer: No participation in gymnastics until symptoms resolve and motion recovers

Explanation:

Question 4:

Options:

Central band ligament
Accessory band ligament
Annular ligament
Dorsal oblique accessory cord ligament
Distal oblique bundle ligament

Correct Answer: Central band ligament

Explanation:

Question 5:

Options:

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

Correct Answer: incidence of complications.

Explanation:

DISCUSSION: When patients are compared at 5 years follow-up, there are no statistically significant differences between the two groups with respect to kyphosis, the degree of retropulsed bone resorption, pain and function levels, or the ability to return to work. Nonsurgical management of stable neurologically intact burst fractures has a very low incidence of complications.
REFERENCES: Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study. J Bone Joint Surg Am 2003;85:773-781.
Shen WJ, Liu TJ, Shen YS: Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001;26:1038-1045.

Question 6:

A 7-year-old girl is hit by a motor vehicle and sustains the isolated ipsilateral injuries shown in Figures 16a and 16b. What is the optimal definitive method of treatment?

Options:

Spica cast immobilization
Rigid reamed nailing of the femur and a short leg cast
Flexible nailing of the femur and tibia
Reamed nails of the femur and tibia
Spanning external fixator

Correct Answer: Flexible nailing of the femur and tibia

Explanation:

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.
REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures:
A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 7:

Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?

Options:

Patient age of more than 85 years
Retropulsion of the posterior vertebral wall
Acute fracture in a hospitalized patient
Prior compression fracture
Fracture age of 4 months

Correct Answer: Retropulsion of the posterior vertebral wall

Explanation:

DISCUSSION: When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable.
REFERENCES: Phillips FM, Pfeifer BA, Leiberman IH, et al: Minimally invasive treatment of osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty. Instr Course Lect 2003;52:559-567.
Truumees E, Hilibrand A, Vaccaro AR: Percutaneous vertebral augmentation. Spine J 2004;4:218-229.
Rao RD
, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 8:

Options:

Interspinous ligaments
Posterior longitudinal ligament
Anterior longitudinal ligament
Abdominal viscera

Correct Answer: Abdominal viscera

Explanation:

Question 9:

Options:

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

Correct Answer: open reduction and tension band fixation.

Explanation:

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

Question 10:

Options:

External rotation of the distal femoral segment relative to the proximal femoral segment during nailing
Internal rotation of the proximal femoral segment relative to the distal femoral segment during nailing
Iatrogenic decrease in femoral anteversion on the operative leg during nailing
Increased contralateral femoral retroversion during surgery
Internal rotation of the distal segment of the femur relative to the proximal segment of the femur during nailing

Correct Answer: External rotation of the distal femoral segment relative to the proximal femoral segment during nailing

Explanation:

Question 11:

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

Options:

Dressing changes and healing by secondary intention
Split-thickness skin grafting
V-Y advancement flap
Moberg (volar advancement flap)
First dorsal metacarpal artery-island pedicled flap

Correct Answer: V-Y advancement flap

Explanation:

DISCUSSION: V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of
the thumb.
REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

Question 12:

Options:

observation.
physical therapy.
ulnohumeral arthroplasty.
ulnohumeral arthroplasty and ulnar nerve decompression.
semiconstrained elbow arthroplasty.

Correct Answer: ulnohumeral arthroplasty and ulnar nerve decompression.

Explanation:

Question 13:

Based on the radiograph shown in Figure 4, the innervation of what muscle is most at risk with total hip arthroplasty?

Options:

Quadriceps
Extensor hallucis longus
Lateral gastrocnemius
Adductor magnus
Semitendinosus

Correct Answer: Extensor hallucis longus

Explanation:

DISCUSSION: The radiograph reveals a Crowe IV deformity in a patient with developmental dysplasia of the hip. If hip arthroplasty is performed, then some degree of limb lengthening is anticipated. Excessive limb lengthening can result in sciatic nerve palsy in these patients. The peroneal branch of the sciatic nerve is most often affected. Of the muscles listed, only the extensor hallucis longus is innervated by the peroneal branch of the sciatic nerve.
REFERENCES: Eggli S, Hankemayer S, Muller ME: Nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. J Bone Joint Surg Br 1999;81:843-845.
Schmalzried TP, Amstutz HC, Dorey FJ: Nerve palsy associated with total hip replacement:
Risk factors and prognosis. J Bone Joint Surg Am 1991;73:1074-1080.

Question 14:

Options:

Stress view radiographs of the left hip
Non-weight bearing and pelvic bone scan in 7 days
Non-weight bearing and repeat the CT scan after 48 hours from injury
MRI hip and pelvis
Weight bearing activity as tolerated with close follow-up

Correct Answer: Stress view radiographs of the left hip

Explanation:

The next best step would be an MRI hip and pelvis to investigate for an occult fracture of the left hip.
Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of presumed hip fracture not apparent on initial radiographs. MRI has been shown to be able to detect occult fractures earlier than bone scan, with better spatial resolution. Usually the MRI should be obtained in less than 24 hours from the time of injury. For situations in which MRI is not immediately available, bone scan can be considered after 72 hours form the time of injury. However, this may compromise patient care and put the patient at risk of fracture displacement.
Cannon et al. reviewed the imaging of choice in occult hip fracture. They showed that physical examination yields a poor sensitivity identifying occult hip fractures, with log-rolling and straight-leg raise as 50% and 70%, respectively. The most sensitive modality for occult fracture identification was MRI.
Iwata et al. retrospectively reviewed a cohort of 35 patients with clinically suspected fractures of the hip that underwent MRI. All radiographs were negative. In 26 of these patients, a T1-weighted coronal MRI showed a hip fracture with 100% sensitivity.
Roberts et al. reviewed the 2015 AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly. They report moderate evidence that supports MRI as the advanced imaging of choice for diagnosis of presumed hip fractures not apparent on initial radiographs.
Figure A is a AP radiograph of the left hip and pelvis. Apart from a healed fracture of the ischiopubic rami and generalized osteopenia, there is no obvious hip fracture. Figure B is a coronal CT image that does not demonstrate evidence of an acute hip fracture. Illustration A is a T1 weighted MR image that shows a non displaced fracture (white arrow) through the intertrochanteric region of the left proximal femur.
Incorrect Answers:
(SBQ12TR.32) A 20-year-old male is taken to the emergency department following a motorcycle collision with the injury seen in Figures A and B. He undergoes serial debridements with placement of an antibiotic bead pouch, followed by intramedullary nailing and free tissue transfer. His preoperative examination is notable for absent plantar sensation. Which of the following is predictive of a worse long term outcome in this patient?
Absent plantar sensation at presentation
Depression at 3 months post-injury
Use of an intramedullary nail
Free tissue transfer instead of rotational flap
Need for multiple debridements
The presence of depression at the 3 months post-injury is a significant predictor of worse long term outcome as well as lower return to work rates in patients that present with limb threatening lower extremity trauma.
The findings of the Lower Extremity Assessment Project (LEAP study) has challenged many of the long-held beliefs of lower extremity trauma surgery, including the concept that patients with absent plantar sensation should undergo immediate amputation . The LEAP study has also brought to light the importance of socioeconomic and psychosocial factors in patient outcomes following these injuries.
Bosse et al analyzed a subgroup of 55 patients from the LEAP study with absent plantar sensation at presentation. Those patients that underwent limb salvage despite absent sensation (n=26) had no significant difference in functional outcome when compared with either insensate patients who underwent amputation or a matched control group of sensate patients with similar injuries. All but one patient in the salvage group had return of some sensation at 2-year follow up and the authors concluded that an insensate plantar foot at presentation should not be included in the algorithm for amputation.
Mackenzie and Bosse reviewed the results of the LEAP study with particular emphasis on the social and economic variables that influence outcomes in severe lower extremity. The authors note that 19% of patients screened positive for severe depression. The presence of anxiety, pain and depression at 3 months post-injury were significant predictors of poor outcome
Incorrect Answers:
tissue for type IIIB tibia fractures. Answer 5: The number of debridements has not been shown to influence outcome.

Question 15:

Options:

bed rest and pain medication.
revision of the right acetabular component.
revision of the right femoral component.
revision of the right total hip replacement.
resection arthroplasty.

Correct Answer: bed rest and pain medication.

Explanation:

Question 16:

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

Options:

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

Correct Answer: Closed reduction and spica casting

Explanation:

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

Question 17:

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

Options:

Observation
Tape the toe to the adjacent toes for 8 weeks
Tenotomy of the flexor tendons
Transfer of the flexor tendons to the extensor mechanism
Arthrodesis of the proximal interphalangeal joint

Correct Answer: Tenotomy of the flexor tendons

Explanation:

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child. Taping techniques result in no change or only a temporary decrease in deformity. Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer. Arthrodesis is rarely indicated.
REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: A
double-blind, randomized, prospective trial. J Bone Joint Surg Br 1993;75:662-663.
Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.
J Bone Joint Surg Br 1984;66:770-771.

Question 18:

Options:

Rheumatoid arthritis
Osteoarthritis
Metastatic carcinoma
Osteonecrosis
Gout

Correct Answer: Osteonecrosis

Explanation:

Question 19:

Options:

observation.
closed reduction and cast immobilization.
bilateral medial open reduction of the hips.
anterior open reduction with femoral shortening.
valgus osteotomy.

Correct Answer: observation.

Explanation:

Question 20:

Options:

Contact area and contact pressure both decrease.
Contact area and contact pressure both increase.
Contact area and contact pressure both remain the same.
Contact area increases and contact pressure decreases.
Contact area decreases and contact pressure increases.

Correct Answer: Contact area increases and contact pressure decreases.

Explanation:

Question 21:

Options:

Admission for 24-hour observation for possible intracranial hematoma
Discharge with a soft collar and follow-up in 24 hours
CT of the cervical spine
Repeat radiographs of the cervical spine, including flexion and extension views
Hard cervical collar for 6 weeks

Correct Answer: CT of the cervical spine

Explanation:

Question 22:

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely to occur when placing a sharp retractor

Options:

directly posterior to the posterior cruciate ligament (PCL).
posteromedial to the PCL.
posterolateral to the PCL.
in the posteromedial corner of the knee.

Correct Answer: posterolateral to the PCL.

Explanation:

Question 23:

Options:

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

Correct Answer: lactate and base deficit levels.

Question 24:

A 21-year-old college defensive lineman sustains a minimally displaced (less than 1 mm) midthird scaphoid fracture during the first game of the season. Management should consist of

Options:

cast immobilization and a return to play as symptoms allow.
cast immobilization and a return to play when union is achieved.
open reduction and internal fixation, followed by early range of motion with a return to play when union is achieved.
open reduction and internal fixation, followed by a return to play with protective casting.
symptomatic treatment, with definitive treatment at the end of the season.

Correct Answer: cast immobilization and a return to play as symptoms allow.

Explanation:

Question 25:

Figures 28a and 28b show AP and lateral radiographs of the knee. Based on these findings, which of the following structures has most likely been injured?

Options:

Popliteal artery
Quadriceps tendon
Patellar tendon
Anterior cruciate ligament
Peroneal nerve

Correct Answer: Anterior cruciate ligament

Explanation:

Question 26:

Options:

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

Correct Answer: Bristow-Latarjet

Explanation:

Question 27:

Options:

Peripheral nerve sheath tumor
Malignant peripheral nerve sheath tumor
Malignant fibrous histiocytoma
Liposarcoma
Synovial sarcoma

Correct Answer: Malignant peripheral nerve sheath tumor

Explanation:

DISCUSSION: The images reveal a large mass in the posterior thigh arising from the sciatic nerve. The lesion is edematous, and the gadolinium image reveals rim enhancement, suggesting necrosis, given that the STIR image is not uniformly bright as would be seen in a cystic lesion. The PET scan has increased uptake, in this case a standard unit value (SUV) of greater than 2.0. These findings are all very suggestive of a malignant process. The history of neurofibromatosis makes a malignant peripheral nerve sheath tumor, or neurofibrosarcoma, the most likely diagnosis. The term “peripheral nerve sheath tumor” has replaced neurolemmoma and schwannoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 225-230.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4218-4235.

Question 28:

Options:

Complete metabolic workup
Advanced imaging with a CT scan
Laboratory studies for CBC, ESR and CRP
Nuclear medicine studies

Correct Answer: Laboratory studies for CBC, ESR and CRP

Explanation:

Question 29:

Options:

revision in situ pinning and application of a cast.
hip fusion.
curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.
non-weight-bearing on the affected side and electrical stimulation of the fracture site.
vascularized fibula grafting and application of a cast.

Correct Answer: curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.

Explanation:

Question 30:

Options:

Equal functional outcome when limb salvage is compared with amputation
Worse functional outcome with limb salvage than with primary amputation
Better functional outcome when amputation is compared with limb salvage
Amputation within 6 months of injury
Permanent loss of plantar sensation

Correct Answer: Equal functional outcome when limb salvage is compared with amputation

Explanation:

Question 31:

The arrow in the axial T 1 -weighted MRI scan shown in Figure 18 is pointing to which of the following structures?

Options:

Ulnar artery
Ulnar nerve in Guyon’s canal
Deep branch of the ulnar nerve only
Median nerve
Radial artery

Correct Answer: Ulnar nerve in Guyon’s canal

Explanation:

Question 32:

What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery?

Options:

Within 1 hour before incision
Within 2 hours before incision
Immediately after incision
Within 1 hour after incision

Correct Answer: Within 1 hour before incision

Explanation:

Question 33:

A B Figures 19a and 19b are the CT scans of an 18-year-old man who was a restrained driver in a rollover motor vehicle collision. What was the primary mechanism of injury?

Options:

Axial load
Rotation
Extension
Distraction

Correct Answer: Distraction

Explanation:

Question 34:

Options:

Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics
Emergent irrigation and debridement in the operating room with vacuum-assisted wound closure
Emergent irrigation and debridement in the operating room with 7 days of intravenous antibiotics
Wound closure in the emergency department with follow-up wound check in 1 week
Exploration and removal of all bullet fragments in the emergency department and 10 day course of oral antibiotics

Correct Answer: Irrigation and local wound care in the emergency department followed by 3 days of oral antibiotics

Explanation:

Question 35:

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Options:

Incidental finding on imaging tests
Pain
Presence of a mass
Deformity
Neurologic symptoms

Correct Answer: Presence of a mass

Explanation:

Question 36:

-Images from an MRI scan of this patient’s left hip are shown in Figure 30c through 30e. What is the most likely cause of his acute pain?

Options:

Significant cartilage loss on the acetabulum
Labral tear
Femoral neck stress fracture
Tendonopathy of the rectus femoris

Correct Answer: Labral tear

Explanation:

DISCUSSION FOR QUESTIONS 30 THROUGH 32
This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.Surgical treatment for cam impingement can be effective for symptomatic patients. Even among highlevel athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable to those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.Byrd and Jones described 5 patients who developed transient neurapraxias that resolved uneventfully.The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 37:

Options:

curettage.
systemic antibiotics.
observation and protected weight bearing.
chemotherapy.
radiation therapy.

Correct Answer: curettage.

Explanation:

Question 38:

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 39:

Options:

Prior arthroscopy
Current smoking history
BMI of 22
Age of 40

Correct Answer: Current smoking history

Explanation:

Question 40:

Options:

Lateral meniscus repair
Corticosteroid injection and physical therapy
Medial meniscus repair
Unloader brace

Correct Answer: Medial meniscus repair

Explanation:

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more
appropriate in the older patient with pre-existing advanced degenerative changes.

Question 41:

Options:

Deltoid ligament
Calcaneofibular ligament
Anterior tibiofibular ligament
Posterior tibiofibular ligament

Correct Answer: Calcaneofibular ligament

Explanation:

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization
and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 42:

Figure 11 shows the radiograph of a 26-year-old man with type I diabetes mellitus who was struck by a motor vehicle. What is the most common complication associated with this pelvic fracture?

Options:

Infection
Sciatic nerve palsy
Heterotopic ossification
Deep venous thrombosis
Degenerative arthritis

Correct Answer: Deep venous thrombosis

Explanation:

DISCUSSION: The most common complication following acetabular or pelvic ring injury is deep venous thrombosis (DVT). Without prophylaxis, rates of DVT are as high as 70% to 80%. With prophylaxis, the rates are around 10%. Infection rates in surgical repair of acetabular fractures are relatively low but a history of diabetes mellitus and a significant Morel-Lavalle lesion certainly increase the risk. However, even with these two complicating factors, the rates of infection are still lower than 10%. Sciatic nerve palsy rates from the injury alone approach 20% and iatrogenic injury is usually less than 2%. Degenerative changes to the hip following this injury approach 20% to 25%, even with an anatomic reduction.
REFERENCES: Geerts WH, Code KI, Jay RM, et al: A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601-1606.
Steele N, Dodenhoff RM, Ward AJ, et al: Thromboprophylaxis in pelvic and acetabular trauma surgery: The role of early treatment with low-molecular-weight heparin. J Bone Joint Surg Br 2005;87:209-212.

Question 43:

…What is the etiology of the pain associated with this lesion?

Options:

Prostaglandin production
Gram-positive cocci
Osteoclast activation
Loss of structural integrity of the bone DISCUSSION.. Osteoid osteomas are most common in adolescent patients and in boys. Although these tumors can be seen in any bone, almost half are located in the femur and tibia. The significant inflammatory response to this tumor is presumed to be secondary to high levels of prostaglandin production. Characteristic pain at night is relieved by aspirin or NSAIDs. Pain can also be associated with activities and is characterized as being boring and sharp. Radiographs often show distinctive features of thickened bone surrounding a small central core of lower density (a nidus). Thin-cut CT scan is the imaging modality of choice for visualizing the nidus, which typically lies within the cortex of the bone. An MRI scan may be misleading because of the extensive edema associated with this lesion, bringing other differential diagnoses into question. A bone scan is also associated with significant uptake but is nonspecific. Several treatment options are available, including observation and management with NSAIDs for pain control, with the premise that the lesion will “burn out.” This may take several years to occur and few patients are content with this treatment regimen. Surgical resection can be accomplished with en bloc resection, but this approach is fraught with complications associated with resecting large segments of bone. A fluoroscopically assisted “burr-down” technique is effective in removing the nidus and minimizing the stress riser effect to the bone but requires an open surgery. Radiofrequency ablation is the current first-line treatment modality for osteoid osteoma because of its high efficacy and low morbidity. CT-guided radiofrequency ablation removal of the nidus has been successfully used with few recurrences or complications. This is a lesser procedure, compared to en bloc resection or intralesional surgery, and may be performed under general anesthesia or a regional block with sedation. The site of the tumor is identified using fine CT sections, and a radiofrequency probe is inserted into the tumor. The probe heats the tumor tissues to approximately 90°C, effectively obliterating the nidus with minimal damage to surrounding tissues. The nidus is adequately removed in 96% of patients after 1 treatment. The procedure is routinely performed on an outpatient basis by either an interventional radiologist or an orthopaedic surgeon. Most procedures take approximately 2 hours, followed by a 2-hour recovery period, after which the patient may go home with a mild pain reliever. In most cases, the patient may return to work or school in a few days with some restrictions.

Correct Answer: Osteoclast activation

Question 44:

Options:

increased medical complications of treatment.
osteonecrosis of the jaw.
improved long-term survival rates.
anorexia.
decreased quality of life measures.

Correct Answer: osteonecrosis of the jaw.

Explanation:

Question 45:

Options:

Anterior only
Anterior and medial
Anterior and lateral
Posterior and medial
Posterior and lateral

Correct Answer: Posterior and lateral

Explanation:

Question 46:

During anatomic medial patellofemoral ligament (MPFL) reconstruction, the surgeon notes that the graft is becoming too tight with greater knee flexion. What is the most likely cause?

Options:

Femoral attachment placed too distal
Femoral attachment placed too proximal
Patellar attachment placed too distal
Patellar attachment placed too proximal

Correct Answer: Femoral attachment placed too proximal

Explanation:

Question 47:

What is the most frequent late complication of cementless fixation in total knee arthroplasty?

Options:

Infection
Subluxation of the patella
Loss of motion
Femoral loosening
Osteolysis

Correct Answer: Osteolysis

Explanation:

Question 48:

A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show

Options:

fibrosis and edema.
polymorphonuclear cells.
negatively birefringent crystals.
macrophages and lymphocytes.
fibrinous degeneration of collagen fibers.

Correct Answer: fibrosis and edema.

Explanation:

Question 49:

Options:

Weight bearing as tolerated in all extremities
Early protected weight bearing right lower extremity in walking cast, weight bearing as tolerated left upper extremity, non-weight bearing right forearm
Weight bearing as tolerated in bilateral lower extremities and right upper extremity, non-weight bearing left upper extremity
Non-weight bearing bilateral upper extremities and right lower extremity
Non-weight bearing right upper and lower extremities, weight bearing as tolerated left upper and lower extremities without walking cast

Correct Answer: Weight bearing as tolerated in all extremities

Explanation:

Question 50:

Options:

Chevron bunionectomy
Cheilectomy and removal of loose body
MTP arthrodesis
Resection of proximal phalanx

Correct Answer: MTP arthrodesis

Explanation:

Question 51:

A 12-year-old boy with hemophilia A and no known inhibitors sustains a tibia fracture and has pain with passive motion of the deep toe flexors. Appropriate management should consist of

Options:

emergency fasciotomy, followed by factor VIII replacement.
cryoprecipitate, followed by assessment of compartment pressures.
factor VIII replacement, followed by assessment of compartment pressures.
physical therapy to prevent contractures.
splinting, ice, and elevation.

Correct Answer: factor VIII replacement, followed by assessment of compartment pressures.

Explanation:

Question 52:

Options:

Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange
Removal of the femoral and acetabular components and placement of an antibiotic spacer, with 6 weeks of intravenous antibiotics
Head and liner exchange and retention of the femoral and acetabular implants with acetabular bone grafting
Nonsurgical management with the initiation of bisphosphonates and referral to pain management

Correct Answer: Acetabular revision, with placement of a custom triflange acetabular component and femoral head exchange

Explanation:

Question 53:

Options:

10%
25%
50%
75%
Greater than 75%

Correct Answer: Greater than 75%

Explanation:

Question 54:

Options:

a low-profile spinal orthosis.
observation and follow-up radiographs in 6 months.
anterior spinal fusion with instrumentation.
posterior spinal fusion with instrumentation.
in situ posterior spinal fusion.

Correct Answer: observation and follow-up radiographs in 6 months.

Explanation:

Question 55:

Which of the following is an advantage of computer-assisted navigation used to place medullary nail interlocking screws compared to a freehand techinque?

Options:

Reduced fluoroscopy time
More reliable placement of interlocking screws through the nail
Reduced procedure time
Increased quality of fluoroscopic images
Improved accuracy of screw length

Correct Answer: Reduced fluoroscopy time

Explanation:

Question 56:

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 57:

What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?

Options:

Median
Ulnar
Radial
Posterior interosseous
Anterior interosseous

Correct Answer: Radial

Explanation:

Question 58:

A 44-year-old patient who has had a proximal first metatarsal osteotomy has recurrent pain and difficulty wearing many types of shoes. Radiographs show a large 1-2 intermetatarsal angle (IMA).

Options:

Lapidus procedure
First metatarsophalangeal (MTP) joint arthrodesis and lesser metatarsal head resection
Proximal first metatarsal osteotomy
Distal first metatarsal chevron osteotomy
Biplanar distal first metatarsal osteotomy

Correct Answer: Lapidus procedure

Question 59:

Options:

elbow fusion with a contoured dynamic compression plate.
radial head excision and synovectomy.
distraction arthroplasty with interpositional tissue.
total elbow replacement with an unconstrained prosthesis.
total elbow replacement with a semiconstrained prosthesis.

Correct Answer: total elbow replacement with a semiconstrained prosthesis.

Explanation:

Question 60:

Options:

Decreased resistance to oxidative degradation
Decreased toughness
Increased density of nonconsolidated particles
Increased elastic modulus
High levels of residual free radicals

Correct Answer: Decreased toughness

Explanation:

Question 61:

…Giant-cell tumor of bone usually involves the epiphysis of long bones. What is the next most common type of tumor involving this anatomical location?

Options:

Conventional chondrosarcoma
Aneurysmal bone cyst
Chondroblastoma
Osteoblastoma DISCUSSION.. Giant-cell tumor is the most common lesion involving the epiphysis, although its epicenter is usually in the metaphysis, and in the rare case of giant-cell tumor occurring in a skeletally immature patient, giant-cell tumor is located in the metaphysis. It also can involve the flat bone of the pelvis and sacrum. Chondroblastoma exclusively occurs in the epiphysis of skeletally immature patients. It is more common than the other responses. Although conventional chondrosarcoma does not involve the epiphysis, clear-cell chondrosarcoma involves the epiphysis as well; however, it is rare and less common than chondroblastoma. Aneurysmal bone may occur in the epiphysis; however, it is often seen with other benign tumors such as chondroblastoma or giant-cell tumor. It is less common in this location than chondroblastoma. Osteoblastoma does not classically appear at the epiphysis. It is more commonly seen in the spine or the diaphysis of long bones.

Correct Answer: Chondroblastoma

Explanation:

Question 62:

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Options:

equal results for all fracture types.
better outcomes in high-energy fractures.
better outcomes in low-energy fractures.
a higher wound complication rate.
worse outcomes in low-energy fractures.

Correct Answer: worse outcomes in low-energy fractures.

Explanation:

Question 63:

Flow cytometry of tumors measures the

Options:

Size of cells
Amount of DNA in cells
Nucleus-cytoplasm ratio
Specific DNA sequences
Specific messenger RNA sequences

Correct Answer: Amount of DNA in cells

Explanation:

Question 64:

Options:

observation.
a Pemberton osteotomy.
a periacetabular osteotomy.
a Chiari osteotomy.
total hip arthroplasty.

Correct Answer: a periacetabular osteotomy.

Explanation:

Question 65:

Options:

Observation
Application of Pavlik harness
Closed reduction and hip spica casting
Open hip capsulorrhaphy +/- femoral osteotomy +/- pelvic osteotomy
Open hip capsulorrhaphy, adductor and hamstring tenotomy, gastrocnemius recession +/- pelvic osteotomy

Correct Answer: Application of Pavlik harness

Explanation:

Question 66:

Mutations of what gene are associated with subsequent development of osteosarcoma?

Options:

NF1 (neurofibromatosis)
Rb (retinoblastoma)
VEGF (vascular endothelial growth factor)
E-Cadherin
EWS-FLI1 (11,22 translocation)

Correct Answer: Rb (retinoblastoma)

Explanation:

Question 67:

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 68:

The risk of local recurrence after surgical resection of a soft-tissue sarcoma is most closely related to

Options:

the size of the tumor.
the grade of the tumor.
the site of the tumor.
the surgical margin.
radiation therapy.

Correct Answer: the surgical margin.

Explanation:

Question 69:

Options:

the inability to extend the small finger.
weakness of small finger abduction.
sensory loss of the dorsal ulnar hand.
clawing of the small and ring fingers.

Correct Answer: sensory loss of the dorsal ulnar hand.

Explanation:

Question 70:

- A 55 year-old man has multiple lytic lesions in the humeri, clavicles, and scapulae. Which of the following diagnostic studies best confirms a diagnosis of multiple myeloma?

Options:

CT scan of the chest
Bone marrow biopsy
Complete blood cell count
Lateral radiograph of the skull
Erythrocyte sedimentation rate

Correct Answer: Bone marrow biopsy

Explanation:

Question 71:

Options:

Shoulder arthrography
MRI of the cervical spine
CT of the head
Technetium Tc 99m bone scan
Electromyography and nerve conduction velocity studies

Correct Answer: Electromyography and nerve conduction velocity studies

Explanation:

Question 72:

Options:

Incision and drainage
Ice the ankle but don't let him play.
Topical antibiotics for 7 days with an occlusive dressing
Debridement in the training room followed by 5 days of oral antibiotics

Correct Answer: Incision and drainage

Explanation:

The clinical photograph shows a skin infection with an appearance consistent with methicillin-resistant
Staphylococcus aureus
. This infection should be clinically incised and allowed to drain and a course of antibiotics should follow. If this infection is not promptly treated with debridement, it likely will worsen and potentially spread to other teammates. Antibiotics are secondary to surgical debridement but are a necessary adjunct. Although this patient has a history of severe sprain, his malaise and skin appearance do not correlate with a ligament injury or fracture. Debridement in the training room is not appropriate and would likely not fully decompress the fluid collection.

Question 73:

Options:

Silicone replacement arthroplasty through a volar approach
Surface replacement arthroplasty through a volar approach
Silicone replacement arthroplasty through a dorsal approach
Surface replacement arthroplasty through a dorsal approach

Correct Answer: Silicone replacement arthroplasty through a volar approach

Explanation:

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate
,
the worst gain in arc of motion
, and
the greatest extension lag.
However, substantial pain relief and higher satisfaction still were reported after surface replacement
arthroplasty, regardless of the complications.

Question 74:

Options:

Infection
Patellar instability
Aseptic loosening
Progression of tibiofemoral arthritis

Correct Answer: Progression of tibiofemoral arthritis

Explanation:

Question 75:

Options:

Female gender
Use of skin graft
Ability to return to work
Retained plantar sensation
Initial treatment by amputation

Correct Answer: Ability to return to work

Explanation:

The LEAP study is a multicenter prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status,
and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
(SBQ12TR.26) A 44-year-old male presents after being struck by a car. He is hypotensive, and has an obvious open tibia and a closed femoral shaft fracture. A pelvic radiograph is obtained and shown in Figure A. A representative CT scan image in shown in Figure B. The patient is placed in a pelvic binder, and his blood pressure normalizes with crystalloid and a blood transfusion. He then undergoes pelvic angiography, and his internal iliac artery is embolized. Which of the following definitive treatment options is most appropriate in this case?
Review
Topic
Anterior pelvic external fixation with pins placed in the AIIS and a posterior sacroiliac screw
Open reduction and internal fixation of the pubic symphysis with a two hole plate and posterior fixation with a iliosacral screw
Open reduction and internal fixation of the pubic symphysis with a non-locking multi-hole plate and posterior fixation with a iliosacral screw
Anterior pelvic external fixation and posterior triangular osteosynthesis
Open reduction and internal fixation of the pubic symphysis with a locked multi-hole plate and posterior sacral plate fixation
The radiographs and CT scan show a fracture pattern consistent with an APC-III injury. This is most appropriately treated with pubic symphysis ORIF with a multi-hole plate and posterior iliosacral screw fixation.
APC-III pelvic ring injuries are associated with with disruption of the anterior and posterior SI ligaments (SI dislocation) as well as disruption of sacrospinous and sacrotuberous ligaments. They are commonly associated with vascular injury and retroperitoneal bleeding.
Sagi et al studied the radiographic and clinical outcome of symphyseal plating techniques, specifically comparing two hole (THP) vs multi-hole plating (MHP). Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. When comparing the 2 different methods of anterior fixation, they found that the rate of fixation failure was greater in group THP (33%) than group MHP (12%). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (57%) than in the MHP group (15%). On the basis of these findings, the authors recommended multi-hole plating of unstable pubic symphyseal disruptions.
Grimshaw et al performed a biomechanical study to determine the failure risk and potential benefit to use of locked fixation constructs in simulated pelvic ring injuries. The authors used a six-hole 3.5-mm plate specifically designed for the symphysis pubis with the capability of fixation in locked or unlocked mode, six pelves were fixed with locked screws and six pelves were fixed standard unlocked bicortical screws. Biomechanical testing was performed, and no abrupt failures were noted. However, locked plating of the pubic symphysis did not appear to offer any advantage over the standard unlocked technique
Illustrations A, B, and C show the AP, outlet, and inlet postoperative radiographs. Incorrect Answers:
1,4-Anterior pelvic fixation is typically not used as definitive treatment of these
injuries unless performed in a damage-control setting. The patient in this case is stable.
2-Multi-hole plate fixation of the pubic symphysis is preferred over 2-hole plate fixation.
5-Posterior sacral plating is not indicated in this fracture pattern, as there is no significant sacral comminution of vertical shear component. Furthermore, no distinct advantage has been found with locked symphyseal plating.

Question 76:

Among the options listed below, what is the best treatment for the complication shown in Figure 10c?

Options:

- Removal of hardware and bone grafting
- Removal of hardware and total hip arthroplasty (THA)
- Removal of hardware and revision using a first-generation femoral nail
- Removal of hardware and revision using a second-generation femoral nail

Correct Answer: - Removal of hardware and revision using a second-generation femoral nail

Explanation:

DISCUSSION
Proximal femur fractures can be treated using a variety of implants including intramedullary nails, blade plates, and locking plates (now precontoured proximal femur plates). The comminution and lack of medial cortical support may predispose these fractures to nonunion.
The recent popularity of locking plates for proximal femur treatment has increased their use for this fracture; however, a disproportionately high rate of failure of these plates, including early implant failure with plate and screw breakage, cut out with varus collapse, and nonunion have been reported.?
Malreduction predisposes these fractures to failure. The initial postoperative radiographs do not reveal a varus malreduction because the tip of the greater trochanter is below the center of the femoral head.
Once failure occurs, the best fixation method among the options detailed is an intramedullary nail (second generation with screws into the femoral head) and restoration of alignment. THA is usually not recommended for treatment of subtrochanteric femur fractures in young patients.
RECOMMENDED READINGS
Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate.
Injury. 2013 Jun;44(6):751-6. doi: 10.1016/j.injury.2013.02.020. Epub 2013 Mar 21. PubMed PMID: 23522837.
View Abstract at PubMed
Floyd JC, O'Toole RV, Stall A, Forward DP, Nabili M, Shillingburg D, Hsieh A, Nascone JW. Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma. 2009 Oct;23(9):628-33. doi: 10.1097/BOT.0b013e3181b04835. PubMed PMID: 19897983.
View Abstract at PubMed
Glassner PJ, Tejwani NC. Failure of proximal femoral locking compression plate: a case series. J Orthop Trauma. 2011 Feb;25(2):76-83. doi: 10.1097/BOT.0b013e3181e31ccc.
PubMed PMID: 21245709.
View Abstract at PubMed

Question 77:

- A right-handed 35-year old man who underwent a Putti-Platt repair for recurrent anterior instability 20 years ago now has increasing shoulder pain and stiffness. Examination of the shoulder reveals internal rotation to the posterior superior iliac spine and external rotation to 10 degrees with the shoulder adducted. The supraspinatus and infraspinatus are moderately atrophied. What is the most likely diagnosis?

Options:

C5 radiculopathy
Subscapularis rupture
Glenohumeral arthrosis
Rotator cuff arthropathy
Suprascapular nerve compression at the spinoglenoid notch

Correct Answer: Glenohumeral arthrosis

Explanation:

Question 78:

What percent of adult patients with rheumatoid arthritis test positive for rheumatoid factor?

Options:

Less than 20%
20% to 40%
50%
80% to 90%
More than 95%

Correct Answer: 80% to 90%

Explanation:

Question 79:

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

Options:

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

Correct Answer: Articular-sided supraspinatus tendon tear

Explanation:

Question 80:

Options:

Immediate open reduction with an anterior approach
Immediate open reduction with a posterior approach
Obtain an immediate arteriogram
Perform closed reduction and reassess perfusion and pulse

Correct Answer: Perform closed reduction and reassess perfusion and pulse

Explanation:

Question 81:

Options:

Patellofemoral syndrome
Bipartite patella
Stress fracture of the distal femur
Patella alta
Patella baja

Correct Answer: Patellofemoral syndrome

Explanation:

Question 82:

Options:

Acute traumatic Lisfranc fracture-dislocation
Acquired pes planus due to rupture of the posterior tibial tendon
Neuropathic arthropathy
Osteomyelitis
Metatarsal stress fracture

Correct Answer: Neuropathic arthropathy

Explanation:

Question 83:

Which of the following best describes heat stroke? Review Topic

Options:

Transient loss of consciousness with peripheral vasodilation and decreased cardiac output with normal body temperature
A condition involving painful contractions of large muscle groups because of decreased hydration and a decrease of serum sodium and chloride
Hypernatremia in poorly conditioned athletes, manifested by thirst and oliguria with a core temperature of less than 102.2 degrees F (39 degrees C)
Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function
A transient condition that responds to glucose administration

Correct Answer: Hyperthermia, central nervous system dysfunction, and loss of thermoregulatory function

Explanation:

Question 84:

Options:

ixation of the coronoid fragment
Radial head arthroplasty
Repair or reconstruction of the lateral collateral ligament (LCL) complex
Repair or reconstruction of the medial collateral ligament (MCL) This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer: Repair or reconstruction of the lateral collateral ligament (LCL) complex

Explanation:

Question 85:

Options:

Decreased risk of sacral fractures
Decreased risk of proximal functional kyphosis
Easier contouring of the instrumentation
Reduced risk of late pubic ramus fractures
Improved coronal plane correction

Correct Answer: Decreased risk of sacral fractures

Explanation:

Question 86:

Options:

Technetium Tc 99m bone scan
Ultrasound of the hips
CT of the pelvis
MRI of the pelvis
Aspiration of the hip joint

Correct Answer: Aspiration of the hip joint

Explanation:

Question 87:

Options:

Anterior bundle of the medial collateral ligament (MCL)
Posterior bundle of the MCL
Annular ligament
Triceps insertion
Olecranon osteophytes

Correct Answer: Anterior bundle of the medial collateral ligament (MCL)

Explanation:

Question 88:

Options:

arthroscopic synovectomy.
open synovectomy.
staple hemiepiphyseodesis.
knee arthrodesis.
varus osteotomy.

Correct Answer: staple hemiepiphyseodesis.

Explanation:

Question 89:

Options:

Femoral attachment of the medial collateral ligament
Tibial attachment of the medial collateral ligament
Hypertrophic zone of the growth plate
Proliferative zone of the growth plate

Correct Answer: Hypertrophic zone of the growth plate

Explanation:

Question 90:

Osteophyte formation at the posteromedial olecranon and olecranon articulation in high-caliber throwing athletes is most often the result of underlying

Options:

anterior capsular tears.
forearm pronator and flexor muscle weakness.
biceps or brachialis muscle weakness.
ulnar collateral ligament insufficiency.
radial collateral ligament insufficiency.

Correct Answer: ulnar collateral ligament insufficiency.

Explanation:

Question 91:

Options:

Hemorrhage into the iliacus muscle
Hemorrhage into the quadriceps muscle
Severe hip joint hemarthrosis
Slipped capital femoral epiphysis
Avulsion fracture of the anterior superior iliac spine

Correct Answer: Hemorrhage into the iliacus muscle

Explanation:

Question 92:

Options:

ACL injuries are more common in men younger than 30 years of age.
ACL injuries are more common in women younger than 30 years of age.
ACL injuries are usually the result of contact sports.
The incidence of ACL injuries can be decreased by a neuromuscular training program.
ACL injuries are rarely associated with meniscal injury.

Correct Answer: ACL injuries are more common in women younger than 30 years of age.

Explanation:

Question 93:

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Options:

Correct Answer: L5

Explanation:

Question 94:

Options:

Incorrect graft choice
Improper tunnel position
Tibial graft-tunnel mismatch
Poor femoral fixation

Correct Answer: Improper tunnel position

Explanation:

Question 95:

A 21-year-old woman has a nontraumatic rupture of the Achilles tendon. Which of the following commonly prescribed medications has been associated with this condition?

Options:

Ibuprofen
Fluoroquinolones
Bisphosphonates
Metoprolol
Simvistatin

Correct Answer: Fluoroquinolones

Explanation:

Question 96:

Options:

Flexor carpi ulnaris to extensor carpi radialis brevis transfer
Fractional lengthening of the wrist and finger flexor tendons
Wrist arthrodesis with proximal row carpectomy
Botulinum toxin injection

Correct Answer: Wrist arthrodesis with proximal row carpectomy

Explanation:

EXPLANATION:
The patient has a static deformity of the wrist with a fixed flexion deformity of more than 45°. Soft-tissue procedures such as those referenced in options A and B would not be sufficient to address the degree of contracture. Additionally, Botulinum toxin injections would not provide relief for capsular contractures. Wrist arthrodesis combined with a proximal row carpectomy has been shown to provide a functional and
cosmetic alternative for patients with severe wrist flexion contractures.

Question 97:

03 An 18 month old child has bilateral “corner fractures” of the distal femoral metaphyses of unknown origin. Following a skeletal survey, the first step in management should consist of

Options:

notification of child protection services
bilateral long leg casts and discharge
bilateral percutaneous pinning, long leg casts, and discharge
hospital admission and Bryant’s traction. 5- Hospital admission and modified Bryant’s traction Question 65.03

Correct Answer: notification of child protection services

Explanation:

Question 98:

The clinical factors shown to most significantly predict the long-term outcome of Perthes disease of the hip include which of the following? Review Topic

Options:

Limb-length discrepancy, range of motion of the hip
Age at presentation, range of motion of the hip
Age at presentation, limb-length discrepancy
Range of motion, pain/limp for more than 6 months
Limb-length discrepancy, pain/limp for more than 6 months

Correct Answer: Limb-length discrepancy, range of motion of the hip

Explanation:

Age at presentation and range of motion of the hip are the two most significant predictors of long-term outcome. Younger patients and patients who maintain range of motion of the hip are more likely to have a good outcome. In Herring's study, children with a chronologic age of younger than 8 years or a bone age of less than 6 years had significantly more favorable outcomes compared with older children. Limited hip range of motion may be due to muscle spasm early on, or synovitis; but in late disease, it may reflect incongruity of the joint. Classifications based on femoral head shape have also been correlated to prognosis. Significant shortening of the affected hip is not common.
(SBQ13PE.87) A 4-week-old child is suspected to have classic arthrogryposis, also known as amyoplasia. Clinical examination and hip ultrasound reveal a unilateral, non-reducible, hip dislocation. What do you recommend to reduce the hip?
Review
Topic
Pavlik harness application
Semi-rigid abduction brace application
Skeletal traction
Early closed reduction and spica casting
Delayed open reduction with or without pelvic and femoral osteotomy
Delayed open reduction with or without pelvic and femoral osteotomy is recommended in the management of unilateral hip deformities associated with amyoplassia. This procedure should be performed at 6-9 months of age. In order to proceed with reduction, there must be a reasonable arc of flexion/extension and active movement of the lower limbs.
Amyoplasia is the most common recognizable form of arthrogryposis. It most commonly occurs as a sporadic symmetric contracture syndrome that is characterized by symmetrical limb involvement, normal to above-average intelligence, and often a midline facial hemangioma. Approximately 80% of children with amyoplasia will have involvement of the hip ranging from soft tissue contractures to unilateral or bilateral hip dislocations.
Bevan et al. reviewed arthrogryposis. They state that open hip reduction is recommended for the management of unilateral dislocation. There is more controversy with regard to the treatment of bilateral hip dislocations. Open reduction can be performed by a medial or anterolateral approach, with or without pelvic and
femoral osteotomy. This procedure is generally delayed for 6-9 months to facilitate the procedure.
Bernstein et al. also reviewed arthrogryposis. They state that the term 'arthrogryposis' encompasses a broad spectrum of diseases, all with the common phenotype of multiple congenital contractures.
Illustration A shows the characteristic features of an infant with severe arthrogryposis. Note the internal rotation of the shoulders, elbow and knee hyperextension, flexed and ulnarly deviated wrists, flexed finger, external rotation of hips and bilateral clubfeet.
Incorrect answers:

Question 99:

Of all the pelvic ring injury types, anteroposterior compression type III pelvic ring injuries have the highest rate of which of the following?

Options:

Head injury
Pulmonary injury
Traumatic amputation
Need for transfusion
Upper extremity fractures

Correct Answer: Head injury

Explanation:

Question 100:

Options:

0 to 15 degrees
20 to 30 degrees
40 to 90 degrees
100 to 120 degrees
130 to 140 degrees

Correct Answer: 40 to 90 degrees

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

Orthopedic Board Review MCQs: Trauma, Spine & Extremities | Part 51

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 51

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index