OITE & AAOS Orthopedic Board Review MCQs | Part 55

About This Board Review Set

This is Part 55 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 55

This module focuses heavily on: Arthroplasty, Foot, Fracture, Knee.

Sample Questions from This Set

Sample Question 1: A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?...

Sample Question 2: What mechanism contributes to strength gains during conditioning of the preadolescent athlete?...

Sample Question 3: -Which of the following conditions is most likely inherited as an autosomal dominant trait?...

Sample Question 4: An elite football player has sustained a left knee injury during play. A dynamic imaging analysis is performed on the affected knee, which shows anterior shift and internal rotation of the tibia at low flexion angles. There is also some mil...

Sample Question 5: A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exer...

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

00:00

Start Quiz

Question 1

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Bono JV, McCarthy JC, Thornhill TS, Bierbaum BE, Turner RH (eds): Revision Total Hip Arthroplasty. New York, NY, Springer Verlag, 1999, pp 530-592.

Question 2

What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

Explanation

DISCUSSION: Prepubescent athletes gain strength through neurogenic adaptations, including recruitment of motor units, reduced inhibition, and learned motor skills. Myogenic adaptations (muscle hypertrophy) occur after puberty and include increased contractile proteins, thickening of the connective tissue, and increased short-term energy sources such as creatine phosphate.
REFERENCES: Grana WA: Strength training, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 520-526.
Micheli LJ: Strength training, in Sullivan JA, Grana WA (eds): The Pediatric Athlete. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 17-20.

Question 3

Which of the following conditions is most likely inherited as an autosomal dominant trait?

Explanation

Postaxial polydactyly involves polydactyly of the little finger, preaxial polydactyly usually involves the thumb or the index finger. Postaxial polydactyly is further divided into Type A, in which the well formed extra digit artier with the fifth or an extra metacarpal and Type B, a small extra digit that is poorly formed and often is little more than a skin tag. Postaxial polydactyly is inherited as an autosomal dominant trait with marked penetrance.

Question 4

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

Explanation

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

Question 5

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate the arm?

Explanation

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.

Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 6

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

Explanation

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514. View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682. View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 7

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis? Review Topic

Explanation

The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.

Question 8

A 40-year-old man fell off of a ladder at work sustaining the injury shown in Figures A and B. On examination, his skin is intact, but the pulses in his foot are absent. Following closed reduction and splinting, what would be the next best step?

Explanation

OrthoCash 2020

Question 9

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Explanation

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 10

In total knee arthroplasty, in vitro testing has shown that cross-linking can diminish the rate of polyethylene wear by 30% to 80%. What other change in material properties is possible when polyethylene is highly cross-linked?

Explanation

DISCUSSION:
The most important concern regarding highly cross-linked polyethylene relates to decreased mechanical properties. Cross-linking results in reduced ductility, tensile strength, and fatigue crack propagation resistance. These problems have not been shown to cause implant failure in the most recent clinical trials, but they remain the most important mechanical issues associated with current material processing methods.

Question 11

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Explanation

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 12

Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femur fractures?

Explanation

DISCUSSION: Reamed intramedullary femoral nailing is associated with a higher rate of union than nonreamed femoral nailing.
The reference by the Canadian group randomized 224 patients to reamed vs. unreamed femoral nails and found that the relative risk of nonunion was 4.5x greater without reaming, and nonunion was also greater with the use of a small-diameter nail.
The referenced article by Tornetta et al randomized 81 patients to reamed or unreamed nails and found more intraoperative technical complications in the group without reaming. There was no statistical difference in OR time, transfusion requirement or pulmonary complications between the groups. This study showed the overall union rate was similar but when they selected out distal femur fractures, the reamed group healed faster.
The reference by Brumback et al is a review of reamed v. nonreamed nailing, with discussions of reaming techniques and the importance of proper reamer technology and usage.

Question 13

A 72-year-old man undergoes an uncomplicated cementless total hip arthroplasty for advanced osteoarthritis. At his 6-week postoperative follow-up, he has minimal pain and is progressing well with his mobility. Radiographs show early formation of Brooker grade III heterotopic bone around his hip. What is the best treatment of the heterotopic bone at this time?

Explanation

DISCUSSION: The development of heterotopic bone occurs early after hip arthroplasty. The process begins within days after surgery; therefore, prophylactic treatment must be in the early postoperative period (preoperative radiation given within 24 hours of surgery, or postoperative radiation given within 72 hours of surgery, or nonsteroidal antiinflammatory drugs (NSAIDs) given postoperatively for 7 to 21 days - longer duration has not been shown to be of any additional benefit). At 6 weeks, prophylactic treatment with NSAIDs or radiation is no longer effective. Surgery at 10 weeks would be premature because the patient is currently asymptomatic with regards to the heterotopic bone, and surgery prior to full maturation of the bone may increase the risk for more abundant recurrence of bone.
REFERENCES: Balboni TA, Gobezie R, Mamon HJ: Heterotopic ossification: Pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 2006;65:1289-1299. Fransen M, Neal B: Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty. Cochrane Database Syst Rev 2004;3:CD001160.
Neal BC, Rodgers A, Clark T, et al: A systematic survey of 13 randomized trials of non-steroidal antiinflammatory

drugs for the prevention of heterotopic bone formation after major hip surgery. Acta Orthop Scand 2000;71:122-128.

Question 14

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Explanation

Hewett and associates reported in a study of 205 female athletes that female athletes, with increased dynamic valgus and high abduction loads, were at increased risk of ACL injury. The same investigators in an earlier study of 81 high school basketball players reported that female athletes landed with greater total valgus knee motion and a greater maximum valgus knee angle than male athletes. Female athletes were also found to have significant differences between their dominant and nondominant side in maximum valgus knee angle. Lephart and associates reported that in single-leg landing and forward hop tasks that female athletes had significantly less knee flexion and lower leg internal rotation maximum angular displacement, and less knee flexion time to maximum angular displacement than males. Females with an adduction moment during landing should have a lower incidence of ACL tears. Males in general have a lower incidence of ACL tears.

Question 15

A 25-year-old man sustained an L1 compression fracture in a fall from his roof. He is neurologically intact and has no other injuries. Radiographs reveal a 25% loss of height anteriorly and 5 degrees of kyphosis at the fracture site. A CT scan reveals no compromise of the posterior column. Management should consist of

Explanation

DISCUSSION: The patient has a stable fracture that can be initially treated with bed rest, followed by bracing and quick mobilization. The outcome is good and surgery is not required. These fractures can be treated nonsurgically if there is less than 50% compression, 15 degrees of angulation, and intact posterior structures.
REFERENCES: Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Nonoperative management of stable thoracolumbar burst fractures with early ambulation and bracing. Spine 1993;18:971-976.
Rechtine GR II, Cahill D, Chrin AM: Treatment of thoracolumbar trauma: Comparison of complications of operative versus nonoperative treatment. J Spinal Disord 1999;12:406-409.

Question 16

Retrograde ejaculation is most commonly associated with what surgical approach?

Explanation

DISCUSSION: Retrograde ejaculation is the sequela of an injury to the superior hypogastric plexus. This structure needs protection, especially during anterior exposure of the lumbosacral junction. Although the superior hypogastric plexus can be injured with anterior or anterolateral spine surgery at any lumbar level, it is most at risk with anterior transperitoneal approaches to the lumbosacral junction. To avoid this complication, the use of monopolar electrocautery should be avoided during deep dissection in this region. The ideal anterior exposure starts with blunt dissection just to the medial aspect of the left common iliac vein sweeping the prevertebral tissues toward the patient’s right side.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983,

p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 17

below depict the AP and lateral radiographs obtained from a year-old man with long-standing right knee osteoarthritis and pain that is unresponsive to nonsurgical treatment. The patient undergoes navigated cruciate-retaining right total knee arthroplasty. After surgery, this patient continues to experience pain and swelling of the knee with recurrent effusions. He returns to the office reporting continued pain 2 years after surgery. He describes instability, particularly when descending stairs. On examination, range of motion of 0° to 120° is observed, with no extensor lag. Slope of the tibial component is 7°. The knee is stable to varus and valgus stress in extension, but flexion instability is present in both the anterior-posterior direction and the varus-valgus direction. Bracing leads to a slight decrease in symptoms but is not well tolerated. Isokinetic testing demonstrates decreased knee extension velocity at mid push. Radiographs demonstrate well-aligned and fixed knee implants. An infection work-up is negative. What is the most appropriate surgical intervention at this time?

Explanation

DISCUSSION:
The patient’s symptoms at follow-up—pain, swelling, and difficulty descending stairs—suggest knee flexion instability. Considering his history, an incompetent PCL must be considered. Revision of the knee to a posterior stabilized or nonlinked constrained condylar implant (depending on the condition of the ligaments) likely is needed to address his symptoms. The difference in extension stability and flexion stability makes polyethylene exchange a poor option. A constrained rotating hinge design is not necessary. Repeat use of a PCL-retaining insert is not recommended. Tibial and femoral revision both are required. Correction of excessive slope will be attained with tibial revision, femoral component revision is required to convert to a PCL-substituting design. There is also an opportunity to increase posterior condylar offset if needed.

Question 18

During particle-induced osteolysis around implants, what cell secretes most of the interleukin-6 (IL-6)?

Explanation

DISCUSSION: During osteolysis, IL-6 is secreted by fibroblasts in the membrane surrounding the prosthesis. IL-6 also can be secreted by osteoblasts in other settings, but they are not the predominant source of IL-6 in particle-induced osteolysis. The remaining cells are not major sources of IL-6.
REFERENCE: Bukata SV, Gelinas J, Wei X, et al: PGE2 and IL-6 production by fibroblasts in response to titanium wear debris particles is mediated through a Cox-2 dependent pathway. J Orthop Res 2004;22:6-12.

Question 19

A 25-year-old man shot himself at the base of the right index finger while cleaning his handgun. Examination reveals that the finger is cool and cyanotic. A clinical photograph and radiograph are shown in Figures 44a and 44b. What is the recommended treatment?

Explanation

DISCUSSION: The gunshot wound has caused injury to multiple systems: bone, vascular, skin, and tendon; therefore, the treatment of choice is amputation. An immediate ray amputation allows for a more rapid return to activities and less time off work.
REFERENCES: Peimer CA, Wheeler DR, Barrett A, et al: Hand function following single ray amputation. J Hand Surg Am 1999;24:1245-1248.
Neumeister MW, Brown RE: Mutilating hand injuries: Principles and management. Hand Clin 2003;19:1-15.

Question 20

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of Review Topic

Explanation

Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.

Question 21

A 35-year-old patient is involved in a motor vehicle accident and sustains multiple fractures including a closed comminuted proximal meta-diaphyseal tibia fracture. The surgeon is considering bridge plating the fracture using a minimally invasive approach. Which of the following is true regarding bridge plating? Review Topic

Explanation

In bridged plating, only the most proximal and distal screw holes are filled. This creates a flexible, axially stable construct.
Bridge plating is applicable to all long-bone fractures with complex fragmentation and where intramedullary nailing or conventional plate fixation is not suitable. The construct preserves the blood supply to the fracture fragments as the fracture site is undisturbed during the operative procedure. It provides RELATIVE stability, allowing for some motion at the fracture site, leading to callus formation and secondary bone healing. The construct is FLEXIBLE because of increased distance between the 2 screws closest to the fracture (long working length), allowing for stress distribution and permitting more motion at the fracture site. The construct is also
AXIALLY STABLE because the plate acts as an extramedullary splint and resists axial compression.
Livani et al. advocate using an anterior or antero-lateral approach for minimally invasive plating of the humerus. They recommend that distal access is obtained first, allowing identification of the lateral antebrachial cutaneous nerve. For distal fractures, they recommend extending the plate down to the lateral column.
Apivatthakakul et al. defined minimally-invasive plate osteosynthesis (MIPO) danger zones from the lateral epicondyle. They found the musculocutaneous nerve averaged 18-43% of the humeral length, the danger zone for the radial nerve averaged 36-59% of the humeral length, and the most dangerous screws that penetrated or touched the radial nerve lay 47-53% of the humeral length.
Illustration A shows a distal tibia fracture. Illustration B shows radiographs 5 months after bridge plating of this fracture. There is callus formation, characteristic of indirect bone healing.

Question 22

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 23

-In the shoulder position of 90-degree forward flexion and internal rotation, what is the most important static stabilizer of the glenohumeral joint?

Explanation

CLINICAL SITUATION FOR QUESTIONS 48 AND 49
A 17-year-old high school wrestler sustains an abrasion over the posterior aspect of his right elbow during a match. During the next few days the abrasion becomes erythematous and he is placed on oral cephalexin 500 mg four times per day. The erythema extends proximally despite the antibiotic regimen. The patient is afebrile, there is no fluid collection associated with the lesion, and his elbow joint is not involved.

Question 24

Which structure is the primary stabilizer of the lesser metatarsophalangeal (MTP) joint?

Explanation

DISCUSSION
Synovitis of the second MTP occurs in association with instability of the joint. This can be idiopathic or secondary to an external deforming force (such as a hallux valgus or shoe wear causing a claw toe). The primary stabilizer of the MTP joint for translation in the vertical plane is the plantar plate. The flexor digitorum brevis flexes the MTP joint, and the flexor digitorum longus flexes
all joints of the toe. The collateral ligaments are primary stabilizers in the transverse plane and secondary stabilizers in the sagittal plane.
RECOMMENDED READINGS
Deland JT, Sung IH. The medial crosssover toe: a cadaveric dissection. Foot Ankle Int. 2000 May;21(5):375-8. PubMed PMID: 10830654.View Abstract at PubMed
Suero EM, Meyers KN, Bohne WH. Stability of the metatarsophalangeal joint of the lesser toes: a cadaveric study. J Orthop Res. 2012 Dec;30(12):1995-8. doi: 10.1002/jor.22173. Epub 2012 Jun 13. PubMed PMID: 22696467. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 91 THROUGH 95
Figure 91a is the sagittal plane ultrasound of the second web space of a 48-year-old woman who has noted burning pain in the ball of her right foot for 2 years. The pain intermittently radiates into her second and the third toes. Figure 91b shows the surgical procedure and Figure 91c is the pathologic specimen.
A

Question 25

A 35-year-old man has numbness and tingling in the index, middle, and ring fingers. History reveals that he also has had vague wrist pain and stiffness since being injured in a motorcycle accident 1 year ago. Radiographs are shown in Figures 47a through 47c. Management should consist of

Explanation

DISCUSSION: The patient has a chronic unrecognized volar lunate dislocation. Median nerve compression is the result of the lunate displaced into the carpal tunnel. The diagnosis can be made by radiographs; MRI is not necessary. A volar approach allows median nerve decompression with excision of the lunate, whereas a dorsal approach facilitates excision of the scaphoid and triquetrum.
REFERENCES: Rettig ME, Raskin KB: Long-term assessment of proximal row carpectomy for chronic perilunate dislocations. J Hand Surg Am 1999;24:1231-1236.
Howard FM, Dell PC: The unreduced carpal dislocation: A method of treatment. Clin Orthop 1986;202:112-116.

Question 26

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

Explanation

DISCUSSION: Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options.
REFERENCES: Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584.
Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Pochatko DJ, Schlehr FJ, Murphey MD, Hamilton JJ: Distal chevron osteotomy with lateral release for treatment of hallux valgus deformity. Foot Ankle Int 1994;15:457-461.

Question 27

Figure 21 is the intraoperative fluoroscopic image of a 40-year-old man who felt a pop during a twisting injury to his right ankle. He underwent open reduction and internal fixation (ORIF) of a bimalleolar ankle fracture. During the surgery the medial and lateral malleoli fractures were reduced and rigidly was internally fixed. Following fracture fixation, which additional test is recommended to ensure mortise stability?

Explanation

DISCUSSION
Following ORIF of a known osseous injury, stress testing of the syndesmosis is recommended, especially for pronation-external rotation injuries. The Cotton test applies a laterally directed force to the fibula to assess for widening of the distal tibiofibular joint space. A positive Cotton test result indicates that syndesmotic stabilization is indicated. The Thompson test is used to determine Achilles tendon integrity. The squeeze test is a clinical, not intraoperative, assessment of syndesmotic injury. The anterior drawer test assesses the integrity of the anterior talofibular ligament.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882. View Abstract at PubMed
Pakarinen H, Flinkkilä T, Ohtonen P, Hyvönen P, Lakovaara M, Leppilahti J, Ristiniemi J. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. doi: 10.2106/JBJS.J.01287. PubMed PMID:

Question 28

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

Explanation

DISCUSSION:
Despite concerns regarding fracture, osteonecrosis, and patellar clunk, the routine retention of the native patella during primary total knee replacement is associated with a 20% to 30% increased revision risk in
large joint registries. In addition, the retention of the native patella results in a 5.7% revision surgery rate
in patients with anterior knee pain.

Question 29

An 82-year-old man is seen in consultation after being admitted for a fall from ground level. There was no loss of consciousness and the patient recalls striking his head and sustaining a hyperextension-type injury to the cervical spine. Examination reveals an 8-cm head laceration with only mild axial neck tenderness. He has generalized weakness throughout the upper extremities and maintained motor function of the lower extremities. There are no obvious sensory deficits, and the bulbocavernous reflex and deep tendon reflexes are maintained. What is the most appropriate diagnosis at this time? Review Topic

Explanation

Atlantoaxial rotatory instability
Syringomyelia
Spinal cord tumor
Dysraphism
Tethered cord
Early-onset scoliosis is associated with syringomyelia, spinal cord tumor, dysraphism, and tethered cord, and therefore they must be ruled out with a preoperative MRI. There is no association between early-onset scoliosis and atlantoaxial rotatory instability.
Early-onset scoliosis can be classified as idiopathic, neuromuscular, or congenital. For this patient without bony or neurologic abnormalities, it would likely be diagnosed as juvenile (bewteen ages 3 and 10 years) idiopathic scoliosis. Commonly associated spinal pathologies (even in patients with no radiographic or neurologic abnormalities) include syringomyelia, spinal cord tumor, dysraphism, tethered cord, and Arnold-Chiari malformation. Before considering any surgical intervention, such as a growing rod construct, these intra-spinal conditions must be ruled-out with an MRI of the spinal axis.
Gillingham et al. present a review of the etiology, diagnosis, and management of early-onset scoliosis. They cite other studies that demonstrated rates as high as 21% of patients with early-onset scoliosis and a normal neurologic exam having occult spinal pathology such as those mentioned above. They recommend MRI for patients with early-onset scoliosis measuring greater than 20° prior to any surgical intervention.
Figure A is a PA radiograph of a skeletally immature patient with a 90° right thoracic curve. Illustration A is an PA radiograph of the same patient after treatment with a growing-rod construct and correction of the scoliotic curve to 46°.
Incorrect Answers:

Question 30

A 60-year-old woman with a history of osteoporosis fell from a standing height and sustained a supracondylar distal humerus fracture with an intercondylar extension. Which of the following plate constructs yields the highest stiffness for fixation of the fracture?

Explanation

Optimal treatment of distal humeral fractures relies on reestablishment of a congruent articular surface with a fixation construct that is stable enough to allow for early range of motion. Several biomechanical studies have been performed to evaluate the biomechanical strength of various plating configurations. These studies have shown that dual plate configurations are more stable than single plates, regardless of the type of plate used. One third tubular plates have been shown to be significantly weaker than LC-DCP or reconstruction plates, resulting in weaker constructs, and clinically higher rates of hardware failure and nonunion. Whereas traditional teaching has suggested plating in perpendicular planes, recent biomechanical studies have demonstrated that parallel medial and lateral plates confer a greater rigidity to the construct than perpendicular plating schemes.

Question 31

A 39-year-old male with chronic renal disease and type 2 diabetes mellitus fell 1 week ago after slipping on ice. He is unable to bear weight on the right lower extremity or perform active knee extension. He reports no prior history of knee pain or instability. Lachman, posterior drawer, posterolateral recurvatum testing are deferred secondary to patient's pain. He has a palpable dorsalis pedis pulse but does have neuropathy as determined by Semmes-Weinstein filament testing. His radiograph is shown in Figure A and MR images in Figures B and C. What is the most appropriate initial plan for management? Review Topic

Explanation

The clinical presentation, exam, and images are consistent with an acute patellar tendon rupture.
Primary surgical repair within 2 weeks of injury is recommended to prevent extensor mechanism contracture. Patellar tendon ruptures typically occur in patients younger than 40 years old. Most ruptures occur at the junction of the tendon and distal pole of the patella.
Matava et al. presents a level 5 review on patellar tendon ruptures and states that active knee extension is permitted at 3 weeks postoperatively. Non-weightbearing movement exercises like heel slides are encouraged. This can incorporate active knee flexion with passive extension. Alternatively, active knee flexion in the prone position with passive knee extension can be performed. Open chain strengthening exercises such as leg extensions are started later, as are weight bearing resistance exercises like squats, lunges and leg presses.
Volk et al. discuss potential complications and pitfalls of patients with the management of extensor mechanism injuries. They warn that complications can consist of misdiagnosis, delayed surgery, failed repair due to poor surgical planning of injury site, or wound infection.
Figure A demonstrates patella alta which in this case is indicative of complete patellar tendon rupture. Patella alta can be quantified by using the Insall-Salvati ratio (patellar tendon length / patellar bone length): PTL/PBL normal =1, >1.2 is patella alta, <0.8 is patella baja) with the knee flexed to 30 degrees. Figure B and C are sagittal T1 and T2 images showing complete patellar tendon rupture.
Incorrect answers:

Question 32

Based on the image findings, what is the most likely diagnosis?

Explanation

Ganglion cyst
Abscess
Hematoma
Giant cell tumor of tendon sheath
Synovial sarcoma CORRECT ANSWER: 4
Giant cell tumor of the tendon sheath is the most common solid soft-tissue mass in the hand. These tumors are slow-growing and may be present for months or years before coming to medical attention. Patients usually report
mechanical difficulties because of the size or position of the tumor. The gross appearance is that of a lobulated mass that may be multicolored; typically yellow, brown, red, and gray. Histologically the lesion consists of multinucleated giant cells, polygonal mononuclear cells, and histiocytes that may contain abundant hemosiderin or lipid.
A 58-year-old woman has had a slowly progressing mass over the distal interphalangeal (DIP) joint of her dominant hand with a worsening deformity of her nail. She has no significant medical history but underwent bilateral knee arthroplasties 1 year ago. Radiographs reveal a small osteophyte at the DIP joint dorsally. A clinical photograph and a biopsy specimen are shown in Figures 76a and 76b. What is the most likely diagnosis?

Metastatic lung carcinoma
Mucous cyst
Synovial sarcoma
Inclusion cyst
Felon abscess CORRECT ANSWER: 2
A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities.
Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
A patient has carpal tunnel syndrome that requires surgical release. The patient wants to know about the risks and benefits of the various surgical techniques for carpal tunnel release because they have read that an endoscopic technique is the best. What is the most significant advantage of endoscopic release over traditional open release?
Decreased rate of nerve complications
Decreased postoperative pain and analgesic use
Decreased rate of recurrence of carpal tunnel symptoms
Lower rate of vascular complications
Lower infection rate CORRECT ANSWER: 2
Carpal tunnel release is usually performed in one of two ways: open or endoscopically. There has always been great controversy and differing opinions about the advantages and disadvantages of either technique. Recent prospective randomized trials have shown that the primary advantage of the endoscopic technique is decreased pain in the postoperative period. A lower rate of vascular complications was not observed in these most recent studies. Likewise, nerve injury and infection rates were not different in these studies.
All of the following structures are components of the triangular fibrocartilage complex. What structure is considered the most important restraint of dorsal/palmar translation of the radius on the ulna?
Triangular articular disk
Dorsal and palmar radioulnar ligaments
Ulnolunate ligament
Ulnotriquetral ligament
Subsheath of the sixth extensor compartment
Clinical examination of the distal radioulnar joint is frequently described as translation of the ulnar head in reference to the radius. This description is incorrect, since the ulna is the bone that is fixed in space. Anatomically speaking, the radius moves in relation to the fixed ulna. The triangular fibrocartilage complex is composed of all of the structures listed above. The articular disk is a meniscal-like structure that serves a load-bearing function between the ulnar carpal bones and the ulnar head. About 20% of the load borne across the wrist passes through the disk. It has almost no ligamentous (stabilizing) function. At the dorsal and volar margins of the articular disk are thickened true ligamentous ligaments termed the radioulnar ligaments. They take origin from the foveal area of the ulnar head and styloid and insert into the dorsal and volar margins of the sigmoid notch. These two ligaments serve as primary restraints to dorsal and palmar translation of the radius on the ulna. The ulnolunate ligament, ulnotriquetral ligament, and the subsheath of the sixth extensor compartment are ligaments, but they serve to stabilize the carpus to the ulna and radius. They provide minimal stability to the distal radioulnar joint.
Replantation is indicated for which of the following amputations.
multiple level amputation of the small finger at the proximal and distal interphalangeal joints
crushed amputation through the distal phalanx of the middle finger
complete ring avulsion of the ring finger with tendon injury
thumb amputation though the proximal phalanx shaft
middle finger amputation though the proximal phalanx shaft
As outlined by Pederson, the contraindications to replantation are more relative than the indications, but they include the following: Single-finger replantations at the level of zone II (from the A1 pulley to the distal sublimis tendon insertion) are rarely indicated, with the notable exception of the thumb. Amputated parts that are severely crushed and those with multiple
level injuries have poor function even if they survive replantation. While ring avulsion injuries with a vascular injury and no bone, tendon or nerve injury (Urbaniak type 2A ring avulsion injuries) should be repaired, ring avulsion injuries with bone, tendon or nerve injury (Urbaniak type 2B) or with complete degloving (Urbaniak type 3) have poor outcomes and Urbaniak and colleagues recommend amputation for such injuries. Very distal amputations at the level of the nail bed are marginally indicated as there needs to be approximately 4 mm of intact skin proximal to the nailfold for adequate veins to be present.
Indications for replantation that rule out the other 4 choices of this question include the following: Overall, thumb replantation probably offers the best functional return. Even with poor motion and sensation, the thumb is useful to the patient as a post for opposition. A replanted thumb offers the best reconstruction available, toe transfers notwithstanding. Replantation beyond the level of the sublimis tendon insertion (zone I) usually results in good function. Multiple finger amputations present reconstructive difficulties that may be difficult to correct without replantation of one or all of the amputated digits. Any hand amputation from zone III (distally) to zone V (proximally) offers the chance of reasonable function after replantation, usually superior to available prostheses. Although usually indicated, the replantation of any hand or arm proximal to the level of the mid-forearm must be carefully considered.
Figure 14a shows the radiograph of a 19-year-old man who hurt his little finger while falling off his bicycle. A closed reduction of the proximal interphalangeal (PIP) joint is performed in the emergency department. Postreduction radiographs are shown in Figures 14b and 14c. When the PIP joint is put through a range of motion, the middle phalanx redislocates when fully extended. What is the next most appropriate step in management?

Extension block splinting for 3 weeks
Volar plate arthroplasty
Open reduction and internal fixation of the middle phalanx base
Superficialis tendon repair through bone tunnels
Dynamic external fixation

Question 33

What structure is marked Q in the diagram of the brachial plexus shown in Figure 22?

Explanation

DISCUSSION: From proximal to distal, the brachial plexus is divided into roots, trunks, divisions, and cords before forming specific peripheral nerve branches. The structure marked Q is called the posterior cord because it lies posterior to the axially artery at the level of the cords. Its terminal branches are the upper subscapular (V), thoracodorsal (W), lower subscapular (X), axillary (F), and radial (G) nerves.
REFERENCES: Anderson JE (ed): Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Williams and Wilkins, 1978, pp 6-24.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 63.

Question 34

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Explanation

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament

Question 35

Figures 1 and 2 are radiographs of a 25-year-old man who has had persistent right hip pain for over a year. There was an acute injury and the pain has progressively worsened and is now 9/10 in severity. The pain interferes with activities of daily living and the patient's capacity to participate in sports. The patient has failed nonsurgical treatment in the form of physical therapy and activity modification. On physical examination, forward flexion is limited to 90°, internal rotation is limited to 10°, and flexion adduction internal rotation examination is positive. The hip pain was relieved on physical examination after intra-articular administration of local anesthetic. The patient had an MRI and CT scan. What is the most appropriate surgical option?

Explanation

A 50-year-old right-hand dominant man presents after a traumatic fall on an outstretched right upper extremity. Based upon the MRI scans shown in Figures 1 and 2, what examination test would be abnormal?
A. Belly press
B. Hornblower's test
C. External rotation strength
D. Empty can test
A fall on an outstretched upper extremity can commonly result in a traumatic rotator cuff tear. The images require appropriate interpretation of an acute subscapularis tendon rupture with medial subluxation of the biceps tendon. Subscapularis tendon tears result in a positive belly press or lift-off test. Hornblower's tests for external rotation strength with the arm abducted 90° (teres minor weakness). Empty can tests supraspinatus strength. External rotation strength with the arm at the side tests for infraspinatus weakness.
38- Videos 1 and 2 are the coronal plane MRI scan and arthroscopic evaluation of a 48-year-old woman with 2 weeks of posterior knee pain after feeling a “pop” in the knee while climbing stairs. Physical examination reveals passive range of motion of +5° to 120°, with pain limiting her in terminal extension. Failure of surgical repair of the injured structure is most associated with
A. poor vascularity of the injured tissue.
B. BMI >35 kg/m^2.
C. valgus alignment >5°.
D. repair technique. 30
The MRI scan and surgical video are showing an example of a posterior medial meniscal root tear/avulsion. Many studies have shown successful treatment of these tears with repair using various techniques and minimal progression to osteoarthritis (OA). Most studies exclude patients with high BMI. Brophy and associates demonstrated in their series that high BMI was associated with higher rates of clinical OA and need for subsequent surgery.
Multiple studies in the literature demonstrate good results with a variety of techniques. A valgus alignment in this setting would be considered protective, as opposed to a varus alignment >5°, which has also been associated with worse outcomes. The vascularity of the meniscus is consistently poor throughout most of its volume, including the root, and is not considered to be significantly different from person to person and should affect all root repairs equally.
39- A 47-year-old man who is an avid tennis player and laborer has had one year of shoulder pain and weakness. His pain occurs at night and radiates to the deltoid laterally. The patient denies any anterior based pain. He reports no prior surgeries and has been managed with steroid injections and physical therapy. On examination, he has full passive motion with significant weakness with external rotation. His neurologic examination is unremarkable. MRI evaluation reveals a posterior- superior rotator cuff tear with Goutallier grade 4 fatty infiltrate in the supraspinatus and infraspinatus with retraction beyond the glenoid. He is concerned about the lack of rotation of his arm and reports that this disability creates significant disability with his occupation as a mason. What is the best next step?
A. Shoulder arthroscopy and subacromial decompression
B. Tendon transfer
C. Total shoulder arthroplasty
D. Reverse total shoulder arthroplasty
In younger active patients, tendon transfer is considered a preferable treatment option. The patient has failed a course of nonoperative management. Subacromial decompression may offer pain relief but may not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not improve external rotation in this patient, and there is concern for longevity of the implant in younger patient populations.
40- A multicenter prospective study of 7,500 patients that assesses differences in rerupture rates after anterior cruciate ligament (ACL) reconstruction using hamstring autograft shows a decreased rate of rerupture when the graft diameter is >9.0 mm versus <9.0 mm (p = 0.05). A follow-up study done at a single institution of 200 patients fails to show any difference in rerupture rates based upon graft size. If the multicenter trial is assumed to be accurate, which statistical error occurred in the follow-up study?
A. Type-I error
B. Type-II error
C. Selection bias
D. Alpha error
Type-II errors, or beta errors, occur when the null hypothesis is accepted and should have been rejected. An underpowered study is at risk of this type of error. Power is defined as 1-probability of a type-II (beta error), and this is generally set at a level of 80% for most studies. The type-II error occurs when a study concludes that there is no association between the studied variables when in fact one exists. The type-I error, or alpha error, is defined as rejecting the null hypothesis when it should have been accepted. Alpha errors occur when a study suggests an association does exist when in reality it does not. Selection bias occurs when proper randomization is not achieved and therefore, the study cohort is not representative of the population intended to be analyzed.
41- A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). A 60-degree anteromedialization is planned to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?
A. Grade III chondrosis of the proximal patella
B. Caton-Deschamps ratio of 1:1
C. Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
D. Q angle of 17°
TO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and
medialize the tubercle. This will consistently result in a change of 32
patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.
42- During preseason training camp, a 23-year-old football player comes to the sideline complaining of nausea, dizziness and headache after a 2- mile run. Vital signs include blood pressure 110/80, heart rate 115 bpm and core body temperature of 39°C (102°F). He is otherwise alert and oriented. What is the recommended initial treatment?
A. Immediate ice water bath immersion
B. Immediate return to training
C. Rehydration with a carbohydrate- electrolyte beverage
D. Emergent transportation to a local emergency department
The patient has exertional heat exhaustion (EHE). In cases of exertional heat illness with elevated core body temperature, it is critical to differentiate between EHE and exertional heat stroke (EHS). Patients suffering from EHE often complain of dizziness, nausea, cramping and headache. Vital signs can show mild tachycardia and normal to low blood pressure. EHS is defined by elevated core body temperature >40°C (104°F) and organ failure. Rapid cooling is critical in the setting of EHS, but not EHE. In the setting of EHE, the patient should be placed in a cool, shaded area and given fluids. Studies suggest that the presence of carbohydrate (<8%) in combination with electrolytes mildly promotes fluid retention better than drinking water alone.
43- Surgical repair of the injury shown in the MRI scans in Figures 1 through 4 through a single-incision approach has a higher incidence of

Question 36

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Explanation

DISCUSSION: The leg and trunk provide a stable base for arm motion, supply rotational momentum for force generation, and generate 50% to 55% of the total force and kinetic energy in the tennis serve.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p 47.
McClure PW, Michener LA, Sennett BJ, et al: Direct 3-dimensional measurement of scapular kinematics during dynamic movements in vivo. J Shoulder Elbow Surg 2001;10:269-277.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003;19:641-661.

Question 37

An obese 62-year-old man reports a 10-year history of progressive flatfoot deformity and a 3-month history of a painful callus along the plantar medial midfoot that has not improved with custom shoe wear, pedorthics, and callus care. There is no hindfoot motion, but functional ankle motion remains. He does not have diabetes mellitus. Radiographs are shown in Figures 27a and 27b. What is the best surgical option at this point?

Explanation

DISCUSSION: The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The “exostosis” responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.
REFERENCES: Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.
Pinney SJ, Lin SS: Current concept review: Acquired adult flatfoot deformity. Foot Ankle Int 2006;27:66-75.

Question 38

A 6-year-old African-American boy with sickle cell disease has had pain and limited use of his right arm for the past 3 days. History reveals that he sustained a humeral fracture approximately 3 years ago. A lateral radiograph is shown in Figure 25. Based on these findings, a presumptive diagnosis of chronic osteomyelitis is made. What are the two most likely organisms?

Explanation

DISCUSSION: The risk of Salmonella osteomyelitis is much greater in patients with sickle cell disease than the general population. The exact reason for this increased risk is still unclear, but it appears to be associated with an increased incidence of gastrointestinal microinfarcts and abscesses. Both Staphylococcus aureus and Salmonella have been mentioned as the most prevalent causative organisms.
REFERENCES: Piehl FC, David RJ, Prugh SI: Osteomyelitis in sickle cell disease. J Pediatr Orthop 1993;13:225-227.
Givner LB, Luddy RE, Schwartz AD: Etiology of osteomyelitis in patients with major sickle hemoglobinopathies. J Pediatr 1981;99:411-413.
Epps CH Jr, Bryant DD III, Coles MJ, Castro O: Osteomyelitis in patients who have sickle-cell disease: Diagnosis and management. J Bone Joint Surg Am 1991;73:1281-1294.
Lovell and Winter’s Pediatric Orthopaedics, ed 4, 1996.

Question 39

Figures 51a and 51b show the AP and lateral radiographs of the elbow of a 26-year-old man who fell. Closed reduction was performed in the emergency department, and management consisted of immobilization for 3 weeks prior to the initiation of motion. At 12 weeks after injury, he reports continued feelings of instability and catching in his elbow when using his arms to rise from a chair. Which of the following procedures needs to be performed, at a minimum, to reestablish stability of the elbow? Review Topic

Explanation

The patient has chronic posterolateral instability of the elbow following dislocation. The lateral collateral ligament complex is responsible for maintaining stability of the elbow. Because of the chronicity of the injury, the ligamentous tissues are frequently attenuated and not amenable to simple repair; while the native ligament can be imbricated, reconstruction with allograft or autograft is recommended. Medial collateral ligament reconstruction or hinged external fixation is needed only if restoration of the lateral ligamentous complex does not restore elbow stability; however, these procedures are rarely required. Lateral elbow pain when rising from a chair is equivalent to a positive pivot shift test.

Question 40

A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.
REFERENCES: Hattrup SJ, Cofield RH, Cha SS: Rotator cuff repair after shoulder replacement. J Shoulder Elbow Surg 2006;15:78-83.
Sperling JW, Potter HG, Craig EV, et al: Magnetic resonance imaging of painful shoulder arthroplasty. J Shoulder Elbow Surg 2002;11:315-321.

Question 41

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Explanation

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 42

A 14-year-old patient with an L3 myelomeningocele underwent anterior and posterior spinal fusion for a curve of 50°. Follow-up examination 1 week after the procedure now reveals persistent drainage from the posterior wound. Results of laboratory cultures show Streptococcus viridans, Staphylococcus aureus, and Enterococcus. In addition to IV antibiotics, surgical irrigation, and debridement, management should include

Explanation

DISCUSSION: The rate of wound infections has dramatically decreased with the routine use of prophylactic antibiotics. Factors known to increase the risk of infection include instrumentation, prolonged surgical time, excessive blood loss, poor perioperative nutritional status, a history of surgery, and a history of infection. The use of allograft does not result in an increased rate of infection. Adequate treatment requires early diagnosis and intervention. Temperature elevation and persistent wound drainage are highly suspicious for infection. An erythrocyte sedimentation rate and a WBC are not useful in diagnosis unless serial examinations show rising levels. Patients should be taken to the operating room where the entire wound can be reopened, irrigated, and debrided. Bone graft can be washed and replaced. Hardware should not be removed. The wound should be closed over suction drains. IV antibiotics should be given for a period of at least 10 days, followed by 6 weeks orally. Leaving the wound open to granulate with dressing changes results in prolonged hospitalization, inadequate treatment of the infection, and a poor cosmetic result.
REFERENCES: Lonstein JE: Complications of treatment, in Bradford DS, Lonstein JE, Moe JH, et al (eds): Moe’s Textbook of Scoliosis and Other Spinal Deformities, ed 2. Philadelphia, Pa, WB Saunders, 1987, p 476.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 43

5cm from the carpometacarpal joint. The attached deep transverse intermetacarpal ligaments are sacrificed. To prevent scissoring of the remaining digits and small objects falling through the gap between index and ring fingers, which of the following procedures should be performed?

Explanation

A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of

Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers

Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:

A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:

Which of following malformations is most commonly associated with Poland's syndrome?

Figure E CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:

Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?

Figure E CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.

Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?

Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:

A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?

Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:

An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:

Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1 CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers

A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?

Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers

Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?

Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
Incorrect Answers:
A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?

Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:

A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?

Figure E CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.

A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?

Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:

A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?

Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.

A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:

A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?

Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?

Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:

A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?

Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:

A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?

Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?

Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:

Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.

A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?

Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.

A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?

Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:

A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:

Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?

Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:

Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?

Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 44

A 30-year-old man who sustained a tibial fracture with a peroneal nerve palsy 2 years ago now has a drop foot and weak eversion of the foot. He reports success with stretching exercises, but he catches his toes when his foot tires. Examination reveals that the foot is plantigrade and supple. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a supple plantigrade foot that would benefit from a drop foot brace to prevent catching of the toes. Tendon transfer should not be considered until the patient has undergone bracing. Achilles tendon lengthening is not necessary because the foot is plantigrade and flexible. Nerve grafting is not indicated because of the length of time the peroneal nerve palsy has been present.
REFERENCES: Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.
Santi MD, Botte MJ: Nerve injury and repair in the foot and ankle. Foot Ankle Int

1996;17:425-439.

Question 45

Figures 1 and 2 show the intraoperative photographs obtained during surgical treatment for de Quervain tendonitis. For orientation purposes, dorsal is at the top. Figure 1 is obtained just after the initial first extensor compartment release, and Figure 2 shows the floor of the first extensor compartment. If the structure marked by the black dot is not addressed, the most common postoperative problem would be

Explanation

EXPLANATION:
The black dot identifies an accessory compartment of the extensor pollicis brevis (EPB) tendon. The incidence of accessory EPB compartment in patients undergoing surgical treatment for de Quervain syndrome ranges from 46% to 60%. Failure to release this compartment at the time of initial surgery can cause persistent postoperative pain. The patient would not experience altered sensation if this compartment were not released. Altered sensation would most commonly occur following injury to the dorsal radial sensory nerve branch during surgery. EPB tendon subluxation also would not occur should the accessory compartment not be released. For EPB tendon subluxation to occur, its own compartment would need to be released first. Finally, EPB tendon rupture would be an extremely uncommon complication of failure to release the accessory compartment.

Question 46

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

Explanation

DISCUSSION: Although the Holstein-Lewis fracture, described as an oblique distal one third fracture, is best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle one third humeral fractures. Most nerve injuries are neurapraxias or axonotmeses, with up to 90% resolving in 3 to 4 months.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

Question 47

By which mechanism can a true aneurysm of the ulnar artery result?

Explanation

Figures 1 and 2 are the radiographs of a 17-year-old boy who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Question 48

An otherwise healthy 16-year-old dancer reports a 1-month history of leg pain. AP and lateral radiographs of the distal femur are shown in Figures 67a and 67b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The radiographs show a very ill-defined, aggressive, moth-eaten bony destruction involving the distal left femoral diaphysis just above the metaphyseal junction. The differential diagnosis includes Ewing’s sarcoma, osteosarcoma, lymphoma of bone, eosinophilic granuloma, osteomyelitis, and others. MRI would further define the lesion, and soft-tissue and intramedullary extension. There is aggressive periosteal reaction in the posteromedial aspect of the adjacent lesion with some multilayered components in the distal interface of the periosteum. The lateral radiograph shows cortical penetration and irregular periosteal reaction of the posterior margin, suggesting some posterior soft-tissue extension at this site as well.
REFERENCES: Gebhardt MC, Ready JE, Mankin HJ: Tumors about the knee in children. Clin Orthop Relat Res 1990;255:86-110.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Question 49

In displaced calcaneal fractures, what fragment is the only one that remains in its anatomic position?

Explanation

DISCUSSION: The sustentaculum tali remains in its anatomic position because of its supporting ligamentous structures. This provides the key to the reconstruction of the calcaneus. The posterior facet is reduced to the sustentaculum tali and then fixed to it for stability. All of the other components of the calcaneus are then reduced to this complex.
REFERENCES: Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
Eastwood DM, Gregg PJ, Atkins RM: Intra-articular fractures of the calcaneum: Part I. Pathological anatomy and classification. J Bone Joint Surg Br 1993;75:183-188.
Eastwood DM, Langkamer VG, Atkins RM: Intra-articular fractures of the calcaneum: Part II. Open reduction and internal fixation by the extended lateral transcalcaneal approach. J Bone Joint Surg Br 1993;75:189-195.

Question 50

What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

Explanation

DISCUSSION: Cadaver and clinical studies have shown that the sural nerve is at the highest risk for injury with a percutaneous repair of the Achilles tendon.
REFERENCE: Hockenbury RT, Johns JC: A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot Ankle 1990;11:67-72.

Question 51

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Explanation

Arthroscopic anterior labral repair spares the subscapularis, and does not require significant mobilization or incision of the anterior capsule. Therefore, it is less likely to result in significant impairment in external rotation of the glenohumeral joint when compared with traditional open stabilization procedures. Recurrent instability rates are either slightly higher or equivalent to open procedures. Both procedures can be performed on an outpatient basis and require generally identical recovery times.

Question 52

Based on the type of articulation shown in Figure 32, wear is not affected by which of the following factors?

Explanation

DISCUSSION: Wear in total hip arthroplasty is a very complex phenomenon. The radial mismatch of the femoral head to the acetabular component has been shown in multiple studies to be a significant factor in wear. The mismatch can neither be too small nor too large. When the mismatch is too small, seizing of the implants can occur. When the mismatch is too large, contact stresses increase and produce exceptionally high wear. The ideal radial mismatch should be approximately 50 microns. Surface roughness and ball sphericity are two items that are extremely important with respect to wear. High carbon content has been shown to decrease wear. This device has a very large head-to-neck ratio, so impingement-related wear is unlikely.
REFERENCES: Amstutz HC, Grigoris P: Metal on metal bearings in hip arthroplasty. Clin Orthop 1996;329:S11-S34.
Amstutz HC, Campbell P, McKellop H, et al: Metal on metal total hip replacement workshop consensus document. Clin Orthop 1996;329:S297-S303.
McKellop H, Park SH, Chiesa R, et al: In vivo wear of three types of metal on metal hip prostheses during two decades of use. Clin Orthop 1996;329:S128-S140.

Question 53

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Explanation

The main function of the Tib. Post. Tendon is inversion of the subtalar joint and adduction of the forefoot. This initial inversion stabilizes the subtalar joint allowing the gastrosoleus complex to forcibly invert the joint while plantarflexing the ankle. Heel inversion begins during flatfoot when the Tib Post. fires at 7% of the walking cycle. The gastrosoleus kicks in at 30% of the cycle to maintain inversion, which locks the midfoot for push-off.

Question 54

A 13-year-old boy was evaluated for leg length difference. His pelvis balanced when a 1-inch (2.54 cm) block was placed under his left foot. History revealed he had a left distal femur physeal fracture treated with casting at age 10. Radiographs show normal limb alignment, but his left distal femoral physis is closed and his left femur is 2.5 cm shorter than the right. All other physes are open. His bone age is equal to his chronologic age. What surgical treatments will best equalize his discrepancy? Review Topic

Explanation

Because the left distal femoral physis is closed with a leg length difference already at 1 inch, epiphysiodesis of both the right distal femur and proximal tibia/fibula is needed. The amount of correction will be the amount of growth remaining in the left proximal tibia. Presuming the standard rates of growth of 10 mm per year distal femur, 6 mm per year proximal tibia, and 4 mm per year distal tibia, this should yield a correction of 6 mm x 3 years = 1.8 cm by skeletal maturity at age 16. This would leave the boy with an acceptable discrepancy of 7 mm, well under 1 inch/2.54 cm. Closing only the right distal femoral physis will leave the discrepancy unchanged at 1 inch/2.54 cm because no growth differential will exist. Closing the right proximal tibia/fibular physis would mean the left knee will grow at 6 mm per year, but the right will grow at 10 mm per year. The discrepancy would increase by 4 mm per year, or

Question 55

Among patients with lumbar degenerative disk disease and low back pain, what factor is most predictive of clinical outcomes after surgical management? Review Topic

Explanation

The treatment of low back pain ranges from nonsurgical management to surgical management. Whereas many other treatment modalities have been investigated, lumbar arthrodesis remains the primary surgical treatment of lumbar diskogenic pain. Outcomes of surgical management vary but are consistently impacted negatively by workers' compensation status. Neither the radiographic severity of disease, number of spinal segments, nor duration of disease has been correlated with clinical outcomes. While total disk arthroplasty was hoped to be an improvement over fusion, the evidence available to date has shown no significant differences over arthrodesis.

Question 56

What is the most common malignant tumor of the foot?

Explanation

DISCUSSION: Whereas chondrosarcoma is the most frequently occurring malignant bone tumor of the foot and synovial sarcoma is the most common soft-tissue foot malignancy, the most common malignant tumor overall is melanoma. It constitutes approximately 25% of lesions found on the lower extremity. Furthermore, 31% of all melanomas arise in the foot.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 11-26.
Bos GD, Ester RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 57

Which of the following findings is a relative contraindication to primary total knee arthroplasty?

Explanation

DISCUSSION: Contraindications to primary total knee arthroplasty include active infection, an incompetent extensor mechanism, compromised vascularity in the extremity, and local neurologic disruption affecting the competence of the musculature about the knee. Anterior cruciate, posterior cruciate, or lateral ligament incompetence can be managed with primary total knee arthroplasty. Mild flexion contracture and previous high tibial valgus osteotomy are not contraindications to primary total knee arthroplasty.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 513-536.

Question 58

Figures below show the AP and lateral radiographs obtained from a 54-year-old woman who has worsening groin pain 18 months after a primary left total hip arthroplasty. The pain is worst when climbing stairs, when rising from a seated position, and during resisted hip flexion. Her pain improved early after surgery but did not completely resolve. Her C-reactive protein and erythrocyte sedimentation rate results of less than 1 mg/dL and 10 mm/hr, respectively, were obtained in the office. What is the best next step?

Explanation

DISCUSSION:
Iliopsoas impingement is a potential cause of persistent groin pain after a total hip arthroplasty. This patient’s history gives groin pain with resisted hip flexion and during activities that require this level of function. The radiographs depict an acetabular component with substantial retroversion. Typical options for the management of iliopsoas tendon impingement include injections, tenotomy, and acetabular revision. Recently, Chalmers and associates reported more predictable groin pain resolution with 8 mm or more of anterior acetabular component when overhang was revised. The radiographs clearly show more retroversion, with a cup prominence of more than 8 mm anteriorly. MRI with MARS could potentially help in the diagnosis of this impingement but would not help in management (option A). An ultrasound-guided injection would need to be administered into the iliopsoas tendon sheath to be of help and, in this case, would likely be performed for diagnostic purposes due to the extreme anterior overhang (option C). Option D would be useful for mild cases of iliopsoas impingement but likely would not help much in this more extreme case.

Question 59

What postoperative complication occurs at a significantly higher rate in patients undergoing bilateral simultaneous total knee arthroplasty than in patients undergoing unilateral total knee arthroplasty?

Explanation

DISCUSSION: Parvizi and associates studied the 30-day mortality rate after more than 22,000 total knee arthroplasties and found that the rate after bilateral total knee arthroplasty was significantly higher than after unilateral total knee arthroplasty. Aseptic loosening, bleeding, and range of motion have not been shown to be statistically different between patients who had unilateral and simultaneous bilateral total knee arthroplasty.
REFERENCE: Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG: Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 2001;83:1157-1161.

Question 60

Figure 93 shows the axial T2-weighted MRI scan of the lumbar spine of a 70-year-old man. The arrow points to which of the following structures? Review Topic

Explanation

The ligamenta flava (singular, ligamentum flavum, Latin for yellow ligament) are ligaments that connect the laminae of adjacent vertebra, all the way from the axis to the first segment of the sacrum. In T2-weighted sequencing, ligamentous structures possess a low signal intensity. The ligamentum in this patient is markedly thickened, resulting in severe spinal stenosis. The epidural space lies ventral and medial to the ligamentum flavum and should possess a high signal intensity secondary to the presence of cerebrospinal fluid. However, in the case of high-grade stenosis, there may be little if any cerebrospinal fluid present, making the epidural space and central canal difficult to identify. A lumbar synovial cyst should also have high signal intensity because of the presence of synovial fluid.
(SBQ12SP.14) A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. On physical exam he has weakness to knee extension, numbness over the medial malleolus, and a decreased patellar reflex. Which of the following would most likely explain this clinical presentation. Review Topic
Lumbar arachnoiditis
L4/L5 paracentral disc herniation
L3/L4 far lateral (foraminal) disc herniation
L4/L5 far lateral (foraminal) disc herniation
L5/S1 far lateral (foraminal) disc herniation
The clinical presentation is consistent with a L4 radiculopathy. A L4/L5 far lateral (foraminal) disc herniation would compress the exiting root (L4) and cause these symptoms.
The location of a prolapsed lumbar disc determines its symptoms. Central disc herniations may give rise to back pain or cauda equina syndrome. Paracentral disc herniations (90-95% of cases) affect the traversing nerve root. Far lateral disc herniations (5-10%) affect the exiting nerve root.
Gregory et al. summarize physical signs in lumbar disc herniation. They state that the straight-leg-raise is the most sensitive (73-98% sensitive) test and the crossed straight-leg-raise is the most specific (88-98% specific) test for lumbar disc herniation. Other specific tests include weak ankle dorsiflexion (89% specific), absent ankle reflex (89% specific), and calf wasting (94% specific, but a late finding).
Illustration A shows how a paracentral L4/L5 disc herniation affects the traversing L5 root, but a far lateral L4/L5 disc herniation affects the L4 root. Illustration B shows the dermatomal distribution of pain with root involvement from L3 to S1.
Incorrect Answers:

Question 61

In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

Explanation

DISCUSSION: Many clinical studies to date show that the extent of arthritis is the most common variable that has the greatest influence on outcome. The success rate of allograft transplantation is significantly diminished in patients who have grade IV chondromalacia of the knee or notable flattening and general joint incongruity.
REFERENCES: Carter TR: Meniscal allograft transplantation. Sports Med Arthroscopy Rev 1999;7:51-63.
Garrett JC: Meniscal transplantation: A review of 43 cases with two- to seven-year follow-up. Sports Med Arthroscopy Rev 1993;2:164-167.
van Arkel ER, de Boer HH: Human meniscal transplantation: Preliminary results at 2- to 5-year follow-up. J Bone Joint Surg Br 1995;77:589-595.

Question 62

Figures 36a and 36b show the radiographs of a 3-year old child who has a congenital upper extremity deformity. Which of the following features would be a major contraindication to a centralization procedure?

Explanation

DISCUSSION: The patient has bilateral absent radii or radial clubhand. Patients who lack elbow flexion take advantage of the hand position to reach their mouths, and a centralization procedure would take away that ability. This procedure can be performed on patients with partial to complete absence of the radius. A hypoplastic thumb can be addressed at a staged procedure; it does not represent a contraindication to centralization. Complete thumb absence can be addressed by pollicizing the index ray.
REFERENCES: Green DP: Operative Hand Surgery, ed 2. New York, NY, Churchill Livingstone, 1988, pp 269-271.
Goldberg MJ, Meyn M: The radial clubhand. Orthop Clin North Am 1976;7:341-359.

Question 63

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Explanation

DISCUSSION: Retrieval studies have shown that the debris particles produced by

metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller

and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.

J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 64

In the setting of a proximal tibial plateau fracture and its repair, which of the following materials is an isotropic material?

Explanation

DISCUSSION: An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials’ orientation to the applied stress.
REFERENCE: Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 58-59.

Question 65

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Explanation

The high prevalence of latex allergy in patients with myelomeningocoele is thought to result from a heavy degree of latex exposure throughout life, including closure of the spinal defect, multiple orthopedic, urologic, and neurologic procedures, and repeat bladder catheterization. As many as 50% of these patients may have the allergy. Appropriate perioperative management includes utilization of a latexfree protocol.

Question 66

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

Explanation

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

Question 67

Which of the following best describes athletic pubalgia?

Explanation

DISCUSSION: Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures.
REFERENCES: Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC: MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270-277.

Question 68

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Explanation

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.
Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

Question 69

Which of the following factors is considered to be the strongest predictor of outcome following arthroscopic partial meniscectomy? Review Topic

Explanation

In a recent evidence-based review of the literature, the only consistent factor predicting outcome after arthroscopic partial meniscectomy was the extent of osteoarthritis as classified by the modified Outerbridge cartilage score at the time of surgery. All other factors listed (ie, location of meniscal tear, patient age, patient BMI, and amount of meniscal resection) were shown to not predict outcome following partial meniscectomy. While not provided as an answer choice, female gender was shown to be a predictor for slower recovery in the short term.

Question 70

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Explanation

DISCUSSION: Studies examining the impact of graded water debt have clearly shown that the magnitude of core temperature and heart rate increase accompanying work are proportional to the magnitude of water debt at the onset of exercise. Though added thermal burden from hot climates is a factor, it appears to be less significant.
REFERENCES: Latzka WA, Montain SJ: Water and electrolyte requirements for exercise. Clin Sports Med 1999;18:513-524.
Montain SJ, Sawka MN, Latzka WA, et al: Thermal and cardiovascular strain from hypohydration: Influence of exercise intensity. Int J Sports Med 1998;19:87-91.
Sawka MN, Young AJ, Francesconi RP, et al: Thermoregulatory and blood responses during exercise at graded hypohydration levels. J Appl Physiol 1985;59:1394-1401.

Question 71

A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of

Explanation

Most cases of isolated serratus anterior palsy resolve spontaneously, usually within 6 to 9 months after traumatic injury and within 2 years after an infectious cause. Pectoralis major-fascia lata graft is an effective treatment for persistent winging.

Question 72

During primary total knee arthroplasty with trial implants in place, the surgeon notes technically satisfactory patellar resurfacing and restoration of a physiologic mechanical axis but excessively lateral patellar tracking. Treatment should now include

Explanation

DISCUSSION: The most common causes of patellar instability after total knee arthroplasty are valgus malalignment, internal rotation of the femoral or tibial component, medialization of the femoral component, errors in patellar preparation and resurfacing, and failure to perform a lateral release. These factors should be addressed before considering capsular closure. Distal extensor mechanism realignment should be avoided because of the complication rate. The proximal extensor mechanism would not adequately compensate for implant malrotation.
REFERENCES: Barnes CL, Scott RD: Patellofemoral complications of total knee replacement, in Heckman JD (ed): Instructional Course Lectures 42. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 309-314.
Hungerford DS: Alignment in total knee replacement, in Jackson DW (ed): Instructional Course Lectures 44. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 455-468.

Question 73

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Explanation

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 74

When performing an arthroscopic subacromial decompression, bleeding can be encountered when dividing the coracoacromial ligament because of injury to what artery?

Explanation

DISCUSSION: The acromial branch of the thoracoacromial trunk courses along the coracoacromial ligament. This artery enters the ligament approximately 5 mm below the acromial edge. Division of the ligament at its insertion on the acromion minimizes the risk

of bleeding.
REFERENCES: Esch JC, Baker CL: Arthroscopic anatomy and normal variations, in Whipple TL (ed): Surgical Arthroscopy: The Shoulder and Elbow. Philadelphia, PA, JB Lippincott, 1993, pp 63-76.
Caspari RB, Thal R: A technique for arthroscopic subacromial decompression. J Arthroscopy 1992;8:23-30.

Question 75

Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?

Explanation

DISCUSSION: Tears of the pectoralis major tendon are frequently missed during examination. MRI provides excellent visualization of the tendon if the study extends low enough down the arm. The pectoralis major tendon inserts on the crest of the greater tubercle of the humerus, just lateral to the long head of the biceps tendon. The latissimus dorsi tendon inserts medial to the long head of the biceps tendon on the lesser tubercle. The subscapularis tendon inserts on the lesser tuberosity more proximally. The deltoid insertion is more distal.
REFERENCES: Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791.
Carrino JA, Chandnanni VP, Mitchell DB, et al: Pectoralis major muscle and tendon tears: Diagnosis and grading using magnetic resonance imaging. Skeletal Radiol 2000;29:305-313.
Ohashi K, El-Khoury GY, Albright JP, et al: MRI of complete rupture of the pectoralis major muscle. Skeletal Radiol 1996;25:625-628.

Question 76

A 21-year-old woman with Marfan syndrome is seeking evaluation of her scoliosis. She reports no back or leg pain, and the neurologic examination is normal. Lateral and bending radiographs are shown in Figures 7a through 7e. Management should consist of

Explanation

DISCUSSION: Because the patient’s thoracolumbar scoliosis is of a large enough magnitude, observation or bracing is not recommended. The thoracolumbar curve is flexible enough and L4 corrects well enough to the pelvis to consider anterior spinal fusion from T10 to L4.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 161-171.
Turi M, Johnston CE II, Richards BS: Anterior correction of idiopathic scoliosis using TSRH instrumentation. Spine 1993;18:417-422.
Moskowitz A, Trommanhauser S: Surgical and clinical results of scoliosis surgery using Zielke instrumentation. Spine 1993;18:2444-2451.

Question 77

A 2-year-old child is brought in by his parents for evaluation of intoeing. The child has a normal neuromuscular examination, but the heel bisector line is in the fourth web space, indicating a severe flexible metatarsus adductus deformity. The remainder of the lower extremity examination is unremarkable. What is the most appropriate treatment?

Explanation

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.

J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes

of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 78

A 71-year-old woman undergoes a posterior lumbar decompression and fusion from L4-S1. Thirty-six hours after the procedure, she reports severe right-sided chest pain and shortness of breath. Doppler ultrasound reveals a clot proximal to the knee within the femoral vein. A large pulmonary embolus is confirmed by CT angiography. The next most appropriate step in management should consist of

Explanation

DISCUSSION: In a review of 13,000 spinal procedures, nine patients were treated with heparin following development of pulmonary emboli. Of these patients, six had serious complications ranging from wound drainage to paralysis. Heparin therapy instituted within 10 days of the surgical procedure resulted in a 100% complication rate. Vena cava filter placement has a complication rate of 0.12% to 10.1%. Removable filters are currently in clinical trials.
REFERENCES: Cain JE Jr, Major MR, Lauerman WC, et al: The morbidity of heparin therapy after development of pulmonary embolus in patients undergoing thoracolumbar or lumbar spinal fusion. Spine 1995;20:1600-1603.
Roberts AC: Venous imaging and inferior vena cava filters. Curr Opin Radiol 1992;4:88-96.
Becker DM, Philbrick JT, Selby JB: Inferior vena cava filters. Arch Intern Med
1992;152:1985-1994.

Question 79

A further workup reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MARS MR imaging. Revision THA is recommended. The most common complication following revision of a failed metal-on-metal hip arthroplasty is

Explanation

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

Question 80

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Explanation

DISCUSSION: The resultant spasticity and weakness (paresis) following a cerebrovascular accident leads to muscle imbalance that commonly results in contracture of the shoulder in adduction, internal rotation, and varying degrees of forward flexion. In addition, the elbow is usually flexed and the forearm pronated.
REFERENCES: Braun RM, Botte MJ: Treatment of shoulder deformity in acquired spasticity. Clin Orthop 1999;368:54-65.
McCollough NC III: Orthopaedic evaluation and treatment of the stroke patient. Instr Course Lect 1975;24:45-55.

Question 81

A 48-year-old woman with a history of a spinal cord injury as a teenager, has unilateral weakness in the left lower extremity. She has used an ankle-foot orthosis for many years without difficulty but recently has had a recurrent painful callus beneath the great toe that has been recalcitrant to nonsurgical management. Examination reveals intact sensation with an intractable plantar keratosis (IPK) beneath the first metatarsal head. Motor examination reveals no active ankle or great toe dorsiflexion, and 4/5 plantar flexion strength at the ankle and great toe. Passive ankle dorsiflexion is 10 degrees, whereas passive plantar flexion is 40 degrees. Passive great toe dorsiflexion is 30 degrees and plantar flexion is 10 degrees. Foot alignment on standing is normal. Radiographs are shown in Figures 47a and 47b with a marker beneath the IPK. Based on her request for surgical treatment, what is the most appropriate procedure?

Explanation

DISCUSSION: Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure.
REFERENCES: Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627.
Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.
Richardson EG: Hallucal sesamoid pain: Causes and surgical treatment. J Am Acad Orthop Surg 1999;7:270-278.

Question 82

An Asian 45-year-old man has bilateral upper extremity dysfunction. Figure 35a shows a T2-weighted sagittal MRI scan of the cervical spine, and Figure 35b shows a T2-weighted axial MRI scan at the level of the C3 vertebral body. What is the most likely pathologic process?

Explanation

DISCUSSION: Although relatively common in people of Asian origin, OPLL has been reported in other races as well. The radiographic appearance can be variable as there are different types described, but some of the discerning characteristics are seen in these images. On the sagittal view, the bone posterior to the vertebral body extends along the entire length of C2 and C3. This is characteristic of OPLL, whereas cervical spondylosis and DISH more commonly are not confluent. Ankylosing spondylitis more commonly extends significantly into the spinal canal, and neurofibromatosis generally does not cause any bony growth. The axial view shows a large, oval bony projection into the spinal canal, a typical finding of OPLL.
REFERENCES: McAfee PC, Regan JJ, Bohlman HH: Cervical cord compression from ossification of the posterior longitudinal ligament in non-orientals. J Bone Joint Surg Br 1987;69:569-575.
Kricun R, Kricun ME: MRI and CT of the Spine. New York, NY, Raven Press, 1994,

pp 126-130.

Question 83

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Explanation

When you are employed as a team physician, you are obligated to inform the players and the team organization of all athletically relevant medical issues. This differs significantly from the normal rule of patient confidentiality. If the player came to see you and you were not the team physician, you may not inform the team unless the player so desires. As the team physician, you are not obligated to inform the media.

Question 84

A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months, and has had orthotics and shoe wear changes. What objective findings are indicative of the patient’s ability to heal the wound postoperatively?

Explanation

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.

A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 85

An 83-year-old right-hand-dominant woman sustains a displaced right extra-articular distal radius fracture and is treated with closed reduction and casting. At her 4-week follow-up visit, radiographs demonstrate a volar tilt of -5 degrees and 4 mm of positive ulnar variance. Which treatment is recommended?

Explanation

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 86

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Explanation

DISCUSSION: The soleus is elevated/released from the posterior tibia during the medial approach to allow access to the deep posterior compartment. Release of this compartment cannot be done without proper elevation of the soleus. The superficial posterior compartment mass is primarily located in the proximal half of the leg, while the deep posterior musculature is located in the distal 2/3 of the leg.

Question 87

Early postoperative infections following primary total hip arthroplasty are most likely caused by which organism?

Explanation

DISCUSSION:
S aureus is the most common organism cultured in early (fewer than 4 weeks postoperative) periprosthetic infections. Methicillin-resistant S aureus is becoming a more common pathogen in certain patient populations. B hemolytic Streptococcus and some gram-negative infections can also be found in early postoperative infections. S epidermidis, S viridans, and P acnes are more commonly found in late (more
than 4 weeks postoperative) infections.

Question 88

Which clinical finding most strongly suggests that nonsurgical care should be discontinued and surgical intervention is necessary?

Explanation

DISCUSSION
Epidural abscesses are potentially devastating. Nonsurgical care may be chosen for select patients. A baseline failure rate of 8.3% increases based on patient risk factors, which include a history of IV drug abuse, diabetes, age older than 65, CRP level higher than 115, WBC level higher than 12.5, and Staphylococcus aureus as the causative organism. Immunosuppression and abscess size are not significant risk factors for failure of nonsurgical care. Nonsurgical care may be regarded as "failed" if there is worsening of a patient's neurologic status. When nonsurgical care fails, delayed surgery is less successful at restoring motor function (vs early surgery).
RECOMMENDED READINGS
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 89

An obese 10-year-old boy has had left groin pain and a limp for the past 2 months. Examination reveals decreased abduction and internal rotation. Laboratory studies show normal renal function and an elevated thyroid-stimulating hormone (TSH) level. AP and frog lateral radiographs of the pelvis are shown in Figures 30a and 30b. What is the best course of action?

Explanation

DISCUSSION: The radiographs show a grade I slipped capital femoral epiphysis (SCFE) that is classified as stable because the child is able to bear weight. The elevated TSH level indicates possible hypothyroidism. SCFE usually occurs in boys age 12 to 14 years. Because of the patient’s young age and hypothyroidism, he is at increased risk for slippage of the contralateral hip; therefore, prophylactic pinning of the uninvolved side also should be considered. Because of the risk of slip progression, crutch treatment and nonsteroidal anti-inflammatory drugs are not indicated. Realignment osteotomy is not indicated for grade I SCFE. Traction to reduce the slip, followed by pinning, has been advocated for unstable slips but is not indicated here.
REFERENCES: Loder RT, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Wells D, King JD, Roe TF, Kaufman FR: Review of slipped capital femoral epiphysis associated with endocrine disease. J Pediatr Orthop 1993;13:610-614.

Question 90

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

Explanation

DISCUSSION: In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion. It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so. Pin fixation across the elbow delays early motion and is not recommended. Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition.
REFERENCES: Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma. J Bone Joint Surg Am 1985;67:1261-1269.
Moor TJ: Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury. J Orthop Trauma 1993;7:11-14.

Question 91

Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?

Explanation

DISCUSSION: According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries.
The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time.

Question 92

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Explanation

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 93

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Explanation

DISCUSSION: The radiographic findings show 30 degrees of talar tilt (severe) and 10 mm of anterior translation that typically involves laxity of both of the major lateral ligaments of the ankle (anterior talofibular and calcaneofibular). There is no evidence of deltoid laxity.
REFERENCES: Harper MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle 1992;13:435-438.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.

Question 94

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

Explanation

DISCUSSION: The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2. Philadelphia, PA, WB Saunders, 1993, pp 492-503.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 95

An obese 56-year-old woman with hypertension has had posterior heel pain for the past 6 months. She also notes some enlargement over the posterior aspect of the heel. Examination reproduces pain with palpation at the insertion of the Achilles tendon. A lateral radiograph is shown in Figure 45. What is the most likely diagnosis?

Explanation

DISCUSSION: The lateral radiograph shows a traction spur consistent with tendinopathy of the Achilles tendon. There is no displacement of the spur to suggest a rupture of the Achilles tendon, and os trigonum is not seen on the radiograph. The examination findings are not consistent with nerve entrapment.
REFERENCES: Schepsis AA, Wagner C, Leach RE: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.
Saltzman CL, Tearse DS: Achilles tendon injuries. J Am Acad Orthop Surg 1998;6:316-325.

Question 96

Which of the following genetic disorders has an X-linked recessive inheritance pattern?

Explanation

Hemophilia A is inherited in an X-linked recessive fashion.
linked recessive disorders occur when a mutation occurs on the X chromosome that causes the phenotype to be expressed in males and in females who are homozygous for the gene mutation. These disorders are much more common in males since they only have one X chromosome. Other X-linked recessive disorders include: Duchenne muscular dystrophy, Becker's muscular dystrophy, Hunter's syndrome, and spondyloepiphyseal dysplasia (SED) tarda.
Vanderhave et al. reviewed the orthopaedic consideration in patients with hemophilia. Amongst other things, they discuss arthroplasty in patients with this condition. While they are at higher risk for stiffness and acute hemarthrosis following total knee arthroplasty, ~90-95% of patients have good or excellent results.
Illustration A shows how hemophilia is inherited through a punnett square. Illustration B shows how a weak clotting mechanism causes increased bleeding in patients with hemophilia.
Incorrect Answers:

Question 97

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Explanation

DISCUSSION: The patient has a rupture of the long head of the biceps; however, patients older than age 45 years are at greater risk of having an associated rotator cuff tear. An MRI scan should be ordered to avoid missing concomitant rotator cuff pathology. While patients may report pain radiating down the arm at the time of the tendon rupture, an EMG is not indicated. The short head of the biceps is intact and needs no further work-up, even though the muscle descends in most cases. The anterior labrum can be injured but is not associated with this deformity.
REFERENCES: Neer CS II, Bigliani LU, Hawkins RJ: Rupture of the long head of the biceps related to the subacromial impingement. Orthop Trans 1977;1:114.
Hawkins RJ, Murnaghan JP: The shoulder, in Gruess RL, Ronnie WRJ (eds): Adult Orthopaedics. New York, NY, Churchill Livingstone, 1984, pp 945-1054.

Question 98

..A 60-year-old woman with a history of breast cancer has a rapidly enlarging arm mass. The lesion is situated outside of the prior irradiation field, but within an area of heavy lymphedema involvement. Needle biopsy reveals a high-grade sarcoma. What is the most likely diagnosis?

Explanation

RESPONSES FOR QUESTIONS 96 THROUGH 100
Osteosarcoma
Ewing sarcoma
Langerhans cell histiocytosis (LCH)
Osteomyelitis
Primary lymphoma of bone
Match the condition above to the patient description below.

Question 99

The pharmacologic action of botulinum-A toxin can be best described as

Explanation

DISCUSSION: BotulinumA toxin acts by interfering with presynaptic acetylcholine release at cholinergic nerve terminals without destroying nerve endings, nerve terminals, or neuromuscular junctions. Thus, the toxin blocks neuromuscular control and functionally denervates the muscle.

Question 100

A 54-year-old laborer has a 6-month history of lateral elbow pain. An elbow examination reveals full range of motion, tenderness over the lateral epicondyle, and pain with resisted wrist extension with the elbow in extension. Elbow radiograph findings are normal. You perform a steroid injection and the patient's symptoms are decreased 6 weeks later. One year after receiving the injection, this patient—when compared to a patient who did not have a steroid injection—is likely to

Explanation

EXPLANATION:
This patient has signs and symptoms of lateral epicondylitis. Treatments include various forms of physical therapy, iontophoresis, corticosteroid injection, nitroglycerin patch treatment, blood injections, prolotherapy, and surgical intervention. No single treatment is superior to other treatments for this common problem. Several studies have demonstrated a short-term decrease in symptoms following steroid injection (6 weeks) but an increased likelihood of persistent symptoms 1 year after treatment. Steroid injection at this site has not been associated with increased risk for tendon rupture or need for surgical intervention.

Full Question & Answer Text (for Search Engines)

Question 1:

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Options:

Closed reduction and bracing
Retrograde femoral intramedullary nailing
Open reduction and internal fixation of the fracture, leaving the femoral stem in place
Open reduction and internal fixation of the fracture and insertion of a proximally porous-coated stem
Open reduction and internal fixation of fracture fragments and insertion of a fully porous-coated femoral stem with diaphyseal fixation distal to the fracture

Correct Answer: Open reduction and internal fixation of the fracture, leaving the femoral stem in place

Explanation:

Question 2:

What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

Options:

Enhanced neurogenic adaptations
Advanced myogenic adaptations
Increased contractile proteins
Increased short-term energy sources
Thickening of the connective tissue

Correct Answer: Enhanced neurogenic adaptations

Explanation:

Question 3:

- Which of the following conditions is most likely inherited as an autosomal dominant trait?

Options:

Syndactyly
Macrodactyly
Camptodactyly
Preaxial polydactyly
Postaxial polydactyly

Correct Answer: Postaxial polydactyly

Explanation:

Question 4:

Options:

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

Correct Answer: Medial collateral ligament

Explanation:

Question 5:

Options:

Rotator cuff tear
inadequate strengthening exercises
Instability
Tuberosity nonunion
Prosthetic loosening

Correct Answer: Tuberosity nonunion

Explanation:

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.
Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 6:

Options:

Nonsteroidal anti-inflammatory drugs
MRI of the spine
CT myelography
Flexion-extension plain films

Correct Answer: MRI of the spine

Explanation:

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514.
View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682.
View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 7:

Options:

Calcific tendinitis
Poliomyelitis
Diskogenic cervical spine disease
Impingement
Brachial neuritis

Correct Answer: Brachial neuritis

Explanation:

Question 8:

Options:

Re-evaluate pulses
Vascular surgery consultation
CT angiogram
Formal angiogram
Surgical exploration and stabilization Corrent answer: 1 This patient sustained a posterior ankle fracture/dislocation. After closed reduction and splinting, the next best step should be to re-evaluate pulses. With any dislocation, an immediate closed reduction should be performed. Though the initial vascular examination was abnormal in this case, the dislocation is contributing to this finding. This unique ankle fracture is known as the hyperplantarflexion variant. It is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. Gardner et al. review the hyperplantarflexion variant and found that the fracture of the posteromedial tibial rim was the main feature of this injury which is sustained by a hyperflexion mechanism. They also reported that posterior malleolus fractures are present in a majority of these injuries as well. On MRI they determined that the deltoid and posterior tibiofibular ligaments were intact in all cases. They conclude, when treating these fractures with ORIF of the posteromedial and posterior fragments with antiglide fixation, excellent results were obtained. Hinds et al. name the unique double cortical density at the inferomedial tibial metaphysis the "spur sign." They found the spur sign to be present in 79% of variant ankle fracture cases. They found the positive predictive value and negative predictive value to be 100% and 99%, respectively when this sign is present. Figures A and B demonstrate the hyperplantarflexion variant ankle fracture. Illustration A demonstrates the spur sign, as indicated by the red arrow. Incorrect Answers:

Correct Answer: Surgical exploration and stabilization Corrent answer: 1 This patient sustained a posterior ankle fracture/dislocation. After closed reduction and splinting, the next best step should be to re-evaluate pulses. With any dislocation, an immediate closed reduction should be performed. Though the initial vascular examination was abnormal in this case, the dislocation is contributing to this finding. This unique ankle fracture is known as the hyperplantarflexion variant. It is composed of a posterior tibial lip fracture with posterolateral and posteromedial fracture fragments separated by a vertical fracture line. Gardner et al. review the hyperplantarflexion variant and found that the fracture of the posteromedial tibial rim was the main feature of this injury which is sustained by a hyperflexion mechanism. They also reported that posterior malleolus fractures are present in a majority of these injuries as well. On MRI they determined that the deltoid and posterior tibiofibular ligaments were intact in all cases. They conclude, when treating these fractures with ORIF of the posteromedial and posterior fragments with antiglide fixation, excellent results were obtained. Hinds et al. name the unique double cortical density at the inferomedial tibial metaphysis the "spur sign." They found the spur sign to be present in 79% of variant ankle fracture cases. They found the positive predictive value and negative predictive value to be 100% and 99%, respectively when this sign is present. Figures A and B demonstrate the hyperplantarflexion variant ankle fracture. Illustration A demonstrates the spur sign, as indicated by the red arrow. Incorrect Answers:

Explanation:

OrthoCash 2020

Question 9:

What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?

Options:

Radioscapholunate arthrodesis
Scaphotrapeziotrapezoid arthrodesis
Scaphocapitate arthrodesis
Proximal row carpectomy
Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Correct Answer: Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Explanation:

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion.
REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750.
Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 10:

Options:

Increased ductility
Increased wettability
Diminished fatigue strength
Decreased resistance to abrasive wear

Correct Answer: Diminished fatigue strength

Explanation:

Question 11:

The spinal cord terminates as the conus medullaris at what vertebral level in adults? Review Topic 1 T12

Options:

Correct Answer: L2

Explanation:

The spinal cord anatomy changes at the thoracolumbar junction. The spinal cord terminates as the conus medullaris at the lower portion of L1 in women and the pedicle of L1 in men.

Question 12:

Reamed femoral intramedullary nailing is associated with a higher rate of which of the following, as compared to nonreamed nailing for distal femur fractures?

Options:

Malalignment
Pulmonary complications
Need for transfusion
Iatrogenic fracture
Union

Correct Answer: Malalignment

Explanation:

Question 13:

Options:

Observation, repeat radiographs, and reexamination in 6 weeks
A 14-day course of indomethacin
A 4-week course of indomethacin
Plan for a return to the operating room at 10 weeks for excision of the heterotopic bone
Arrange urgently for 800 centigrey of radiation to the soft tissues and areas of heterotopic bone around the hip, with shielding of the implants

Correct Answer: Observation, repeat radiographs, and reexamination in 6 weeks

Explanation:

DISCUSSION: The development of heterotopic bone occurs early after hip arthroplasty. The process begins within days after surgery; therefore, prophylactic treatment must be in the early postoperative period (preoperative radiation given within 24 hours of surgery, or postoperative radiation given within 72 hours of surgery, or nonsteroidal antiinflammatory drugs (NSAIDs) given postoperatively for 7 to 21 days - longer duration has not been shown to be of any additional benefit). At 6 weeks, prophylactic treatment with NS
AID
s or radiation is no longer effective. Surgery at 10 weeks would be premature because the patient is currently asymptomatic with regards to the heterotopic bone, and surgery prior to full maturation of the bone may increase the risk for more abundant recurrence of bone.
REFERENCES: Balboni TA, Gobezie R, Mamon HJ: Heterotopic ossification: Pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 2006;65:1289-1299. Fransen M, Neal B: Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty. Cochrane Database Syst Rev 2004;3:CD001160.
Neal BC, Rodgers A, Clark T, et al: A systematic survey of 13 randomized trials of non-steroidal antiinflammatory
drugs for the prevention of heterotopic bone formation after major hip surgery. Acta Orthop Scand 2000;71:122-128.

Question 14:

Which of the following cohorts of patients is at highest risk of a future anterior cruciate ligament (ACL) tear? Review Topic

Options:

Men with a hip abduction moment during landing
Men with a neutral hip abduction-adduction moment during landing
Men with varus knee abduction moment during landing
Women with a hip adduction moment during landing
Women with a knee valgus moment during landing

Correct Answer: Women with a knee valgus moment during landing

Explanation:

Question 15:

Options:

bed rest only for 6 weeks.
mobilization in a kinetic therapy bed for 6 weeks, followed by a hyperextension brace.
a total contact thoracolumbosacral orthosis and rapid mobilization.
anterior decompression, vertebral reconstruction, and stabilization.
posterior reduction, stabilization, and grafting.

Correct Answer: a total contact thoracolumbosacral orthosis and rapid mobilization.

Explanation:

Question 16:

Retrograde ejaculation is most commonly associated with what surgical approach?

Options:

Anterior retroperitoneal approach to L5-S1
Anterior transperitoneal approach to L5-S1
Anterior retroperitoneal approach to L4-5
Minimally invasive lateral trans-psoas approach to L4-5
Open lateral approach to L4-5

Correct Answer: Anterior transperitoneal approach to L5-S1

Explanation:

DISCUSSION: Retrograde ejaculation is the sequela of an injury to the superior hypogastric plexus. This structure needs protection, especially during anterior exposure of the lumbosacral junction. Although the superior hypogastric plexus can be injured with anterior or anterolateral spine surgery at any lumbar level, it is most at risk with anterior transperitoneal approaches to the lumbosacral junction. To avoid this complication, the use of monopolar electrocautery should be avoided during deep dissection in this region. The ideal anterior exposure starts with blunt dissection just to the medial aspect of the left common iliac vein sweeping the prevertebral tissues toward the patient’s right side.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983,
p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 17:

Options:

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

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

Explanation:

Question 18:

During particle-induced osteolysis around implants, what cell secretes most of the interleukin-6 (IL-6)?

Options:

Osteoblasts from surrounding bone
B-lymphocytes in the bone marrow
Fibroblastic cells in the periprosthetic lining
T-lymphocytes in the circulating blood
Macrophages in the granuloma

Correct Answer: Fibroblastic cells in the periprosthetic lining

Explanation:

Question 19:

Options:

Open reduction and internal fixation and arterial reconstruction
Crossed pinning with Kirschner wires
Open (Guillotine) finger amputation
Index ray amputation
Application of an external fixator

Correct Answer: Index ray amputation

Explanation:

DISCUSSION: The gunshot wound has caused injury to multiple systems: bone, vascular, skin, and tendon; therefore, the treatment of choice is amputation. An immediate ray amputation allows for a more rapid return to activities and less time off work.
REFERENCES: Peimer CA, Wheeler DR, Barrett A, et al: Hand function following single ray amputation. J Hand Surg Am 1999;24:1245-1248.
Neumeister MW, Brown RE: Mutilating hand injuries: Principles and management. Hand Clin 2003;19:1-15.

Question 20:

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of Review Topic

Options:

an arm sling.
nonsteroidal anti-inflammatory drugs and a rapid return to activity.
arthroscopic partial claviculectomy.
acromioclavicular joint reduction and stabilization.
acromionectomy.

Correct Answer: acromioclavicular joint reduction and stabilization.

Explanation:

Question 21:

Options:

A locked plate construct (locked screws) or hybrid construct (locked and non-locked screws) is necessary.
Periosteal stripping is performed through two incisions proximal and distal to the fracture.
Bridge plating is performed following direct reduction of the fracture.
AO Type A diaphyseal fractures are best treated with this technique.
Bridge plating with a long working length creates a flexible, axially stable construct.

Correct Answer: A locked plate construct (locked screws) or hybrid construct (locked and non-locked screws) is necessary.

Explanation:

Question 22:

- 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 23:

-In the shoulder position of 90-degree forward flexion and internal rotation, what is the most important static stabilizer of the glenohumeral joint?

Options:

Rotator interval
Infraspinatus
Anterior band of the inferior glenohumeral ligament
Posterior band of the inferior glenohumeral ligament DISCUSSION -In the position of 90 degrees forward flexion and internal rotation, the most important static stabilizer of the glenohumeral joint is the posterior band of the inferior glenohumeral ligament. This position places the posterior-inferior glenohumeral ligament in an anterior-posterior direction and under tension. The superior glenohumeral ligament and the middle glenohumeral ligament provide static stability in the fully adducted and midrange-adducted positions, respectively. The subscapularis and infraspinatus provide primarily dynamic stability to the glenohumeral joint. Though not fully clear, the rotator interval appears to provide more static stability with the arm adducted, limiting inferior and posterior translation, and less so in the forward flexion and internal rotation position.

Correct Answer: Posterior band of the inferior glenohumeral ligament DISCUSSION -In the position of 90 degrees forward flexion and internal rotation, the most important static stabilizer of the glenohumeral joint is the posterior band of the inferior glenohumeral ligament. This position places the posterior-inferior glenohumeral ligament in an anterior-posterior direction and under tension. The superior glenohumeral ligament and the middle glenohumeral ligament provide static stability in the fully adducted and midrange-adducted positions, respectively. The subscapularis and infraspinatus provide primarily dynamic stability to the glenohumeral joint. Though not fully clear, the rotator interval appears to provide more static stability with the arm adducted, limiting inferior and posterior translation, and less so in the forward flexion and internal rotation position.

Explanation:

CLINICAL SITUATION FOR QUESTIONS 48 AND 49
A 17-year-old high school wrestler sustains an abrasion over the posterior aspect of his right elbow during a match. During the next few days the abrasion becomes erythematous and he is placed on oral cephalexin 500 mg four times per day. The erythema extends proximally despite the antibiotic regimen. The patient is afebrile, there is no fluid collection associated with the lesion, and his elbow joint is not involved.

Question 24:

Which structure is the primary stabilizer of the lesser metatarsophalangeal (MTP) joint?

Options:

Flexor digitorum brevis
Flexor digitorum longus
Plantar plate
Collateral ligament

Correct Answer: Plantar plate

Explanation:

DISCUSSION
Synovitis of the second MTP occurs in association with instability of the joint. This can be idiopathic or secondary to an external deforming force (such as a hallux valgus or shoe wear causing a claw toe). The primary stabilizer of the MTP joint for translation in the vertical plane is the plantar plate. The flexor digitorum brevis flexes the MTP joint, and the flexor digitorum longus flexes
all joints of the toe. The collateral ligaments are primary stabilizers in the transverse plane and secondary stabilizers in the sagittal plane.
RECOMMENDED READINGS
Deland JT, Sung IH. The medial crosssover toe: a cadaveric dissection. Foot Ankle Int. 2000 May;21(5):375-8. PubMed PMID: 10830654.
View Abstract at PubMed
Suero EM, Meyers KN, Bohne WH. Stability of the metatarsophalangeal joint of the lesser toes: a cadaveric study. J Orthop Res. 2012 Dec;30(12):1995-8. doi: 10.1002/jor.22173. Epub 2012 Jun 13. PubMed PMID: 22696467.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 91 THROUGH 95
Figure 91a is the sagittal plane ultrasound of the second web space of a 48-year-old woman who has noted burning pain in the ball of her right foot for 2 years. The pain intermittently radiates into her second and the third toes. Figure 91b shows the surgical procedure and Figure 91c is the pathologic specimen.
A
B
C

Question 25:

Options:

splinting and injections for carpal tunnel syndrome.
scaphoid excision and four-bone fusion.
proximal row carpectomy via dorsal and volar incisions.
MRI of the wrist.
carpal tunnel release.

Correct Answer: proximal row carpectomy via dorsal and volar incisions.

Explanation:

Question 26:

Options:

Chevron osteotomy to correct hallux valgus
Custom orthosis to prevent further deformity
Observation only
Steroid injection to decrease inflammation
Extra-depth shoes

Correct Answer: Chevron osteotomy to correct hallux valgus

Explanation:

Question 27:

Options:

Thompson
Cotton
Squeeze
Anterior drawer

Correct Answer: Cotton

Explanation:

DISCUSSION
Following ORIF of a known osseous injury, stress testing of the syndesmosis is recommended, especially for pronation-external rotation injuries. The Cotton test applies a laterally directed force to the fibula to assess for widening of the distal tibiofibular joint space. A positive Cotton test result indicates that syndesmotic stabilization is indicated. The Thompson test is used to determine Achilles tendon integrity. The squeeze test is a clinical, not intraoperative, assessment of syndesmotic injury. The anterior drawer test assesses the integrity of the anterior talofibular ligament.
RECOMMENDED READINGS
Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.
View Abstract at PubMed
Pakarinen H, Flinkkilä T, Ohtonen P, Hyvönen P, Lakovaara M, Leppilahti J, Ristiniemi J. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. doi: 10.2106/JBJS.J.01287. PubMed PMID:

Question 28:

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

Options:

no patellar complications.
an increased occurrence of anterior knee pain.
a reduced patellar fracture rate.
a reduced risk for revision surgery.

Correct Answer: a reduced risk for revision surgery.

Explanation:

Question 29:

Options:

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

Correct Answer: Anterior cord syndrome

Explanation:

Incomplete cord syndromes have variable neurologic findings with partial loss of sensory and/or motor function below the level of injury. Incomplete cord syndromes include the anterior cord syndrome, the Brown-Séquard syndrome, central cord syndrome, and posterior cord syndrome. Central cord syndrome is characterized with greater motor weakness in the upper extremities than in the lower extremities. The pattern of motor weakness shows greater distal involvement in the affected extremity than proximal muscle weakness. Anterior cord syndrome involves a variable loss of motor function and pain and/or temperature sensation, with preservation of proprioception. The Brown-Séquard syndrome involves a relatively greater ipsilateral loss of proprioception and motor function, with contralateral loss of pain and temperature sensation. Posterior cord syndrome is a rare injury and is characterized by preservation of motor function, sense of pain, and light touch, with loss of proprioception and temperature sensation below the level of the lesion. Spinal shock is the period of time, usually 24 hours, after a spinal injury that is characterized by absent reflexes, flaccidity, and loss of sensation below the level of the injury.
(SBQ13PE.25) A 7-year-old girl presents with a early onset scoliosis as seen in the PA radiograph in Figure A. Images do not demonstrate any vertebral anomalies. Physical exam shows normal neurologic function in her lower extremities. An MRI of the spinal axis should be obtained to rule out all of the following pathologies EXCEPT:
Review Topic
Atlantoaxial rotatory instability
Syringomyelia
Spinal cord tumor
Dysraphism
Tethered cord
Early-onset scoliosis is associated with syringomyelia, spinal cord tumor, dysraphism, and tethered cord, and therefore they must be ruled out with a preoperative MRI. There is no association between early-onset scoliosis and atlantoaxial rotatory instability.
Early-onset scoliosis can be classified as idiopathic, neuromuscular, or congenital. For this patient without bony or neurologic abnormalities, it would likely be diagnosed as juvenile (bewteen ages 3 and 10 years) idiopathic scoliosis. Commonly associated spinal pathologies (even in patients with no radiographic or neurologic abnormalities) include syringomyelia, spinal cord tumor, dysraphism, tethered cord, and Arnold-Chiari malformation. Before considering any surgical intervention, such as a growing rod construct, these intra-spinal conditions must be ruled-out with an MRI of the spinal axis.
Gillingham et al. present a review of the etiology, diagnosis, and management of early-onset scoliosis. They cite other studies that demonstrated rates as high as 21% of patients with early-onset scoliosis and a normal neurologic exam having occult spinal pathology such as those mentioned above. They recommend MRI for patients with early-onset scoliosis measuring greater than 20° prior to any surgical intervention.
Figure A is a PA radiograph of a skeletally immature patient with a 90° right thoracic curve. Illustration A is an PA radiograph of the same patient after treatment with a growing-rod construct and correction of the scoliotic curve to 46°.
Incorrect Answers:

Question 30:

Options:

Single posterior Y plate
Single medial plate with bicortical locking screws
Dual plating with medial and posterolateral LC-DCP
Dual plating with medial and posterolateral one third tubular plates
Dual plating with medial and lateral LC-DCP

Correct Answer: Dual plating with medial and lateral LC-DCP

Explanation:

Question 31:

Options:

Primary repair of injured structure
Primary repair of injured structure combined with anterior and medial tibial tubercle transfer
Immobilization of knee in full extension with a progressive weight-bearing exercise program
Semitendinosus or gracilis tendon autograft reconstruction of the injured structure
CT angiography followed by primary repair of injured structure if the limb has vascular stability

Correct Answer: CT angiography followed by primary repair of injured structure if the limb has vascular stability

Explanation:

Question 32:

Based on the image findings, what is the most likely diagnosis?

Options:

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

Correct Answer: Preiser’s disease

Explanation:

The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis. Preiser’s disease is osteonecrosis typically involving most or all of the scaphoid. Kienbock’s disease involves the lunate. Intraosseous ganglia are easily diagnosed on MRI but typically have a fluid-filled area surrounded by denser bone in the periphery. Scapholunate dissociation can be seen on MRI as an injury to the scapholunate ligament and widening of the scapholunate interval, neither of which is seen on this image.
Which of the following describes the correct proximal to distal progression of the annular and cruciform pulleys of the digits?
A1, C1, A2, C2, A3, A4, C3
A1, A2, A3, C1, C2, C3, A4
A1, C1, C2, A2, A3, A4, C3
A1, A2, C1, A3, C2, A4, C3
A1, A2, A3, A4, C1, C2, C3
The correct progression of the annular and cruciform pulley in the digits is A1, A2, C1, A3, C2, A4, C3. The two cruciform pulleys are collapsible elements adjacent to the more rigid annular pulleys of the flexor tendon sheath. This arrangement enables unrestricted flexion of the proximal interphalangeal joint.
In Dupuytren’s disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?
Palmarly and radially
Dorsally and ulnarly
Palmarly and ulnarly
Dorsally and radially
Directly dorsal
CORRECT ANSWER: 3
Retrovascular cords are common in Dupuytren’s disease and commonly require surgical treatment. Nerve injury in Dupuytren’s surgery is an
infrequent complication that occurs partly because the digital nerves can be displaced from their normal anatomic relationships by retrovascular cords. The nerves are displaced superficially, toward the center of the digit (palmarly and ulnarly). This displacement is typically seen at the level of the metacarpophalangeal joint.
Ganglion cysts about the wrist most commonly arise from what structure?
First carpometacarpal joint
Second carpometacarpal joint
Scapholunate interosseous ligament
Radioscaphocapitate ligament
Capitohamate interosseous ligament
Ganglion cysts are the most common mass or mass-like lesions seen in the hand and wrist. They arise in a variety of locations, including synovial joints or tendon sheaths. The most common location is the dorsal/radial wrist arising from the dorsal scapholunate interosseous ligament.
Spontaneous entrapment of the posterior interosseous nerve most commonly occurs in which of the following locations?
Lateral intermuscular septum
Extensor carpi radialis brevis
Arcade of Frohse
Midsubstance of the supinator
Leash of Henry
CORRECT ANSWER: 3
The extensor carpi radialis brevis, supinator muscle, arcade of Frohse, and leash of Henry are potential sites of compression for the posterior interosseous nerve. The most common location of spontaneous entrapment is the arcade of Frohse. The lateral intermuscular septum is a site of compression for the radial nerve.
A 45-year-old carpenter complains of difficult gripping a hammer, which worsens with repeated use. On physical exam, he is able to passively flex the proximal interphalangeal (PIP) joint when the metacarpophalangeal (MCP) joint is flexed but not when the MCP joint is extended. What is the most likely explanation?
Quadrigia effect
Extrinsic tightness
Intrinsic tightness
Central slip rupture
Lumbrical plus
CORRECT ANSWER: 3
The patient exhibits a positive Bunnell test, indicative of intrinsic tightness, which commonly affects those who use objects that require repetitive grip.
Bunnell (intrinsic tightness) test is performed and is positive when there is a loss of PIP flexion when the MCP joint is extended; with the MCP flexed, PIP motion is typically normal.
Espiritu et al. performed a cadaveric study to quantitatively assess the amount of release needed to overcome intrinsic tightness. Index, middle, ring, and little fingers regained flexion following release of 59%, 65%, 26%, and 33% of each extensor hood, respectively.
Lee and Gellman review their preferred methods of operative treatment of specific intrinsic deformities caused by intrinsic tightness.
Video 1. A clinical example on how to perform the Bunnell test for intrinsic tightness.
Incorrect answers:
A 33-year-old woman reports a mass on the right hand that has been enlarging for 1 year. An intraoperative photograph is shown in Figure 28a, and a biopsy specimen is shown in Figure 28b. What is the most likely diagnosis?
Ganglion cyst
Abscess
Hematoma
Giant cell tumor of tendon sheath
Synovial sarcoma
CORRECT ANSWER: 4
Giant cell tumor of the tendon sheath is the most common solid soft-tissue mass in the hand. These tumors are slow-growing and may be present for months or years before coming to medical attention. Patients usually report
mechanical difficulties because of the size or position of the tumor. The gross appearance is that of a lobulated mass that may be multicolored; typically yellow, brown, red, and gray. Histologically the lesion consists of multinucleated giant cells, polygonal mononuclear cells, and histiocytes that may contain abundant hemosiderin or lipid.
A 58-year-old woman has had a slowly progressing mass over the distal interphalangeal (DIP) joint of her dominant hand with a worsening deformity of her nail. She has no significant medical history but underwent bilateral knee arthroplasties 1 year ago. Radiographs reveal a small osteophyte at the DIP joint dorsally. A clinical photograph and a biopsy specimen are shown in Figures 76a and 76b. What is the most likely diagnosis?
Metastatic lung carcinoma
Mucous cyst
Synovial sarcoma
Inclusion cyst
Felon abscess
CORRECT ANSWER: 2
A mucous cyst is thought to be a ganglion arising from the DIP joint in patients with osteoarthritis. They are frequently associated with nail deformities.
Treatment involves removal of the cyst with debridement of DIP joint osteophytes.
A patient has carpal tunnel syndrome that requires surgical release. The patient wants to know about the risks and benefits of the various surgical techniques for carpal tunnel release because they have read that an endoscopic technique is the best. What is the most significant advantage of endoscopic release over traditional open release?
Decreased rate of nerve complications
Decreased postoperative pain and analgesic use
Decreased rate of recurrence of carpal tunnel symptoms
Lower rate of vascular complications
Lower infection rate
CORRECT ANSWER: 2
Carpal tunnel release is usually performed in one of two ways: open or endoscopically. There has always been great controversy and differing opinions about the advantages and disadvantages of either technique. Recent prospective randomized trials have shown that the primary advantage of the endoscopic technique is decreased pain in the postoperative period. A lower rate of vascular complications was not observed in these most recent studies. Likewise, nerve injury and infection rates were not different in these studies.
All of the following structures are components of the triangular fibrocartilage complex. What structure is considered the most important restraint of dorsal/palmar translation of the radius on the ulna?
Triangular articular disk
Dorsal and palmar radioulnar ligaments
Ulnolunate ligament
Ulnotriquetral ligament
Subsheath of the sixth extensor compartment
Clinical examination of the distal radioulnar joint is frequently described as translation of the ulnar head in reference to the radius. This description is incorrect, since the ulna is the bone that is fixed in space. Anatomically speaking, the radius moves in relation to the fixed ulna. The triangular fibrocartilage complex is composed of all of the structures listed above. The articular disk is a meniscal-like structure that serves a load-bearing function between the ulnar carpal bones and the ulnar head. About 20% of the load borne across the wrist passes through the disk. It has almost no ligamentous (stabilizing) function. At the dorsal and volar margins of the articular disk are thickened true ligamentous ligaments termed the radioulnar ligaments. They take origin from the foveal area of the ulnar head and styloid and insert into the dorsal and volar margins of the sigmoid notch. These two ligaments serve as primary restraints to dorsal and palmar translation of the radius on the ulna. The ulnolunate ligament, ulnotriquetral ligament, and the subsheath of the sixth extensor compartment are ligaments, but they serve to stabilize the carpus to the ulna and radius. They provide minimal stability to the distal radioulnar joint.
Replantation is indicated for which of the following amputations.
multiple level amputation of the small finger at the proximal and distal interphalangeal joints
crushed amputation through the distal phalanx of the middle finger
complete ring avulsion of the ring finger with tendon injury
thumb amputation though the proximal phalanx shaft
middle finger amputation though the proximal phalanx shaft
As outlined by Pederson, the contraindications to replantation are more relative than the indications, but they include the following: Single-finger replantations at the level of zone II (from the A1 pulley to the distal sublimis tendon insertion) are rarely indicated, with the notable exception of the thumb. Amputated parts that are severely crushed and those with multiple
level injuries have poor function even if they survive replantation. While ring avulsion injuries with a vascular injury and no bone, tendon or nerve injury (Urbaniak type 2A ring avulsion injuries) should be repaired, ring avulsion injuries with bone, tendon or nerve injury (Urbaniak type 2B) or with complete degloving (Urbaniak type 3) have poor outcomes and Urbaniak and colleagues recommend amputation for such injuries. Very distal amputations at the level of the nail bed are marginally indicated as there needs to be approximately 4 mm of intact skin proximal to the nailfold for adequate veins to be present.
Indications for replantation that rule out the other 4 choices of this question include the following: Overall, thumb replantation probably offers the best functional return. Even with poor motion and sensation, the thumb is useful to the patient as a post for opposition. A replanted thumb offers the best reconstruction available, toe transfers notwithstanding. Replantation beyond the level of the sublimis tendon insertion (zone I) usually results in good function. Multiple finger amputations present reconstructive difficulties that may be difficult to correct without replantation of one or all of the amputated digits. Any hand amputation from zone III (distally) to zone V (proximally) offers the chance of reasonable function after replantation, usually superior to available prostheses. Although usually indicated, the replantation of any hand or arm proximal to the level of the mid-forearm must be carefully considered.
Figure 14a shows the radiograph of a 19-year-old man who hurt his little finger while falling off his bicycle. A closed reduction of the proximal interphalangeal (PIP) joint is performed in the emergency department. Postreduction radiographs are shown in Figures 14b and 14c. When the PIP joint is put through a range of motion, the middle phalanx redislocates when fully extended. What is the next most appropriate step in management?
Extension block splinting for 3 weeks
Volar plate arthroplasty
Open reduction and internal fixation of the middle phalanx base
Superficialis tendon repair through bone tunnels
Dynamic external fixation

Question 33:

What structure is marked Q in the diagram of the brachial plexus shown in Figure 22?

Options:

Medial cord
Lateral cord
Posterior cord
Upper trunk
Lower trunk

Correct Answer: Posterior cord

Explanation:

Question 34:

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Options:

Interosseous ligament
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Deltoid ligament
Tibiotalar ligament

Correct Answer: Interosseous ligament

Explanation:

Question 35:

Options:

Hip arthroscopy with labral repair, rim trimming and femoral osteochondroplasty
Hip arthroscopy with labral repair and periacetabular osteotomy with femoral osteochondroplasty
Open surgical hip dislocation with labral repair, rim trimming and femoral osteochondroplasty
Hip arthroscopy with labral repair and reverse periacetabular osteotomy with femoral osteochondroplasty The radiographs show a large cam lesion on the anterosuperior aspect of the femoral head, and this is confirmed by high alpha angle (76). Cam and pincer lesions commonly cause labral tears and lead to femoroacetabular impingement. After failure of nonoperative treatment, surgery involves hip arthroscopy, labral repair or debridement, rim trimming (resection of acetabulum), and femoral osteochondroplasty. A periacetabular osteotomy is the preferred surgery in dysplastic patients. Dysplasia is defined as undercoverage of the femoral head, typically a center-edge angle <25. Reverse periacetabular osteotomy is used for a true retroverted acetabulum. Lastly, open dislocation is the preferred method when the hip deformity is too severe to treat arthroscopically or when the femoral head is significantly overcovered by the acetabulum (center-edge angle >40).

Correct Answer: Open surgical hip dislocation with labral repair, rim trimming and femoral osteochondroplasty

Explanation:

Question 36:

In overhead athletic activities, the kinetic chain generates what percentage of force from the leg and trunk segments of the chain?

Options:

20% to 30%
30% to 40%
50% to 60%
60% to 70%
80% to 90%

Correct Answer: 50% to 60%

Explanation:

Question 37:

Options:

Exostectomy
Lateral column lengthening
Medial slide calcaneal osteotomy
Talonavicular arthrodesis
Triple arthrodesis

Correct Answer: Triple arthrodesis

Explanation:

DISCUSSION: The deformity is long-standing, the hindfoot is immobile, and the radiographs reveal severe degenerative arthritis involving the entire hindfoot, severe deformity, and talonavicular dislocation. The “exostosis” responsible for the callus is the talar head; resection would severely destabilize the foot. Degenerative arthritis and fixed deformity preclude lateral column lengthening, medial slide calcaneal osteotomy, and talonavicular arthrodesis. Triple arthrodesis is the only viable option.
REFERENCES: Johnson JE, Yu JR: Arthrodesis techniques in the management of Stage II and III acquired adult flatfoot deformity. Instr Course Lect 2006;55:531-542.
Pinney SJ, Lin SS: Current concept review: Acquired adult flatfoot deformity. Foot Ankle Int 2006;27:66-75.

Question 38:

Options:

Haemophilus influenzae and Staphylococcus aureus
Kingella kingae and Streptococcus pneumoniae
Staphylococcus aureus and Salmonella
Streptococcus pneumoniae and Staphylococcus aureus
Salmonella and Shigella

Correct Answer: Staphylococcus aureus and Salmonella

Explanation:

Question 39:

Options:

Medial collateral ligament repair
Medial collateral ligament reconstruction
Hinged external fixation
Lateral collateral ligament repair
Lateral collateral ligament reconstruction

Correct Answer: Lateral collateral ligament reconstruction

Explanation:

Question 40:

Options:

Anterior shoulder dislocation
Humeral component loosening
Glenoid component loosening
Glenoid component catastrophic fracture
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.
REFERENCES: Hattrup SJ, Cofield RH, Cha SS: Rotator cuff repair after shoulder replacement. J Shoulder Elbow Surg 2006;15:78-83.
Sperling JW, Potter HG, Craig EV, et al: Magnetic resonance imaging of painful shoulder arthroplasty. J Shoulder Elbow Surg 2002;11:315-321.

Question 41:

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Options:

First rib
Intra-articular disk ligament
Costoclavicular ligament
Interclavicular ligament
Posterior sternoclavicular joint capsule

Correct Answer: Posterior sternoclavicular joint capsule

Explanation:

DISCUSSION: Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint.
REFERENCES: Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 42:

Options:

removal of all hardware.
temporary placement of antibiotic beads.
wound closure over drains.
bedside dressing changes.
a RAST test for latex allergy.

Correct Answer: wound closure over drains.

Explanation:

Question 43:

Options:

iliac crest bone grafting
ring metacarpal transposition
second toe transfer
index metacarpal transposition
suture of deep transverse intermetacarpal ligaments

Correct Answer: iliac crest bone grafting

Explanation:

Index metacarpal transposition is indicated to reduce the space left between the index and ring finger. In this case, the middle ray is amputated because of malignancy.
With amputation of the middle or ring metacarpals, small objects fall through the gap and the adjacent fingers scissor. For single central ray defects, techniques to reduce the gap include transposition of the index finger (for middle ray amputation), small finger (for ring ray amputation), complete removal of the metacarpal (without leaving a proximal metacarpal base stump) to allow the bases of index and ring metacarpals to migrate together and reconstruction of the deep transverse metacarpal ligament. The technique of index transposition may vary depending on the osteotomy (straight vs step-cut) and fixation (K wires vs plate) as seen in the illustrations below.
Muramatsu et al. describe bony transposition for reconstruction after ray amputation for malignancy. The advantage is immediate closure of the space. The disadvantages include prolonged postoperative immobilization until union, malrotation (leading to scissoring), mal-tension of tendon (because of different metacarpal heights), and delayed or nonunion.
Lyall et al. advocate total middle ray amputation. They believe that leaving the metacarpal base behind leads to difficulty in aligning the adjacent rays as the index and ring must angulate over the bony obstruction to close the distal gap, leading to scissoring. They believe that index transposition leaves an abnormally wide 1st web space and a remnant 2nd metacarpal stump that can protrude dorsally.
Figure A is an AP radiograph of the right hand showing a destructive lesion of the proximal phalanx of the middle finger abutting the metacarpophalageal joint. Figure B is a STIR coronal MRI image showing the tumor mass extending into surround soft tissue. Illustration A is a diagram showing index transposition for middle ray amputation using a straight osteotomy and crossed K-wires. Illustration B is a diagram showing index transposition using a step-cut osteotomy and multiple K-wire fixation to the adjacent metacarpals. Illustration C is a diagram showing index transposition using a straight osteotomy and plate fixation. Illustration D is a diagram showing an alternative technique of suturing deep transverse metacarpal ligaments together to close the gap.
Incorrect Answers
A 65-year-old man fell and injured his right wrist. Radiographs taken in the emergency room are seen in Figure A. He was treated as a sprain and no further follow-up was planned. He sustained 2 minor falls over the next 6 years and his wrist pain recurred. Recent radiographs are seen in Figure B. Surgical treatment that will best address his symptoms and preserve wrist motion consists of
Anterior and posterior interosseous neurectomy
Scaphotrapezialtrapezoidal (STT) fusion
Complete wrist arthrodesis
Proximal row carpectomy
Four-corner fusion with scaphoidectomy
Four-corner fusion with scaphoidectomy is indicated for Stage III SLAC wrist.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease (scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This procedure can also be done in addition to other bony procedures for Stages II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis with proximal migration of the capitate into the scapholunate interval) is treated with either scaphoidectomy with 4CF or total wrist fusion.
Some other conditions exist: If capitolunate arthritis exists, PRC is contraindicated and 4CF is performed. If radiolunate arthritis exists, both PRC and 4CF are contraindicated and total wrist fusion is performed. If both radiolunate and capitolunate surfaces are preserved, then either PRC or a 4CF may be performed.
Cohen et al. compare PRC with 4-corner fusion plus scaphoid excision. PRC is technically easier, but leads to shortening of the carpus with weakness and incongruity exists between the capitate and lunate fossa of the distal radius. Scaphoid excision and four-corner fusion maintains carpal height and preserves the radiolunate relationship, but is more technically demanding, there is risk of nonunion, and it requires longer postop immobilization. Pain relief is more reliable following 4-corner fusion.
Figure A shows scapholunate ligament disruption. Figure B shows late stage SLAC wrist. There is capitolunate arthritis but no radiolunate arthritis.
Illustration A shows an example of PRC. Illustration B shows an example of 4CF and scaphoidectomy.
Incorrect Answers
Which of the following statements is true regarding zone II flexor tendon injuries?
At this level, FDS and FDP are located within separate tendon sheaths
FDS repair has not been shown to improve outcomes
Improved gliding is seen with repair of 1 slip of FDS compared to repairing both slips
Repairing FDS does not affect post-operative digit strength
FDP repair has not been shown to improve outcomes
In zone II flexor tendon injuries, repairing only one slip of FDS has been shown to improve gliding when compared to repair of both slips.
Zone II flexor tendon injuries have notoriously had poor outcomes secondary to high rates of adhesion formation at the pulleys. However, new advances in post-operative rehabilitation have significantly improved outcomes to the point where it is no longer considered "no man's land." Management of the FDS has been a source of controversy. In the past, the FDS was occasionally excised to theoretically make more room for the FDP. This has now been largely abandoned and the FDS is repaired whenever possible. Whether or not to repair both slips of FDS remains controversial, with in vitro data suggesting that gliding resistance is improved if only one slip is repaired.
Zhao et al. review the effect of partial vs. complete FDS excision following repair of FDP for zone II flexor tendon injuries. Preserving the whole FDS resulted in a significantly larger increase in gliding resistance after FDP repair than did full or partial FDS removal, which were not significantly different from each other.
Illustration A shows the zones of flexor tendon injury. Note that zone II injuries occur between the FDS insertion and the distal palmar crease. Illustration B shows the anatomy of the flexor tendons in detail. Video V shows a technique for repair of zone II injuries.
Incorrect Answers:
A 6-year-old girl sustains transverse amputations through her long and ring fingertips after getting her hand caught in a lawn mower. She presents to the emergency room 30 minutes after the injury with the amputated tissue which was placed on ice in a waterproof bag. On physical exam the amputation levels are found to be 6 millimeters distal to the lunula. The wounds are noted to be fairly
contaminated with no evidence of exposed bone. Skin defects are less than 1 centimeter. Which of the following is the most appropriate management at this time?
Emergent replantation of the amputated parts
Revision amputation through the distal interphalangeal joint
Thorough irrigation and debridement followed by elective Moberg advancement flaps
Thorough irrigation and debridement followed by elective Z-plasty reconstruction
Thorough irrigation and debridement, soft dressing application, and followup within 1 week
Distal fingertip amputations can be successfully managed with local wound care and healing by secondary intention if no bone is exposed and the soft tissue defects are minimal. This is especially true in the pediatric population.
Distal fingertip amputations are common injuries seen in the emergency department. If bone is not exposed, the wounds can be successfully treated with local wound care and dressing changes, followed by soaks in a hydrogen-peroxide solution after 7-10 days. Some controversy exists in the pediatric population if the soft tissue loss is > 1 cm, with options for management including a V-Y advancement flap or conservative management with dressing changes.
Quell et al. review the results of 82 patients with fingertip amputations treated conservatively; 31 of the digits were treated with primary closure with or without shortening of bone and 54 digits were treated with semiocclusive dressings. No complications were observed, and all healed fingertips were well padded and painless.
Tupper et al. review sixteen patients with twenty fingertip injuries who underwent V-Y plasty for transverse fingertip amputations. Sensitivity was 73% of normal, with eight patients reporting hypersensitivity. Contrary to popular belief, they believe normal sensation following a V-Y plasty is not a reasonable expectation.
Illustration A shows the three levels of fingertip amputations. Zone I is distal to the phalanx; Zone II is distal to the lunula; and Zone III is proximal to the lunula.
Incorrect Answers:
Which of following malformations is most commonly associated with Poland's syndrome?
Figure E
CORRECT ANSWER: 4
Figure D demonstrates symbrachydactyly which is most commonly associated with Poland's syndrome.
Poland's syndrome is a rare birth defect characterized by underdevelopment or absence of the chest muscle in conjunction with ipsilateral symbrachydactyly. Poland syndrome most often affects the right side of the body, and occurs more often in males than in females.
Ireland et al. reviewed 43 consecutive cases of Poland's syndrome, and reviewed the relevant literature up to that point. The authors state that the clinical features are variable but always include congenital aplasia and syndactyly, and the right side is affected more than the left. They also note that although the hand remains hypoplastic and functional capacity is limited by the inherent skeletal anomalies, surgical treatment improves functional capacity and cosmetic appearance in the majority of patients.
Van Heest summarizes normal formation and growth of the upper limb as a basis for understanding malformation, with the goal of providing a basic understanding of the evaluation necessary for appropriate counseling and referrals for treatment of the child with hand and upper extremity congenital deformities.
Incorrect Answers:
A 55-year-old male laborer comes in with a chief complaint of clumsiness with his right hand for the past 3 months including difficulty using a hammer while at work. He has had no injury to the right upper extremity. On physical examination, he has persistent small finger abduction/extension with finger extension and active adduction. An EMG is performed and demonstrates ulnar nerve conduction velocities of 31 m/sec (normal >52m/sec). The patient symptoms are most accurately described as:
Axonotmesis with ischemia origin
Axonotmesis with myelin disruption
Neurapraxia with ischemia origin
Neurapraxia with endoneurium disruption
Neurotmesis
CORRECT ANSWER: 3
The history and clinical presentation are consistent with ulnar entrapment neuropathy at the level of the cubital tunnel. This would be classified as a neuropraxia with ischemia origin.
Compression injuries to the peripheral nerves are often the result of microvascular dysfunction as the nerves traverse a high to low pressure gradient. Peripheral nerve injury can be classified as neuropraxia, axonotmesis, and neurotmesis. Compressive neuropathies are typically neuropraxias, with local myelin damage but not compromise of the major components of the nerve. In axonotmesis, there is Wallerian degeneration and myelin loss distal to the site of injury. The most severe type is that of neurotmesis. Neurotmesis is composed of a spectrum of injury in which the endoneurium is always disrupted (perineurium or epineurium may be intact). The worst form of neurotmesis is that of nerve transection.
Elhassan et al. review the pathophysiology of cubital tunnel syndrome. They report nerve dysfunction results from ischemic changes secondary to compression. Compressive effects on the nerves can last greater than 24 hours, even after the source of compression has been removed.
Rempel et al. review the pathophysiology of peripheral nerve compression syndromes. The authors indicate that deforming pressures to nerves are often the result of stenotic soft tissue canal boundaries. This leads to interference with local microvasculature of the nerve itself.
Illustration A demonstrates the Wartenberg sign, where the patient has persistent small finger abduction/extension resulting from weakness of the 3rd palmar interosseous/small finger lumbrical.
Illustration B reveals clawing which results from overpowering of the intrinsic muscles by the extrinsic muscles; a tenodesis effect results in flexion of the PIP/DIP joints. This is more severe in ulnar nerve compression at Guyon’s canal. Illustration C shows the Froment sign, where the FPL attempts to compensate for a deficient pinch, because of weakness of the adductor pollicis. Illustration D demonstrates atrophy of the 1st dorsal webspace from chronic compressive changes. Illustration E demonstrates atrophy of the thenar compartment which is consistent with carpal tunnel syndrome.
Incorrect Answers:
Which of the following hand injuries seen in Figures A-E is most appropriately treated with a first dorsal metacarpal artery flap?
Figure E
CORRECT ANSWER: 3
Figure C shows a dorsal thumb laceration with exposed tendon that would be most appropriately treated with a first dorsal metacarpal artery (FDMA) flap.
The first dorsal metacarpal artery is a branch of the radial artery that supplies the dorsal hand skin from the thumb metacarpal to the long metacarpal, as well as the skin on the dorsal surfaces of the thumb and index to the proximal interphalangeal joint. The flap is raised distal to proximal as an island flap containing the FDMA, branches of the radial nerve, fascia of the underlying interosseous muscle of the first web space, and skin overlying the MP joint and proximal phalanx of the finger. It is an excellent option for large soft tissue defects on either side of the thumb. In this case, skin grafting is contraindicated because of exposed tendon without paratenon.
Sherif et al. detail the anatomy of the first dorsal metacarpal artery. They found three consistent branches, including the radial, ulnar, and intermediate branch. In part II of their study, they review the results of 23 patients where the FDMA flap was used as a fasciocutaneous or fascial flap for the coverage of soft tissue hand defects.
Illustration A shows a FDMA flap being raised for coverage of a thumb defect. Incorrect Answers:
bone can be allowed to heal through secondary intention.
Figure A is a radiograph of a 35-year-old women who sustained an isolated left wrist injury after a fall onto an outstretched hand. She has been complaining of left dorsal wrist pain since the fall. Examination reveals a positive Watson's scaphoid shift test. What ligamentous structure is an important secondary stabilizer to prevent dorsal intercalated segment instability (DISI) deformity in this patient?
Transverse carpal ligament
Dorsal intercarpal ligaments
Triangular fibrocartilage complex
Dorsal lunotriquetral ligament
Volar lunotriquetral ligament
The integrity of the dorsal intercarpal ligaments is important in preventing dorsal intercalated segment instability (DISI) deformity and persistent scapholunate instability.
Scapholunate instability is the most common carpal instability. The primary stabilizing structure of the scaphoid and lunate bones is the scapholunate ligament, which is commonly injured with a fall on an outstretched hand.
Secondary stabilizers of the scaphoid and lunate include the dorsal intercarpal ligaments and the dorsal radiocarpal ligaments. Failure to recognize injury of these structures can cause persistent dorsal intercalated segment instability (DISI). This can predispose patients to a SLAC wrist and early wrist osteoarthritis.
Mitsuyasu et al. examined the role of dorsal intercarpal ligaments (DIC) in scapholunate instability. They showed that the DIC had an important role in stabilizing the scaphoid and lunate bones with static and dynamic movements. The authors of this study suggest that the DIC ligament should be assessed intraoperatively and consideration should be given to repair and/or reconstruction with surgical management of scapholunate ligament tears.
Viegas et al. showed that the dorsal intercarpal and the dorsal radiocarpal ligaments form a lateral V configuration over the dorsal wrist. This configuration acts as an indirect dorsal stabilizing effect on the scaphoid
throughout the range of motion of the wrist. Their integrity acts to ensure normal wrist kinematics.
Figure A shows an AP and lateral radiograph of the left hand. There is significant gapping between the scaphoid and lunate articulation. This is indicative of a complete scapholunate dissociation, however both wrists should be imaged as this deformity may exist without injury. Illustration A shows the anatomy of the dorsal intercarpal and the dorsal radiocarpal ligaments.
Incorrect Answers:
A 50-year-old patient presents with stiffness in her hand. A clinical photo is shown in Figure A. During surgical exposure, the neurovascular bundle is identified and dissected. What is the clinically most important pathologic structure to identify and what is its location relative to the neurovascular bundle in the digit?
Spiral cord which is central and superficial to the neurovascular bundle
Central cord which is midline and superficial to the neurovascular bundle
Retrovascular cord which is central and superficial to the neurovascular bundle
Spiral cord which is lateral and deep to the neurovascular bundle
Central cord which is lateral and deep to the neurovascular bundle
Based on clinical findings, the patient has evidence of Dupuytren’s contracture affecting her ring finger. Relative to the neurovascular bundle, the spiral cord will lie lateral and deep.
Dupuytren’s disease is a benign hand condition characterized by pathologic nodules and cords of existing fascial bands. The most clinically relevant structure in Dupuytren's disease, is the spiral cord. The spiral cord is the result of pathology of 4 structures: the middle layer of the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The spiral cord is found predominantly at the palmodigital transition. The spiral cord displaces the neurovascular bundle centrally and superficially.
Benson et al. review the etiology, pathophysiology and treatment options for Dupuytren’s contracture. They highlight that while the pretendinous band is located volar and central to the neurovascular bundle in the palm, the spiral band and lateral digital sheath cause the neurovascular bundle to be displaced superficially and volarly as they become pathologically affected.
Black et al. review the pathoanatomy, diagnosis and management of Dupuytren's disease. They note that the spiral cord lies superficial to the neurovascular bundle proximal to the MCP joint. Distal to the MCP joint it passes deep to the bundle. At that location, the spiral cord lies lateral to the
neurovascular bundle as the lateral digital sheet becomes involved
Figure A demonstrates the cord formation that is characteristic of the pathologic Dupuytren’s condition. It is the central cord that causes contracture of the MCP, whereas the retrovascular and spiral cords cause contractures of the DIP and PIP respectively. Illustration A shows the relationship of spiral cord formation in Dupuytren's disease relative to the normal anatomy of the palmar fascia. The structures implicated in the formation of the spiral cord are the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament, more dorsally located, is spared in Dupuytren's disease. The neurovascular bundle is displaced superficially and towards the midline, as the pathological cord spirals around. Illustration B shows the presence of other affected structures, including the natatory ligament and the central band. The central band is an extension of the pretendinous cord and attaches to the base of the middle phalanx. It may insert onto the tendon sheath of the flexor tendon at this level. Formation of natatory cords cause webspace contractures. Formation of central cords lead to flexion contractures of the PIP. Illustration V is a video that provides an educational overview of Dupuytren's.
Incorrect Answers:
An infant is brought to your office for evaluation of his hands. Clinical photos are shown in Figures A and B. The clinical features are most consistent with a genetic mutation in which of the following:
Sonic Hedgehog (SHH)
FGFR2
FGFR3
PMP22
COL1A1
CORRECT ANSWER: 2
Based on the clinical features seen in the figures provided, the most likely syndrome is that of Apert syndrome, which is consistent with a mutation in FGFR2.
Apert syndrome is an autosomal dominant condition that gives rise to facial dysmorphism and complex syndactyly of the hands. The craniosynostosis that develops causes flattening of the skull and facial features.
Goldberg et al review congenital hand conditions and the malformations associated with them. They indicate that not only does identification allow for natural history to be better elucidated, but also timing of surgical intervention can be better gauged.
Figures A and B demonstrate clinical features consistent with Apert Syndrome. The “rosebud” hand is a complex syndactyly that affects the index, middle and ring fingers most commonly. Hypertelorism is exemplified with increased distance between the eyes; additionally, acrocephaly is noted with forehead broadening and skull flattening.
Incorrect Answers
1: Mutation in sonic hedgehog gene (SHH) is associated with a longitudinal deficiency of the radius. This is seen in conditions like TAR, Holt-Oram and VACTERL syndromes.
3: Mutation in FGFR3 leads to achondroplasia
4: Mutation in PMP22 gives rise to Charcot Marie Tooth syndrome 5: Mutation in COL1A leads to osteogenesis imperfecta
A 45-year-old patient presents with recurrence of radial sided wrist pain after undergoing a first dorsal compartment release about 3 months ago. The surgery was completed by one of your partners; operative reports indicate that the sheath was incised on the dorsal edge. On physical exam she is found to have normal appearing skin, a negative Tinel’s sign, and a positive Finklestein test. What is the most likely cause of the recurrence of her symptoms?
Development of neuroma
Complex regional pain syndrome
Failure to decompress the EPB sub-sheath
Failure to decompress the EPL sub-sheath
Failure to decompress the APB sub-sheath
Based on the history and clinical findings this patient has de Quervain’s tenosynovitis. The recurrence of her symptoms can be attributed to a failure to recognize and decompress the EPB sub-sheath.
De Quervain’s tenosynovitis is a stenosing inflammatory condition of the first dorsal compartment of the wrist (APL/EPB). Surgical release of the compartment is indicated after conservative measures have failed. At the time of the operation, the incision is made on the dorsal side of the sheath to prevent volar subluxation of the tendons. Failure to identify and release a distinct EPB sub-sheath or a separate fibro-osseous compartment of the APL can lead to a recurrence of symptoms.
Alegado et al. report a case of a patient with dysesthesias in the superficial radial nerve distribution 3 months after undergoing first dorsal compartment release for de Quervain’s tenosynovitis. They found a persistent fibrous remnant of the dorsal aspect of the sheath causing elevation of the superficial radial nerve. They recommend sheath excision or incision of the sheath at its dorsal attachment to avoid this complication.
Ashurst et al. report a case of a patient presenting with bilateral de Quervain’s tenosynovitis secondary to excessive text messaging. Conservative measures
afforded the patient complete symptomatic recovery. They recommend limitation of texting, in conjunction with other standard treatments, to treat text messaging- associated de Quervain’s tenosynovitis
Ilyas et al. review the etiology, diagnosis and management of De Quervain’s tenosynovitis. Non-surgical management is largely successful and includes splinting and cortisone injections. In refractory cases, surgical release of the first dorsal compartment is completed. They recommend meticulous care of the radial sensory nerve and identification of all separate sub-sheaths.
Illustration A shows an operative photo in a patient with multiple APL slips and an EPB that is hidden within a sub-sheath. Video V gives a brief overview of de Quervain’s tenosynovitis.
Incorrect Answers
A 28-year-old NFL running back complains of continued hand pain three days following an injury sustained while being tackled. He was splinted on the field. He has tenderness over the long finger metacarpal head, with subluxation of the extensor tendon into the intermetacarpal area during active metacarpophalangeal joint flexion. A representative MRI is shown in Figure A. What is the next best step in management of this patient?
Observation alone
Continued splinting in flexion
Continued splinting in extension
Open repair of the disrupted junctura tendinae
Open repair of the disrupted sagittal band
Based on the history and physical exam findings this patient has sustained a traumatic rupture of the sagittal band. In this professional athlete, the next best step would be to perform an open repair of the sagittal band. This will allow for earlier aggressive rehabilitation and a quicker return to sport.
Sagittal band ruptures may be traumatic (as in this case) or attritional in nature (as in rheumatoid arthritis). A direct blow to the MCP leads to forced flexion of the digit and subsequent stretching/rupture of the affected structure. On physical exam the tendons are most unstable with the wrist flexed; MCP flexion will lead to dislocation of the tendon into the intermetacarpal gutter.
Acute injuries may be treated with extension bracing for 4-6 weeks, but in professional athletes, direct open repair of the sagittal band is indicated.
Catalano et al. review sagittal band injuries treated with a thermally molded
plastic splint that held the MCP in ~25-35 degrees of hyperextension. Patients were evaluated over 14 months; out of 11 sagittal band injuries, splinting was successful in eight of them. They recommend initial nonsurgical management with custom splinting.
Hame et al. review the results of the management of sagittal band injuries in the professional athlete. The lesion commonly found was the disruption of the extensor mechanism with predictable sagittal band tears. In their series, all patients regained full range of motion and returned to their respective sports. They recommend surgical intervention in elite athletes in the form of extensor tendon centralization and sagittal band repair.
Figure A shows a T1 weighted axial cut of the affected hand; subluxation of the tendon (arrow) can be identified with disruption of the sagittal band (arrowhead).
The video provided briefly reviews injury to the sagittal band. Incorrect Answers
Compressive injury to the posterior interosseous nerve will lead to EMG fibrillations in which of the following muscles?
Extensor Carpi Radialis Longus/Extensor Carpi Radialis Brevis/Brachoradialis
Extensor Carpi Radialis Longus/Supinator/Abductor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Longus
Brachoradialis/Supinator/Extensor Pollicis Longus
Extensor Pollicis Longus/Supinator/Abductor Pollicis Brevis
Based on the choices above, fibrillations will be seen in the extensor pollicis longus, supinator and abductor pollicis longus muscles.
The radial nerve splits into the superficial radial branch and the posterior interosseous nerve (PIN) at the anterior aspect of the radiocapitellar joint, just proximal to the supinator muscle. The PIN innervates the EDC, EDM, ECU,
EPB, EPL, EIP, APL and sometimes the ECRB. Compressive neuropathy of the PIN leads to motor dysfunction, namely weakness with wrist and finger extension.
Lubhan et al. review uncommon compression neuropathies affecting the upper extremity. They indicate that PIN syndrome may be caused by rheumatoid arthritis and compressive ganglion cysts. Depending on which nerve branch is affected, partial lesions may develop. They recommend use of conservative measures (rest, activity modification and splinting) first. Decompressive procedures may be indicated in symptoms lasting greater than 3 months.
Illustration A shows the course of posterior interosseous nerve from proximal to distal along the course of the supinator. This proximal edge of the supinator (Arcade of Froshe), the fibrous edge of the ECRB and the leash of Henry are three main points of compression of the PIN.
Incorrect Answers
Figure A shows a traumatic laceration of the distal forearm with a 5cm segmental median nerve defect. Which of the following repair or reconstruction techniques would allow for the best recovery of motor function?
Autogenous venous nerve conduit
Collegen synthetic nerve conduit
Biodegradable polyglycolic acid
Processed nerve allograft
Nerve autograft
CORRECT ANSWER: 5
Figure A shows a traumatic laceration with 5cm of median nerve defect. The use of nerve autograft for this size defect has been shown to have the best recovery of motor function.
The optimal surgical treatment of nerve laceration is direct tension-free repair. In segmental nerve defects this approach cannot be achieved. The use of interposed autologous nerve grafting remains the gold standard of repair in this setting. The use of alternative techniques, such as processed allografts and synthetic conduits, have not shown to have equivalent recovery of motor function as compared to nerve autograft.
Giusti et al. used a rat model to examine techniques of peripheral nerve repair. They showed that nerve autograft resulted in better motor recovery than did the use of processed allograft or a collagen conduit.
Deal et al. discussed tubular interposition substitutes, or nerve conduits, as an alternative to nerve autograft in segmental nerve defect. Nerve conduits can include autogenous nerve conduits (venous or arterial) and synthetic nerve conduits (collagen, PGA, or caprolactone). In general, there is an upper limit of 3-cm when using nerve conduit.
Figure A is an image of the volar forearm. There is a traumatic laceration to
the anterior compartment tendons as well as the median nerve.
Incorrect Answers:
A 45-year-old man presents with a three-month history of unilateral symptoms in his right wrist and hand. He first noticed a palpable nodule over the volar aspect of his wrist about three months ago. The nodule would become painful after weekends of heavy drinking at which time he noticed tingling sensation in his index and middle fingers. He notes that ibuprofen has helped improve the pain in the past. On clinical examination, he has a palpable, nontender, solid nodule over the volar aspect of his wrist. He has no motor or sensory deficits and negative carpal tunnel provocative tests. An axial CT and MRI image are provided in figures A and B. What would be the most appropriate next step in the management of his symptoms?
Fine needle aspiration
Chemotherapy
Night splints
Establish a tissue diagnosis and referral to a rheumatologist
Surgical excision
CORRECT ANSWER: 4
The clinical presentation is consistent with carpal tunnel syndrome caused by an atypical space occupying lesion - in his case, gout. The most appropriate next step in the management of his symptoms would be establishing a tissue diagnosis and referral to a rheumatologist where medical therapy, such as prophylaxis with colchicine, could be initiated.
Carpal tunnel syndrome is the most common compressive neuropathy, affecting up to 10% of the general population. Risk factors include female sex,
advanced age, obesity, and repetitive motion activities. Typically, patients will develop symptoms of median nerve compression including thenar muscle atrophy, numbness in the radial 3.5 digits, night pain, and positive Tinel's and Phalen tests. First line management is non-operative, including NSAIDs, night splints, and activitiy modification. Carpal tunnel release surgery is indicated for those who have failed conservative management.
Chen et al. described 23 unusual cases of CTS in which space-occupying lesions were responsible for the symptoms and signs of median nerve compression. In patients with an atypical presentation, such as male gender, non-middle-aged, or unilateral involvement, space-occupying lesions such as gout, synovial sarcoma, lipoma, and ganglions should be investigated as a cause.
Fitzgerald et al. discussed gout affecting the hand and wrist. The medical treatment of gout includes NSAIDs such as indomethacin or ibuprofen for acute flares, and colchicine and allopurinol for chronic prophylaxis.
Figures A and B represent axial CT and MRI images showing calcification and gouty tophi deposition in the carpal tunnel floor.
Incorrect Answers:
Which statement most accurately describes the physiology of peripheral nerve regeneration following an axonotmesic lesion?
The proximal nerve segment undergoes Wallerian degeneration
Axon growth occurs from the distal segment to proximal segment
Neurotrophic factors direct phagocytic activity
Proximal axon budding allows for antegrade (or distal) axon migration
Axoplasm and myelin are degraded distally predominantly by Schwann cells for the first 12 months following injury
Axonomesis is a disruption of the nerve axon following injury. Repair/regeneration of the nerve occurs via proximal budding, followed by antegrade (or distal) axon migration.
The peripheral nerve regeneration process begins with the distal segment undergoing Wallerian degeneration (axoplasm and myelin are degraded distally by phagocytes). Existing Schwann cells proliferate and line-up along the basement membrane. Proximal budding occurs after a one-month delay. This is followed by sprouting axons that migrate in an antegrade fashion to connect to the distal tube. Repair of the nerve can take months, and often have poor outcomes.
Lee et al. reviewed peripheral never injury and repair. They commented that Wallerian degeneration (i.e., breakdown of the axon distal to the site of injury) is initiated 48 to 96 hours after transection. The Schwann cells then align themselves longitudinally, creating columns of cells called Büngner bands. At the tip of the regenerating axon is the growth cone.
Illustration A shows a chart of peripheral nerve injury. The two main classification systems are Seddon and Sunderland. Video V is a lecture discussing peripheral nerve injury and management.
Incorrect Answers:
A 28-year-old male injures his hand while playing basketball and presents to the emergency room. Closed reduction is performed and is stable. Post-reduction rehabilitation is discussed with the patient.
Which of the following radiographs demonstrates an injury that would be treated best by dorsal extension block splinting?
Figure E
CORRECT ANSWER: 2
Dorsal extension-block splinting is the treatment of choice for dorsal proximal interphalangeal joint (PIPJ) fracture dislocations that are stable following reduction and have less than 40% articular surface fracture involvement.
Dorsal PIPJ dislocations are a common injury, often resulting from jamming or hyperextending the finger. In the absence of an associated fracture or presence of a small volar plate avulsion, dorsal PIPJ dislocations are often
treated with closed reduction and buddy-taping to the adjacent digit. Injuries that are unstable following reduction or those associated with an intra-articular fracture of the middle phalanx are stabilized with a dorsal extension-block splint to maintain reduction. It is important to initiate early range of motion exercises within the constraints of the splint to minimize scar formation and subsequent PIPJ contracture.
Elfar et al. reviewed fracture-dislocations of the PIPJ. Dorsal PIPJ fracture-dislocations can be categorized as avulsion or impaction shear injuries.
Avulsion fractures result from hyperextension of the PIPJ, tensioning the volar plate (VP) with eventual VP rupture or avulsion of the volar lip of the middle phalanx. Axial load applied to the digit in PIPJ flexion drives the head of the proximal phalanx across the middle phalangeal base, resulting in a shear fracture or comminuted impaction fracture of the middle phalanx, depending on the amount of energy imparted and the bone quality.
Morgan et al. reviewed hand injuries in athletes. Dorsal PIPJ dislocations without associated fracture that are stable following successful reduction are treated by buddy taping the injured digit to the non-injured digit adjacent to the compromised collateral ligament. Buddy taping with active motion should be continued for 6 weeks. Unstable injuries and those with an intra-articular fracture of the middle phalanx should be treated with dorsal extension-block splinting with incremental extension of the splint on a weekly basis for 4 weeks, followed by buddy-taping for 3 months during sports activities.
Figure A shows a simple dorsal PIPJ dislocation. Figure B shows a dorsal PIPJ fracture dislocation. Figure C shows a simple volar PIPJ dislocation. Figure D shows a volar PIPJ fracture dislocation. Figure E shows a dorsal avulsion fracture at the base of the distal phalanx (bony mallet injury). Illustration A depicts an dorsal extension-block splint that blocks extension of the digit past a set point while allowing full active flexion of the digit. Illustration B is a lateral radiograph of a digit showing a small minimally displaced volar plate avulsion fracture at the PIPJ with minimal intra-articular involvement (as compared to Figure B). This injury may be managed with buddy taping and active range of motion as tolerated.
Incorrect Responses:
extension for 6-8 weeks to limit flexion of the digit and therefore fracture displacement.
A 35-year-old mixed martial arts fighter and recreational cocaine user presents with symptoms concerning for hypothenar hammer syndrome (HHS). Significant ischemia is found on physical exam. Arteriography is shown in Figure A. What is the most appropriate next step in treatment?
Conservative treatment with cocaine abstinence
Conservative treatment with activity modifications and medical management with calcium channel blockers
Therapeutic endovascular fibrinolysis
Excision of involved segment and reconstruction with or without a vein graft
Medical management with coumadin for 6 months
Figure A shows a bilobed aneurysm overlying the ulnar artery with normal appearing distal vasculature. Hypothenar hammer syndrome (HHS) can be associated with an aneurysm and is most appropriately treated with resection of the involved segment and either reconstruction with a primary anastomosis or vein graft.
HHS syndrome consists of two separate entities, thrombosis and aneurysm. In the setting of thrombosis without aneurysm, conservative management is preferred. If the thrombosis is acute (<2 weeks), endovascular fibrinolysis has shown good results. In patients with an HHS and an aneurysm, surgery is required for resection to prevent distal embolization and remove the often painful aneurysmal mass.
Yuen et al. review HHS. In patients with HHS and aneurysms, resection of the involved segment of the ulnar artery prevents distal embolic events, eliminates the painful mass, relieves ulnar nerve compression, and removes the thrombus which initiated the reflex vasospasm and closed off the collateral
vessels in the region.
Lifchez et al. review the long-term outcomes of 11 patients with HHS treated with ulnar artery reconstruction. 2 of the patients underwent excision and direct ulnar artery repair, and the rest underwent reconstruction with a vein graft. All patients had a mean improvement in digital brachial index, decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively.
Nitecki et al. review a case series of 6 patients with HHS. They state that the treatment of thrombosis should be largely conservative, but thrombolytic treatment could be considered if the event happened <2 weeks prior to presentation.
Illustration A shows an excised ulnar artery aneurysm in a patient with HHS. Note the typical "corkscrew" appearance of the distal segment.
Incorrect Answers:
A 36-year-male was using a high-pressure paint gun when he suffered the injury shown in Figure A. Which of the following variables would have the worst impact on his prognosis?
Delay in surgical treatment
Injected solvent was grease
Injected solvent was water-based paint
An entry wound of greater than 3 cm
Injected solvent was at room temperature
The clinical presentation is consistent for a high-pressure injection injury. Delays in surgical treatment are associated with serious sequelae.
High-pressure injection injuries are characterized by extensive soft tissue damage associated with a benign high-pressure entry wound. They should be treated with irrigation & debridement, foreign body removal and broad-spectrum antibiotics. There is a higher rates of amputation when surgery is delayed.
Bekler et al. looked at the results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up. Ten of the injuries required formal operative debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation. They concluded that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
Rosenwaser et al. report wide débridement of all involved tissues, decompression of tissue compartments, exploration and incision of tendon sheaths, removal of injected material, and saline irrigation are critical in the management of high-pressure injection injuries to the hand. They emphasize
delayed surgery has been associated with increased incidence of morbidity and amputation.
Figure A shows a typical high-pressure injection injury. Notice the benign looking entry wound.
Incorrect Answers:
A healthy 50-year-old secretary is about to undergo an open carpal tunnel release. Which of the following peri-operative steps will have the greatest influence on minimizing the risk of a surgical site infection in this patient?
Administration of cefazolin within 1 hour before incision
Administration of cefazolin within 1 hour before incision followed by 5 days of cephalexin post-op
Cleanse with bacitracin solution immediately before skin incision
Standard sterilization and prepping
Administration of one dose of cephalexin within 1 hour before incision
The patient is undergoing a clean, elective hand surgery. Prophylactic antibiotics, systemic or local, are not indicated for these procedures.
Carpal tunnel syndrome is the most common compressive neuropathy. Individuals who fail medical management (night splints, NSAIDs, activity modification) are candidates for carpal tunnel release surgery (CTS). The surgery may be performed open or endoscopically. The reported incidence of post-operative infections following CTS varies between studies from 0% to 8%.
Whittaker et al. performed a prospective, randomized, double-blinded, placebo
controlled trial investigating the use of antibiotic prophylaxis in clean, incised hand injuries. They found no significant difference in infection rates between patients who received IV flucloxacillin, IV followed by oral flucloxacillin, and an oral placebo (13% vs. 4% vs. 15%, p=0.19). They did not support the use of routine antibiotic prophylaxis prior to clean hand surgery.
Bykowski et al. retrospectively reviewed 8,850 outpatient elective hand surgeries and found no significant difference in the rate of surgical site infection, including patients with diabetes or history of smoking. They concluded that antibiotics should not be routinely administered prior to clean, elective hand surgeries.
Harness et al. found no statistical difference in the incidence of surgical site infection following CTS without prophylactic antibiotic compared with patients who received prophylactic antibiotics (0.7% vs. 0.4%, p=0.354). They did not recommend routine antibiotic prophylaxis.
Illustration A reviews the anatomic components of the carpal tunnel. Incorrect Answers:
infection in clean, elective hand surgery. Surgeons should consider the potential risks of antibiotics prior to administration, including Clostridium difficile colitis, antibiotic allergies, bacterial resistance, and so on.
A 30-year-old male laborer sustained a right wrist injury 9 months ago. He continues to have symptoms of recurrent ulnar-sided wrist pain that impairs his ability to work. An MRI is performed and
shows a triangular fibrocartilage complex (TFCC) injury. Which of the following is an indication to combine a Wafer procedure with arthroscopic TFCC debridement?
Ulnar styloid fracture
Radial styloid fracture
2 mm of positive ulnar variance and ulnocarpal impingment
2 mm of negative ulnar variance and radiocarpal joint arthritis
Scapholunate ligament injury
A Wafer procedure is indicated for positive ulnar variance and symptomatic ulnocarpal impingement associated with degenerative TFCC tears.
Ulnar impaction syndrome and triangular fibrocartilage complex (TFCC) injuries are relatively common causes of ulnar-sided wrist pain. Positive ulnar variance causes increased contact pressures between the lunate and the ulnar head. The Wafer procedure removes 2-4 mm of distal ulnar head to reduce ulnar variance to neutral or negative. This is thought to reduce ulnar impaction and decrease pain.
Faber et al. examined the role of MRI in wrist injuries. They showed that the sensitivity and specificity to detect TFCC tears using MRI is approximately 80%. They conclude that there is no supporting evidence for routine MRI's for patients with non-specific ulnar-sided wrist pain.
Illustration A is a coronal view MRI (without arthrogram) of the right wrist that shows a TFCC tear (blue arrow) with positive ulnar variance. Illustration B shows a series of images showing a TFCC tear on MRI and intra-operatively.
Incorrect Answers:
A 27-year-old male sustains the injury shown in Figure A. He is taken to the operating room and the lesion is repaired primarily. Two months later, he feels a "pop" while using his hand and is no longer able to flex the distal phalanx of the involved digit. He is taken to the operating room for surgical exploration where 1.8 cm of scar tissue between the tendon ends is identified. The tendon sheath is found to be intact and allows smooth passage of a pediatric urethral catheter. What is the next step in management?
Resection of scar and primary repair of tendon ends.
Resection of scar and adjacent 1cm of tendon, placement of Hunter rod for staged reconstruction.
Debulking of scar, partial excision of 25% of the A2 and A4 pulleys.
Resection of scar, harvest of ipsilateral palmaris longus tendon for tendon reconstruction.
Resection of scar and proximal tendon, tendon transfer from adjacent digit.
This patient sustained an FDP laceration that was treated initially with primary repair. He subsequently re-ruptured the tendon 2 months later. With scar >1 cm, tendon grafting is indicated and primary tendon grafting with palmaris longus is commonly performed as it is the most accessible tendon in the operative field.
Flexor tendon lacerations commonly result from volar lacerations. Concomitant neurovascular injury is common. Partial lacerations <60% of tendon width are treated with debridement and early range of motion. With partial lacerations, the least amount of gliding resistance can be obtained with debridement alone. Lacerations >60% of tendon width are treated with flexor tendon repair and controlled mobilization. Failed primary repair and chronic untreated injuries are indications for flexor tendon reconstruction and intensive postoperative rehabilitation.
Lilly et al. reviewed complications after flexor tendon injuries. Common complications include adhesions, joint contracture, tendon rupture, triggering, pulley failure and bowstringing, quadrigia, swan-neck deformity and lumbrical plus deformity.
Figure A shows a zone II laceration of the left index finger FDP.
Incorrect Answers:
A 55-year-old female patient presents with pain along the thumb ray and increasing deformity of her right hand. Key pinch causes her pain. The appearance of her hand is seen in Figure A. Range of motion of her thumb is seen in Figure B. What is the most likely cause of her deformity?
Type II hypoplastic thumb
Median nerve neuropathy
Lupus thumb deformity
Extensor tendon rupture
Osteoarthritis of the trapeziometacarpal joint
The patient has 1st carpometacarpal (CMC) arthritis.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an adduction deformity gradually develops, with 1st webspace contracture. With progressive 1st CMC stiffness, the thumb metacarpophalangeal joint (MCP) develops hyperextension deformity to compensate for the loss of motion, leading to a secondary "Z" deformity.
Rozental et al. reviewed hand and wrist reconstruction. They believe that arthrosis arises from loss of the anterior oblique ("beak") ligament.
Compensatory MCP hyperextension should be treated with MCP capsulodesis or arthrodesis.
Van Heest et al. reviewed thumb CMC arthritis. Treatment for Eaton stage I/II arthritis is open/arthroscopic debridement, volar ligament reconstruction (with APL or FCR tendons), or metacarpal extension osteotomy. For stage III/IV arthritis, treatment options include implant arthroplasty or resection arthroplasty +/- LRTI (with APL, FCR or palmaris longus), and fusion (young patients).
Figure A shows adduction contracture of the 1st webspace, with hyperextension deformity of the 1st MCP joint. Figure B illustrates decreased thumb abduction because of adduction contracture with decreased palmar abduction (normal, 45deg) and decreased radial abduction (normal, 60deg). Illustration A is a radiograph showing thumb CMC arthritis with Z deformity. Illustration B shows lupus thumb deformity ("hitchhiker thumb"). Illustration C shows hand changes in inflammatory arthritis.
Incorrect Answers:
A 26-year-old man presents with chronic hand weakness. The clinical appearance of his hand, and radiographs are shown in Figures A through C. Surgical exploration and decompression is performed. Besides addressing thumb interphalangeal and index distal interphalangeal joint flexion, which is the most appropriate treatment to restore thumb opposition?
Ring flexor digitorum superficialis transfer to the abductor pollicis brevis
Extensor indicis proprius transfer to the abductor pollicis brevis
Neurotization of thenar muscles
Camitz palmaris longus transfer to the abductor pollicis brevis
Thumb carpometacarpal joint arthrodesis
This patient has a high median nerve neuropathy because of a supracondylar spur and ligament of Struthers. Reconstruction is best performed with extensor indicis proprius (EIP) transfer to the abductor pollicis brevis (APB).
In low median nerve palsy, the primary concern is restoration of thumb opposition. In high median nerve palsy, thumb opposition and IP flexion, and index and middle finger flexion have to be addressed. The four common opposition transfers include (1) ring or long FDS, (2) EIP, (3) Camitz palmaris longus (PL), or the Huber abductor digiti minimi (ADM).
Anderson et al. reviewed EIP transfer vs FDS transfer. They found a higher percentage of excellent results in the EIP group. In their series, complications included index finger extensor lag (EIP transfer if the extensor expansion was not repaired) and limited donor finger extension because of lateral band damage or adhesions between the remaining FDS tendon and flexor sheath (FDS transfer).
Cawrse et al. modified the Huber ADM opponens transfer by releasing the proximal end to prevent compression of the ulnar nerve in Guyon's canal by the rotated ADM belly. They found that this technique successfully restored
opposition and thenar bulk.
Figure A shows thenar wasting. Figures B and C show a supracondylar spur. The ligament of Struthers attaches from this spur to the medial epicondyle, under which median nerve and brachial artery pass. Illustration A shows EIP transfer. Illustration B shows FDS transfer. Illustration C shows Camitz PL transfer. Illustration D shows Huber ADM transfer.
Incorrect Answers:
A 2-year-old child is referred by her pediatrician for fixed flexion deformity of the left thumb. She has been wearing a splint for the last 6 months. She has ventricular septal defect and left renal agenesis. The interphalangeal joint does not extend past 40 degrees of flexion as seen in Figures A and B. There is no triggering. There is a firm, nontender nodule overlying the metacarpophalangeal joint as outlined in blue in Figure C. What is the diagnosis and most appropriate treatment?
Thumb camptodactyly. Therapy including passive stretching exercises.
Congenital clapsed thumb. Percutaneous release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley.
Pediatric trigger thumb. Open release of the A1 pulley and resection of the tendon nodule.
Blauth Type I hypoplastic thumb. Open release of the A1 pulley and volar plate, and resection of the tendon nodule.
This child has pediatric trigger thumb (PTT). The potential for spontaneous resolution beyond the age of 2 years is limited. Surgical release of the A1
pulley is indicated.
Pediatric trigger thumb presents as fixed flexion at the interphalangeal joint (IPJ) rather than triggering. It is likely to be acquired (rather than congenital). It is associated with the presence of Notta's nodule, a thickening of the FPL tendon and overlying tendon sheath. Treatment involves A1 pulley release.
The role of non-surgical management (splinting/stretching) remains unclear. The duration of non-surgical treatment is long (up to 30 months) and compliance can be difficult.
Shah et al. reviewed pediatric trigger thumb. The condition is associated with MCP hyperextension. The authors note no advantage to percutaneous release as general anesthetic is required anyway.
Marek et al. performed a retrospective review and survey response review of surgery for pediatric trigger thumb. They found that age at the time of surgery influences residual flexion contracture and rate of recovery. They found surgery to be safe and effective, and recommend: (1) surgery for a 2-year-old child with a locked thumb for 6 months, (2) observation for a child <1 year if the thumb is triggering (not locked), and (3) a 6-month observation period if observation is advocated.
Figures A and B show a fixed flexion deformity of the thumb and an attempt at thumb extension. Figure C shows the outlined Notta nodule.
Incorrect Answers:
A 48-year-old hairdresser presents with pain and swelling of his ring finger for 4 days. On examination, there is generalized tenderness along the entire digit. Passive extension of the digit triggers
excruciating pain. The clinical appearance of the digit is shown in Figure A. What is the most appropriate next step in management?
Acyclovir
Intravenous antibiotics, splinting and elevation
Closed tendon sheath irrigation from the level of the A1 pulley (proximal) to the distal interphalangeal joint (distal)
Continuous closed tendon sheath irrigation from the wrist (proximal) to the distal interphalangeal joint (distal)
Open irrigation and debridement
This patient has advanced pyogenic flexor tenosynovitis (PFT) with visible ischemia/necrosis. Open irrigation and debridement is necessary.
Pyogenic flexor tenosynovitis is usually caused by a puncture wound (although it may infrequently arise from hematogenous spread). The most common organism is Staphylococcus aureus. Kanavel signs help differentiate this disease from herpetic whitlow, septic arthritis, gout/pseudogout, and other hand infections such as paronychia, felons, cellulitis, and deep space infections.
Draeger et al. reviewed the treatment of pyogenic flexor tenosynovitis (PFT). They recommend open irrigation and debridement for advanced PFT and atypical or chronic tenosynovial infections where tenosynovectomy may be
indicated. Both midaxial and volar zigzag incisions can be used.
Pang et al. reviewed factors affecting the prognosis of PFT. Of the 4 Kanavel signs, they found that fusiform swelling was most often present (97% of patients), followed by pain on passive extension (72%), semiflexed digit posture (69%), and tenderness along the flexor tendon sheath (64%).
Figure A shows advanced PFT demonstrating subcutaneous purulence and local ischemia in addition to fusiform digital swelling. Illustration A shows the Nevasier technique of closed tendon sheath irrigation. Illustration B shows the setup for continuous tendon sheath irrigation using nested catheters.
Illustration C shows the incision for open irrigation and debridement.
Incorrect Answers:
Madelung's deformity of the distal radius is caused by which of the following?
Premature fusion of the distal radial ulnar joint
Physeal growth mismatch between the distal radius and ulna
Nutritional deficiency affecting the physeal zone of provisional calcification
Impaired growth of the volar and ulnar aspect of the distal radial physis
Unrecognized trauma
CORRECT ANSWER: 4
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal radius caused by impaired growth of the volar and ulnar aspect of the distal radial physis. It may be caused by either a bony lesion in the palmar/ulnar corner of the distal radial physis or an abnormal radial-carpal ligament (Vicker's ligament). The other answers do not cause Madelung's deformity.
Leri-Weill dyschondrosteosis is a rare genetic disorder caused by mutation in the SHOX gene that causes mesomelic dwarfism with associated Madelung's defomity of the forearm.
Illustration A is a radiographic example of Madelung's deformity.
A 17-year-old boy presents with pain in his right elbow for 2 years and limitation in elbow motion bilaterally. He denies any pain or discomfort in his left elbow. He reports no history of trauma to either elbow. He has had two courses of physical therapy, but has noted no noticeable improvement in pain or motion. Examination demonstrates no elbow tenderness on palpation, and there are no neurological deficits. Manual reduction is unsuccessful. The range of motion of both elbows is shown in Figure A. Radiographs of left and right elbow are shown in Figure B and C respectively. What is the most appropriate treatment plan for the right and left elbow?
Bilateral open reduction and application of a hinged external fixator to both elbows
Radial head resection of the right elbow and non-operative management of the left elbow.
Bilateral radial head arthroplasty
Physical therapy and splinting to both elbows
Radial head resection and interposition arthroplasty for the right elbow and radial head resection alone for the left elbow
This patient has bilateral congenital radial head dislocation (CRHD). The right side is symptomatic with significant loss of motion. The left is asymptomatic with minimal loss of active motion. Therefore the most appropriate treatment is radial head resection of the right elbow and non-operative management of the left elbow.
It is important to differentiate CRHD from traumatic dislocation. Clinical features of CRHD include bilateral involvement, presence at birth, other congenital anomalies, familial occurrence, irreducible by closed methods, and
lack of a history of trauma. Radiological features include dome-shaped radial head and hypoplastic capitellum, relatively short ulna or long radius, deficient trochlea, prominent medial epicondyle, grooving of the distal radius, and anterior curvature of the posterior outline of the ulna.
Bengard et al. reviewed 10 surgically treated and 6 nonsurgically treated CRHD patients. They found no change in flexion-extension and carrying angle postoperatively, but forearm rotation was improved. Surgically treated patients had significant improvement in elbow pain. Ultimately, >25% of patients had wrist pain postop and this must be weighed in the decision process of treatment. They recommend radial head excision as an effective intervention in selected patients with significant elbow pain.
Figure A is a table showing moderately diminished ROM of the right elbow, and minimally reduced ROM of the left elbow. Figures B and C both show posterior dislocation of the radial head (a line along the long axis of the radius should intersect the capitellum in all views).
Incorrect Answers:
Which of the following muscles provide the primary deforming forces to Bennett and Rolando fractures (base of the 1st metacarpal fractures)?
Pronator quadratus
Flexor pollicis longus
Extensor pollicis longus
Adductor pollicis longus and abductor pollicis
Abductor pollicis longus and adductor pollicis
The primary deforming forces in Bennett and Rolando fractures are the Abductor pollicis longus and adductor pollicis.
In a Bennet's or Rolando fracture-dislocation the volar-ulnar fracture fragment is held reduced by the anterior oblique ligament while strong deforming forces pull the remaining metacarpal shaft proximally and dorsally, angulate the shaft ulnarly and supinate the shaft. Most important in these deforming forces are the abductor pollicis longus (APL) inserting on the base of the metacarpal which pulls the metacarpal shaft proximally and dorsally and the adductor pollicis (AP) which inserts on the ulnar base of the proximal phalanx and angulates the metacarpal shaft ulnarly and supinates the shaft. Less important is the extensor pollicis longus (EPL) which inserts on the base of the distal phalanx and also adds to the ulnar angulation of the distal fragment.
Soyer reviews the diagnosis, pathoanatomy, and treatment for fractures at the base of the 1st metacarpal. Understanding the biomechanics, anatomical deforming forces, and the exact fracture pattern aids the treating surgeon in determining the most appropriate method of fixation. The most essential factor for obtaining a good functional result is anatomic restoration of the articular surface.
Elgafy et al. examined the terminal anatomy of the posterior interosseous nerve in their cadaver study - identifing six terminal branches and describing methods to avoid injury. They describe how treating surgeons can maximize function and recovery after base of the 1st metacarpal fractures by understanding these nervous branches and specific fracture pattern treatment to avoid iatrogenic injury to the PIN.
A 28-year-old man sustained a complete laceration of the flexor digitorum profundus of his index finger while cutting a watermelon 3 days ago. A clinical photograph is shown in Figure A. The surgeon plans to repair the tendon using a 4-strand core suture technique. Which method of tendon repair will give him the best results in terms of load to failure and gliding resistance?
Repair with core suture purchase 5mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 10mm from the cut edge only. No epitendinous suture
Repair with core suture purchase 5mm from the cut edge. Circumferential
simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential Silfverskiold epitendinous suture.
Repair with core suture purchase 10mm from the cut edge. Circumferential simple running epitendinous suture.
Repair with core suture purchase 10mm from the cut edge, coupled with circumferential simple running epitendinous suture will give him the best load to failure and gliding resistance.
The strength of tendon repairs depend on the number of strands crossing the repair site. Ideally, repairs should have 4-6 strands to allow for early active motion. A running epitendinous suture is recommended to improve tendon gliding and repair strength.
Gulihar et al. compared 3 different epitendinous suture techniques. They found that compared with an intact tendon, gliding resistance increased 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture. They thus recommend a simple running suture when an epitendinous suture is needed.
Lee et al. compared core suture purchase at 3, 5, 7 and 10mm from the cut edge. The 10mm-repair group had the highest 2-mm gap force and ultimate failure load. They recommend 10-mm suture purchase for optimal performance and to allow early active motion.
Figure A shows a laceration to the volar aspect of the index finger in flexor zone II. Illustration A shows a core suture purchase distance from the cut edge (represented by "X", where 10mm is the ideal distance). Illustration B shows 3 different epitendinous suture techniques (A, simple running; B, Silfverskiold; C, Halsted).
Incorrect Answers:
A 28-year-old professional baseball player injures his middle finger sliding into the catchers shin guard at home plate. He complains of pain and deformity of the middle finger. A radiograph is provided in figure A. All of the following are true EXCEPT:
Anatomic reconstruction of the articular surface is prognostic of clinical function
Proximal interphalangeal joint subluxation precludes a normal gliding flexion arc
Hinging at the fracture site must be avoided
Early motion should be initiated in postoperative therapy
Early degenerative arthritis can be expected if the joint is not adequately reduced.
The radiograph demonstrates a dorsal fracture dislocation of the proximal interphalangeal joint of the middle finger. Kiefhaber and Stern review the presentation, evaluation, and treatment of PIP fractures. Congruent reduction of the joint to allow the middle phalanx to glide around the proximal phalangeal head is paramount to prevent joint subluxation and instability.
Anatomic reconstruction of the articular surface is desirable but not necessary for successful clinical outcome.
A 30-year-old male sustains a 3.5 cm long thumb pulp injury seen in Figure A. He undergoes a procedure to restore the soft tissue envelope. Which treatment option is contraindicated because of increased risk of interphalangeal joint stiffness?
Moberg volar advancement flap
Foucher first dorsal metacarpal artery flap
Littler neurovascular island flap
Free great toe pulp transfer
Holevich first dorsal metacarpal artery flap
This patient has a large thumb pulp defect measuring 3.5 cm in length, extending proximal to the interphalangeal joint (IPJ) crease. Inset of a Moberg flap large enough to cover the defect would necessitate IPJ flexion >45 degrees, increasing the risk of IPJ stiffness.
Thumb pulp defects may be resurfaced by different means, depending on size. The Moberg flap is suited for medium (1.8-3 cm) defects. For defects >1.5 cm, there is increased risk of wound dehiscence, parrot beak nail deformity, and decreased soft tissue padding. Modifications such as V-Y flaps, bilateral Z-plasties, Burrow triangles, 2 lateral triangular flaps at the proximal edge of the flap, or advancement of an island flap with skin grafting of the secondary defect (O’Brien modification), are recommended.
Baumeister et al. reviewed the functional outcome of Moberg flaps. These flaps do not cause marked impairment of active ROM and any reduction in the AROM of the IP joint is because of a loss of hyperextension.
Horta et al. reviewed the use of multiple flaps (Moberg, radial innervated cross-finger, Venkataswami-Subramanian, Foucher, Tezcan, and Littler). They recommended the Foucher flap because of good sensibility, single-stage surgery, and no need for cortical reintegration (unlike the Littler flap)
Figure A shows a large thumb pulp defect. Illustration A shows the options for resurfacing thumb pulp defects of different sizes. Illustration B is a diagram of these options. Illustrations C and D depict the Holevich dorsal metacarpal artery flap (with overlying skin strip). Illustrations E and F depict the Foucher dorsal metacarpal artery flap (islanded).
Incorrect Answers:
Percutaneous screw fixation for non-displaced scaphoid waist fractures has been shown to have which of the following differences compared to closed treatment?
Increased direct and indirect cost
Slower return to work
Higher union rates
Reduced time to fracture union
Improved motion and grip strength after 2 years
Fixation of non-displaced scaphoid fractures with a percutaneous screw has resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster return to work or sports.
Arora et al found the indirect cost reduction by a quicker return to work was shown to offset the direct costs of surgical intervention.The operatively treated group had a better mean DASH-score than the conservative group. Fracture
union was seen in the screw fixation group at a mean of 43 days and in the cast immobilization group at a mean of 74 days.
Bond et al found in active military personnel there was faster healing but no difference in ultimate union rates or final grip strength or range of motion between percutanous screw fixation and non-operative groups. The average time to fracture union in the screw fixation group was seven weeks compared with twelve weeks in the cast immobilization group. There was no significant difference in the range of motion of the wrist or in grip strength at the two-year follow-up evaluation.
Constriction ring syndrome, also known as amniotic band syndrome, is a congenital disorder associated with which paediatric foot condition?
Equinovalgus foot
Clubfoot (Congenital talipes equinovarus)
Tarsal coalition
Congenital vertical talus
Polydactyly
CORRECT ANSWER: 2
Constriction ring syndrome is a congenital disorder that is most commonly associated with clubfeet (congenital talipes equinovarus). The reported incidence of clubfeet with concomitant constriction bands ranges from 12-56%.
Constriction ring syndrome is a collection of congenital malformations that occur as a result of intrauterine rings or bands that constrict fetal tissue. The etiology of constrictive ring syndrome remains elusive, though Streeter postulated in 1930 that a germline developmental abnormality is responsible for the development of amniotic constriction bands, hence one of the synomonous terms used to describe the disorder, Streeter’s dysplasia. Normal anatomy is found proximal to the band. Distally, a constrictive band can cause compression of lymphatic and neurovascular structures and result in lymphedema, altered circulation and neuropathy. In severe cases congenital amputation can occur. In terms of other orthopaedic conditions, constrictive ring syndrome is associated with clubfeet, acrosyndactyly and pseudoarthrosis. With respect to clubfeet, surgical treatment is commonly required, which consists of z-plasty releases of the constricted bands, in addition to surgical correction of the clubfoot deformity.
Gomez reviewed 35 children with clubfeet associated with constriction ring syndrome. In this cohort there was a poor response to casting, as 77% of the children required surgical corrections. Z-plasty releases of the deep bands were performed before the clubfoot correction.
Allington et al. examined the outcome of treatment of clubfeet distal to a lower extremity band in 18 patients (21 feet). Sixteen children (88.9%) underwent surgical treatment after manipulation and serial casting were unsuccessful.
Mild initial foot deformities and constriction bands located in the distal aspect of the lower leg were associated with the best outcomes.
Incorrect Answers:
You are consulted on a newborn male inpatient who presents with the clinical sign shown in Figure A. All of the following are commonly associated with this syndrome EXCEPT?
Bronchopulmonary dysplasia
Cardiac defects
Cleft palate
Encephalocele
Rigid talipes equinovarus

Question 44:

Options:

Posterior tibial tendon transfer to the cuboid
Anterior tibial tendon transfer to the cuboid
Achilles tendon lengthening
Ankle-foot orthosis with dorsiflexion assist
Nerve grafting

Correct Answer: Ankle-foot orthosis with dorsiflexion assist

Explanation:

Question 45:

Options:

persistent pain.
tendon subluxation.
altered sensation.
tendon rupture.

Correct Answer: persistent pain.

Explanation:

Question 46:

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

Options:

Proximal one third spiral
Proximal one third transverse
Distal one third spiral
Distal one third transverse
Middle one third

Correct Answer: Middle one third

Explanation:

Question 47:

By which mechanism can a true aneurysm of the ulnar artery result?

Options:

Blunt trauma
Stab wound
Gunshot wound
Arterial catheterization True aneurysms contain all arterial layers. As such, they occur following an arterial injury that allows the vessel to gradually dilate. A true aneurysm is more uniform in shape and is characterized by having an endothelial lining. True aneurysms result from repeated blunt trauma or vessel diseases that weaken the wall. A pseudoaneurysm, or false aneurysm, results from an arterial wall penetration. The extravasated hematoma subsequently organizes and then recanalizes. The lumen of this false aneurysm has no endothelial lining. Pseudoaneurysms result from penetrating injuries from external sources or from fractures.

Correct Answer: Blunt trauma

Explanation:

Figures 1 and 2 are the radiographs of a 17-year-old boy who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Question 48:

Options:

Immobilization/casting
Rest, limited weight bearing, and repeat radiographs in 4 weeks
MRI of the femur
Biopsy
Chemotherapy

Correct Answer: MRI of the femur

Explanation:

DISCUSSION: The radiographs show a very ill-defined, aggressive, moth-eaten bony destruction involving the distal left femoral diaphysis just above the metaphyseal junction. The differential diagnosis includes Ewing’s sarcoma, osteosarcoma, lymphoma of bone, eosinophilic granuloma, osteomyelitis, and others. MRI would further define the lesion, and soft-tissue and intramedullary extension. There is aggressive periosteal reaction in the posteromedial aspect of the adjacent lesion with some multilayered components in the distal interface of the periosteum. The lateral radiograph shows cortical penetration and irregular periosteal reaction of the posterior margin, suggesting some posterior soft-tissue extension at this site as well.
REFERENCES: Gebhardt MC, Ready JE, Mankin HJ: Tumors about the knee in children. Clin Orthop Relat Res 1990;255:86-110.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 175-186.

Question 49:

In displaced calcaneal fractures, what fragment is the only one that remains in its anatomic position?

Options:

Posterior tubercle
Posterior articular facet
Anterior process
Sustentaculum tali
Lateral wall

Correct Answer: Sustentaculum tali

Explanation:

Question 50:

What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

Options:

Posterior tibial
Calcaneal
Intermediate branch of the superficial peroneal
Lateral plantar
Sural

Correct Answer: Sural

Explanation:

Question 51:

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Options:

Decreased healing time at the glenoid-labral junction
Completion of the procedure on an outpatient basis
Faster return to play than with open procedures
Preservation of external rotation
Decreased risk of recurrent instability in comparison to open repair

Correct Answer: Preservation of external rotation

Explanation:

Question 52:

Based on the type of articulation shown in Figure 32, wear is not affected by which of the following factors?

Options:

Radial mismatch of the femoral head to the acetabular component
Sphericity of the bearings
Surface finish of the articulation
Carbon content of the metal-on-metal bearing
Head-to-neck ratio

Correct Answer: Head-to-neck ratio

Explanation:

DISCUSSION: Wear in total hip arthroplasty is a very complex phenomenon. The radial mismatch of the femoral head to the acetabular component has been shown in multiple studies to be a significant factor in wear. The mismatch can neither be too small nor too large. When the mismatch is too small, seizing of the implants can occur. When the mismatch is too large, contact stresses increase and produce exceptionally high wear. The ideal radial mismatch should be approximately 50 microns. Surface roughness and ball sphericity are two items that are extremely important with respect to wear. High carbon content has been shown to decrease wear. This device has a very large head-to-neck ratio, so impingement-related wear is unlikely.
REFERENCES: Amstutz HC, Grigoris P: Metal on metal bearings in hip arthroplasty. Clin Orthop 1996;329:S11-S34.
Amstutz HC, Campbell P, McKellop H, et al: Metal on metal total hip replacement workshop consensus document. Clin Orthop 1996;329:S297-S303.
McKellop H, Park SH, Chiesa R, et al: In vivo wear of three types of metal on metal hip prostheses during two decades of use. Clin Orthop 1996;329:S128-S140.

Question 53:

A normal functioning posterior tibialis tendon is best confirmed by which of the following physical findings?

Options:

Pronation of the foot during the stance phase of gait
Heel inversion at the beginning of a single limb heel rise
Active inversion of the nonweightbearing foot
Active plantar flexion of the first ray against resistance
Active plantar flexion of the foot during the push-off phase of gait

Correct Answer: Heel inversion at the beginning of a single limb heel rise

Explanation:

Question 54:

Options:

Right distal femoral and proximal tibia/fibula epiphysiodesis
Right distal femoral epiphysiodesis
Right proximal tibia/fibula epiphysiodesis
Left proximal tibia/fibula epiphysiodesis

Correct Answer: Right distal femoral and proximal tibia/fibula epiphysiodesis

Explanation:

Question 55:

Among patients with lumbar degenerative disk disease and low back pain, what factor is most predictive of clinical outcomes after surgical management? Review Topic

Options:

Duration of symptoms
Workers' compensation
Use of disk arthroplasty
Severity of disk degeneration
Number of spinal segments treated

Correct Answer: Workers' compensation

Explanation:

Question 56:

What is the most common malignant tumor of the foot?

Options:

Chondrosarcoma
Synovial sarcoma
Osteosarcoma
Clear cell sarcoma
Melanoma

Correct Answer: Melanoma

Explanation:

DISCUSSION: Whereas chondrosarcoma is the most frequently occurring malignant bone tumor of the foot and synovial sarcoma is the most common soft-tissue foot malignancy, the most common malignant tumor overall is melanoma. It constitutes approximately 25% of lesions found on the lower extremity. Furthermore, 31% of all melanomas arise in the foot.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 11-26.
Bos GD, Ester RJ, Woll TS: Foot tumors: Diagnosis and treatment. J Am Acad Orthop Surg 2002;10:259-270.

Question 57:

Which of the following findings is a relative contraindication to primary total knee arthroplasty?

Options:

Incompetent anterior cruciate ligament
Incompetent posterior cruciate ligament
Incompetent extensor mechanism
Flexion contracture of 20 degrees
Previous high tibial valgus osteotomy

Correct Answer: Incompetent extensor mechanism

Explanation:

Question 58:

Options:

MRI with MARS of the left hip
Revision of the left acetabular component
Intra-articular ultrasound-guided left hip injection
Physical therapy for the left hip

Correct Answer: Revision of the left acetabular component

Explanation:

Question 59:

Options:

Aseptic loosening
Mortality
Infection
Bleeding
Limited motion requiring manipulation

Correct Answer: Mortality

Explanation:

Question 60:

Figure 93 shows the axial T2-weighted MRI scan of the lumbar spine of a 70-year-old man. The arrow points to which of the following structures? Review Topic

Options:

Lamina
Facet joint
Lumbar synovial cyst
Ligamentum flavum
Epidural space

Correct Answer: Lamina

Explanation:

The ligamenta flava (singular, ligamentum flavum, Latin for yellow ligament) are ligaments that connect the laminae of adjacent vertebra, all the way from the axis to the first segment of the sacrum. In T2-weighted sequencing, ligamentous structures possess a low signal intensity. The ligamentum in this patient is markedly thickened, resulting in severe spinal stenosis. The epidural space lies ventral and medial to the ligamentum flavum and should possess a high signal intensity secondary to the presence of cerebrospinal fluid. However, in the case of high-grade stenosis, there may be little if any cerebrospinal fluid present, making the epidural space and central canal difficult to identify. A lumbar synovial cyst should also have high signal intensity because of the presence of synovial fluid.
(SBQ12SP.14) A 36-year-old male presents with acute onset of right buttock and leg pain following lifting a heavy object. On physical exam he has weakness to knee extension, numbness over the medial malleolus, and a decreased patellar reflex. Which of the following would most likely explain this clinical presentation.
Review
Topic
Lumbar arachnoiditis
L4/L5 paracentral disc herniation
L3/L4 far lateral (foraminal) disc herniation
L4/L5 far lateral (foraminal) disc herniation
L5/S1 far lateral (foraminal) disc herniation
The clinical presentation is consistent with a L4 radiculopathy. A L4/L5 far lateral (foraminal) disc herniation would compress the exiting root (L4) and cause these symptoms.
The location of a prolapsed lumbar disc determines its symptoms. Central disc herniations may give rise to back pain or cauda equina syndrome. Paracentral disc herniations (90-95% of cases) affect the traversing nerve root. Far lateral disc herniations (5-10%) affect the exiting nerve root.
Gregory et al. summarize physical signs in lumbar disc herniation. They state that the straight-leg-raise is the most sensitive (73-98% sensitive) test and the crossed straight-leg-raise is the most specific (88-98% specific) test for lumbar disc herniation. Other specific tests include weak ankle dorsiflexion (89% specific), absent ankle reflex (89% specific), and calf wasting (94% specific, but a late finding).
Illustration A shows how a paracentral L4/L5 disc herniation affects the traversing L5 root, but a far lateral L4/L5 disc herniation affects the L4 root. Illustration B shows the dermatomal distribution of pain with root involvement from L3 to S1.
Incorrect Answers:

Question 61:

In patient selection for meniscal allograft transplantation, which of the following variables has the greatest influence on outcome?

Options:

Grade of chondromalacia
Limb alignment
Patient age
Patient weight
Postoperative level of activity

Correct Answer: Grade of chondromalacia

Explanation:

Question 62:

Options:

Complete absence of the thumb
Thrombocytopenia
Patient age of less than 5 years
Lack of elbow motion
Absence of the radial artery

Correct Answer: Lack of elbow motion

Explanation:

Question 63:

Compared to metal-on-polyethylene total hip bearing surfaces, the debris particles generated by metal-on-metal articulations are

Options:

larger and less numerous.
larger and more numerous.
smaller and less numerous.
smaller and more numerous.
not detectable.

Correct Answer: smaller and more numerous.

Explanation:

DISCUSSION: Retrieval studies have shown that the debris particles produced by
metal-on-metal articulations in total hip arthroplasty are several orders of magnitude smaller
and may be up to 100 times more numerous than those found with metal-on-polyethylene articulations.
REFERENCES: Davies AP, Willert HG, Campbell PA, et al: An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements.
J Bone Joint Surg Am 2005;87:18-27.
Firkins PJ, Tipper JL, Saadatzadeh MR, et al: Quantitative analysis of wear and wear debris from metal-on-metal hip prostheses tested in a physiological hip joint simulator. Biomed Mater Eng 2001;11:143-157.

Question 64:

In the setting of a proximal tibial plateau fracture and its repair, which of the following materials is an isotropic material?

Options:

Proximal tibial cortical bone
Articular cartilage of the tibial plateau
Stainless steel tibial plate
Medial or lateral meniscus
Calcium phosphate cement

Correct Answer: Stainless steel tibial plate

Explanation:

DISCUSSION: An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials’ orientation to the applied stress.
REFERENCE: Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007, pp 58-59.

Question 65:

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Options:

Use of regional rather than general anesthesia
Observation of a latex-avoidance protocol
Latex skin allergen testing
Premedication with corticosteroids and antihistamines
Avoidance of prophylactic antibiotics derived from penicillin

Correct Answer: Observation of a latex-avoidance protocol

Explanation:

Question 66:

Options:

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

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

Explanation:

Question 67:

Which of the following best describes athletic pubalgia?

Options:

A syndrome of lower abdominal and adductor pain
Painful symptoms emanating from the symphysis pubis
Painful symptoms associated with dysfunction of the iliopsoas tendon
Stress fracture of the pubic ramus
Entrapment of the pudendal nerve

Correct Answer: A syndrome of lower abdominal and adductor pain

Explanation:

Question 68:

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Options:

Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation

Correct Answer: Can be protective to an injured spine

Explanation:

Question 69:

Which of the following factors is considered to be the strongest predictor of outcome following arthroscopic partial meniscectomy? Review Topic

Options:

Patient age
Patient body mass index
Amount of meniscal resection
Location of the meniscal tear
Modified Outerbridge cartilage score

Correct Answer: Modified Outerbridge cartilage score

Explanation:

Question 70:

For the athlete performing heavy exercise, the magnitude of core temperature and heart rate increase is most proportional to

Options:

water debt at the onset of exercise.
sodium debt at the onset of exercise.
potassium debt at the onset of exercise.
ambient temperature.
percentage of lean body mass.

Correct Answer: water debt at the onset of exercise.

Explanation:

Question 71:

- A 32-year-old has diffuse pain, weakness, and limited overhead motion in the shoulder as a result of falling on his outstretched arm 2 months ago. Examination reveals medial scapular winging, and an electromyogram shows denervation of the long thoracic nerve. Management should consist of

Options:

scapulothoracic fusion
strengthening of the periscapular muscles
pectoralis minor-fascia lata graft transfer to the scapula
pectoralis major-fascia lata graft transfer to the scapula
exploration of the long thoracic nerve, with sural nerve graft

Correct Answer: strengthening of the periscapular muscles

Explanation:

Question 72:

Options:

a lateral retinacular release.
a tubercle transfer to reduce the Q angle.
a repeat of the tibial and femoral cuts to introduce 5° of varus.
release of the popliteus.
medial vastus advancement.

Correct Answer: a lateral retinacular release.

Explanation:

Question 73:

A 52-year-old woman who is right hand-dominant sustains an injury to her elbow in a fall. A radiograph is shown in Figure 60. The preferred treatment of this injury pattern should include

Options:

lateral plating of the proximal ulna and fixation of the radial head.
Kirschner wire/tension band fixation of the proximal ulna alone.
closed reduction and casting.
dorsal plating of the proximal ulna and radial head replacement.
total elbow arthroplasty.

Correct Answer: dorsal plating of the proximal ulna and radial head replacement.

Explanation:

DISCUSSION: The patient has a Bado type 2 variant Monteggia fracture with a radial head fracture. The type 2 variant is associated with a higher nonunion rate and poorer outcomes compared to other Bado-type Monteggia fractures. While it is potentially acceptable to repair the radial head, factors such as higher degrees of comminution and older age lead toward replacement as the treatment of choice. Plate and screw fixation is favored over Kirschner wire/tension band fixation because this is not a simple olecranon fracture. Plate placement in a type 2 fracture is dorsal to counteract very high tensile forces associated with fixation failure.
REFERENCES: Egol KA, Tejwani NC, Bazzi J, et al: Does a Monteggia variant lesion result in a poor functional outcome? A retrospective study. Clin Orthop Relat Res 2005;438:233-238.
Jupiter JB, Leibovic SJ, Ribbans W, et al: The posterior Monteggia lesion. J Orthop Trauma 1991;5:395-402.
Konrad GG, Kundel K, Kreuz PC, et al: Monteggia fractures in adults: Long-term results and prognostic factors. J Bone Joint Surg Br 2007;89:354-360.

Question 74:

When performing an arthroscopic subacromial decompression, bleeding can be encountered when dividing the coracoacromial ligament because of injury to what artery?

Options:

Anterior humeral circumflex
Acromial branch of the thoracoacromial trunk
Clavicular branch of the thoracoacromial trunk
Dorsal scapular
Subscapular

Correct Answer: Acromial branch of the thoracoacromial trunk

Explanation:

DISCUSSION: The acromial branch of the thoracoacromial trunk courses along the coracoacromial ligament. This artery enters the ligament approximately 5 mm below the acromial edge. Division of the ligament at its insertion on the acromion minimizes the risk
of bleeding.
REFERENCES: Esch JC, Baker CL: Arthroscopic anatomy and normal variations, in Whipple TL (ed): Surgical Arthroscopy: The Shoulder and Elbow. Philadelphia, PA, JB Lippincott, 1993, pp 63-76.
Caspari RB, Thal R: A technique for arthroscopic subacromial decompression. J Arthroscopy 1992;8:23-30.

Question 75:

Figure 30 shows an axial T1-weighted MRI scan of a patient’s right shoulder. The arrows are pointing to what normal structure?

Options:

Deltoid insertion
Subscapularis tendon
Latissimus dorsi tendon
Short head of the biceps tendon
Pectoralis major tendon

Correct Answer: Pectoralis major tendon

Explanation:

Question 76:

Options:

observation and regular follow-up.
a custom-molded thoracolumbar orthosis.
anterior spinal fusion from T10 to L4.
anterior and posterior spinal fusion from T10 to L4.
posterior spinal fusion from T4 to L4.

Correct Answer: anterior spinal fusion from T10 to L4.

Explanation:

Question 77:

Options:

Observation as the deformity should resolve in time
Wearing of straight last shoes
Serial stretching and casting for the next 6 to 12 weeks
Heyman, Herndon, and Strong capsular release at the tarsometatarsal and intermetatarsal joints
Berman and Gartland dome-shaped osteotomies of the metatarsal bases

Correct Answer: Serial stretching and casting for the next 6 to 12 weeks

Explanation:

DISCUSSION: Weinstein reported on 31 patients (45 feet) with congenital metatarsus adductus followed for an average of 33 years. Twenty-nine feet had moderate to severe deformities treated with manipulation and casting with a 90% success rate. In a young child, surgery is not indicated until nonsurgical management has failed. In patients 2 to 4 years of age, tarsometatarsal capsulotomies are indicated, whereas multiple metatarsal osteotomies are reserved for recalcitrant deformities in children older than 4 years of age. Mild or moderate metatarsus adductus that is passively correctable will resolve without treatment.
REFERENCES: Beaty J: Congenital anomalies of the lower extremity, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philadelphia PA, Mosby, 2003, pp 983-988.
Katz K, David R, Soudry M: Below-knee plaster cast for the treatment of metatarsus adductus.
J Pediatr Orthop 1999;19:49-50.
Weinstein SL: Bristol-Myers Squibb/Zimmer award for distinguished achievement in orthopaedic research. Long-term follow-up of pediatric orthopaedic conditions: Natural history and outcomes
of treatment. J Bone Joint Surg Am 2000;82:980-990.

Question 78:

Options:

pneumatic compression stockings.
subcutaneous heparin administration.
a heparin bolus followed by therapeutic heparin anticoagulation.
warfarin anticoagulation.
placement of a vena cava filter.

Correct Answer: placement of a vena cava filter.

Explanation:

Question 79:

Options:

infection.
instability.
loosening.
periprosthetic fracture.

Correct Answer: instability.

Explanation:

Question 80:

What is the most common contracture deformity of the spastic shoulder secondary to a cerebrovascular accident?

Options:

External rotation, abduction, and extension
External rotation, adduction, and flexion
Internal rotation, abduction, and flexion
Internal rotation, adduction, and extension
Internal rotation, adduction, and flexion

Correct Answer: Internal rotation, adduction, and flexion

Explanation:

Question 81:

Options:

Gastrocnemius recession
Keller bunionectomy
Flexor hallucis longus tendon transfer
Planing/excising the superficial half of the medial sesamoid
Dorsiflexion osteotomy of the first metatarsal

Correct Answer: Planing/excising the superficial half of the medial sesamoid

Explanation:

DISCUSSION: Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure.
REFERENCES: Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627.
Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.
Richardson EG: Hallucal sesamoid pain: Causes and surgical treatment. J Am Acad Orthop Surg 1999;7:270-278.

Question 82:

Options:

Cervical spondylosis
Diffuse idiopathic skeletal hyperostosis (DISH)
Ossification of the posterior longitudinal ligament (OPLL)
Ankylosing spondylitis
Neurofibromatosis

Correct Answer: Ossification of the posterior longitudinal ligament (OPLL)

Explanation:

Question 83:

A player on a professional football team sustains a knee injury and is diagnosed with an anterior cruciate ligament rupture. When employed as the team physician, your ethical obligation is to inform

Options:

the player but not the team.
the team but not the player.
neither the team nor the player.
both the team and the player.
the team, the player, and the media

Correct Answer: both the team and the player.

Explanation:

Question 84:

Options:

Absolute toe pressures of 55 mm Hg
Transcutaneous oxygen level of 20 mm Hg
Arterial brachial indices (ABI) of 1.2 at the level of surgery
ABI 0.3 at the level of surgery
Albumin level of 2.5

Correct Answer: Absolute toe pressures of 55 mm Hg

Explanation:

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.
A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 85:

Options:

- No additional reduction and continued treatment in the cast
- Repeat closed reduction and cast application
- Closed reduction and percutaneous skeletal fixation
- Open reduction and internal fixation

Correct Answer: - No additional reduction and continued treatment in the cast

Explanation:

DISCUSSION
Studies demonstrate that surgical treatment of distal radius fractures in elderly people does not result in improved outcomes. Although nonsurgical treatment resulted in worse radiographic findings for this patient, these findings did not translate into worse functional outcomes.
RECOMMENDED READINGS
Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. Review. PubMed PMID: 21527140.
View Abstract at PubMed
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849.
View
Abstract
at PubMed
American Academy of Orthopaedic Surgeons: Treatment of Distal Radius Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons, March 2013. Available at
http://www.aaos.org/research/Appropriate_Use/drfauc.asp Accessed {10/8/14}. Last Accessed on 10/8/14

Question 86:

During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?

Options:

Superficial posterior
Deep posterior
Lateral
Anterior
Mobile wad

Correct Answer: Superficial posterior

Explanation:

Question 87:

Early postoperative infections following primary total hip arthroplasty are most likely caused by which organism?

Options:

Staphylococcus epidermidis
Streptococcus viridans
Propionibacterium acnes
Staphylococcus aureus

Correct Answer: Staphylococcus aureus

Explanation:

Question 88:

Which clinical finding most strongly suggests that nonsurgical care should be discontinued and surgical intervention is necessary?

Options:

Progressive weakness
C-reactive protein (CRP) level of 75
Increased low-back pain
White blood cell (WBC) count of 11

Correct Answer: Progressive weakness

Explanation:

Question 89:

Options:

Traction followed by reduction and pinning
In situ pinning of the left hip
In situ pinning of both hips
No weight bearing on the left side and nonsteroidal anti-inflammatory drugs
Femoral realignment osteotomy

Correct Answer: In situ pinning of both hips

Explanation:

Question 90:

Options:

semiconstrained total elbow arthroplasty.
ulnohumeral arthroplasty and anterior and posterior capsular releases.
closed reduction and external fixation.
open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.
open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

Correct Answer: open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

Explanation:

Question 91:

Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?

Options:

6 weeks after initiation of weight bearing
4 weeks postoperatively
8 weeks from the date of injury
Once full range of motion of the ankle and knee exist
At the time of bony union

Correct Answer: 6 weeks after initiation of weight bearing

Explanation:

Question 92:

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Options:

Iliopsoas, hip abductors, hip external rotators
Iliopsoas, hip adductors, hip internal rotators
Rectus femoris, hip abductors, hip external rotators
Hamstrings, hip abductors, hip internal rotators

Correct Answer: Iliopsoas, hip abductors, hip external rotators

Explanation:

The radiograph shows a subtrochanteric femoral shaft fracture in a skeletally immature patient. The proximal fragment is displaced into flexion, abduction, and external rotation. Flexion is attributable to the pull of the iliopsoas at the lesser trochanter. Abduction is attributable to the pull of the abductor muscles (gluteus medius and minimus) at the greater trochanter. External rotation is attributable to the pull of the small external rotators, including the piriformis. The majority of the adductor musculature originates on the symphysis pubis and bypasses the proximal femur, inserting further distally on the adductor tubercle. The hamstrings originate on the ischial tuberosity and also bypass the proximal fragment, inserting distally on the proximal tibia and fibula.
(SBQ12TR.39) A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 93:

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Options:

Calcaneofibular alone
Posterior talofibular alone
Posterior talofibular and deltoid
Anterior talofibular and deltoid
Anterior talofibular and calcaneofibular

Correct Answer: Anterior talofibular and calcaneofibular

Explanation:

Question 94:

Options:

Inadequate physical therapy
Exposure of the periosteum of the lateral ulna during surgery
Inappropriate location of the suture anchor
Fixation of the tendon with the forearm fully pronated
Subluxation of the radial head

Correct Answer: Exposure of the periosteum of the lateral ulna during surgery

Explanation:

Question 95:

Options:

Stress fracture of the calcaneus
Painful os trigonum
Insertional Achilles tendinopathy
Entrapment of the calcaneal branch of the posterior tibial nerve
Rupture of the Achilles tendon

Correct Answer: Insertional Achilles tendinopathy

Explanation:

Question 96:

Which of the following genetic disorders has an X-linked recessive inheritance pattern?

Options:

Gaucher disease
Prader-Willi Syndrome
Diastrophic Dysplasia
Hemophilia A
Hypophosphatemic rickets

Correct Answer: Diastrophic Dysplasia

Explanation:

Question 97:

A 50-year-old patient who plays tennis sustained the deformity shown in Figure 27 following a high volley. Further diagnostic work-up should include

Options:

an electromyogram (EMG) of the upper extremity.
an ultrasound of the short head of the biceps.
an MRI scan of the rotator cuff.
a CT scan with contrast of the anterior labrum.
a subclavian venogram.

Correct Answer: an MRI scan of the rotator cuff.

Explanation:

Question 98:

Options:

Lymphangiosarcoma
Acral myxoinflammatory fibroblastic sarcoma
Hemangioendothelioma
Hemangiopericytoma DISCUSSION.. Lymphangiosarcomas that arise in pre-existing lymphedema are aggressive malignancies (ie, Stewart-Treves syndrome) that require resection or amputation. Acral myxoinflammatory fibroblastic sarcoma is a low-grade sarcoma. Hemangioendothelioma and hemangiopericytoma are not typically associated with chronic lymphedema.

Correct Answer: Lymphangiosarcoma

Explanation:

Question 99:

- The pharmacologic action of botulinum-A toxin can be best described as

Options:

Prevention of presynaptic release of acetylcholine
Prevention of synthesis of presynaptic acetylcholine
Activation of acetylcholinesterase at the motor end-plate
Blockage of postsynaptic action of acetylcholine until reserves are depleted
Stimulation of release of presynaptic acetylcholine until reserves are depleted

Correct Answer: Prevention of presynaptic release of acetylcholine

Explanation:

Question 100:

Options:

have no difference in elbow pain.
no longer have elbow pain.
need surgery.
experience tendon rupture.

Correct Answer: have no difference in elbow pain.

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

Orthopedic Surgery Board Review MCQs: Arthroplasty, Fracture & Knee | Part 55

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 55

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index