Orthopedic MCQs: Trauma, Sports Medicine, Nerve - Part 57

About This Board Review Set

This is Part 57 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.

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Topics Covered in Part 57

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

Sample Questions from This Set

Sample Question 1: A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the media...

Sample Question 2: -The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the...

Sample Question 3: Figures 20a and 20b are the radiographs of a 19-year-old woman who was involved in a motor vehicle accident. What mechanism of injury is most consistent with the injury?...

Sample Question 4: A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is th...

Sample Question 5: A patient reports hyperesthesia over the base of the thenar eminence following volar locked plating of a distal radius fracture. A standard volar approach of Henry was used. What is the most likely cause of the hyperesthesia?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient’s desire to return to sport?

Explanation

DISCUSSION: Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing.
REFERENCES: Miller MD, Cooper DE, Warner JJP (eds): Review of Sports Medicine and Arthroscopy. Philadelphia, PA, WB Saunders, 1995, p 230.
Arendt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, p 227.
Altchek DW, Andrews JR (eds): The Athlete’s Elbow. Philadelphia, PA, Lippincott Williams
& Wilkins, 2001, p 91.

Question 2

The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the

Explanation

The segond fragment is avulsed by three fibers which are under tension to this area at proximal lateral aspect of tibia. These fibers are intimate with lateral capsule consisting of 1) posterior fibers of anterolateral femoratibial ligament 2) the anterior expansion of arcuate ligament 3) biceps tendon expansions from posteriolateral direction.

Question 3

Figures 20a and 20b are the radiographs of a 19-year-old woman who was involved in a motor vehicle accident. What mechanism of injury is most consistent with the injury?

Explanation

The radiographs show a lateral compression pelvic ring injury with a displaced superior ramus fracture, or tilt fracture. Tilt fractures are most commonly caused by a lateral compression mechanism. These injuries are often seen in female patients and careful examination, including vaginal examination, is required to rule out open fractures. Lateral compression results in internal rotation, not external rotation, of the pelvic ring. Tilt fractures are not commonly seen with anterior-posterior compression injuries or vertical shear injuries. Sagittal translation is not a term used to describe pelvic ring injuries.

Question 4

A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is the most likely diagnosis?

Explanation

DISCUSSION: Posterior ankle impingement or os trigonum syndrome is well described in dancers, and it is often associated with flexor hallucis longus tendinitis. High-quality MRI imaging will reveal the inflammation about the os trigonum and flexor hallucis longus tendinitis.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont IL, American Academy of Orthopaedic Surgeons, 1998, pp 315-332.
Hamilton WG, Hamilton LH: Foot and ankle injuries in dancers, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1225-1256.

Question 5

A patient reports hyperesthesia over the base of the thenar eminence following volar locked plating of a distal radius fracture. A standard volar approach of Henry was used. What is the most likely cause of the hyperesthesia?

Explanation

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 6

A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?

Explanation

DISCUSSION: Complete rupture of the PCL leads to increased contact pressures in the patellofemoral and medial compartments of the knee. However, whether degenerative arthritis will develop and in which compartments still remains controversial.
REFERENCE: Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, p 767.

Question 7

What approach should be chosen for the injury seen in Figure 67? Review Topic

Explanation

(SBQ12TR.4) Which of the following statements about the lateral femoral cutaneous nerve is true?
Innervates the medial aspect of the proximal thigh
Originates from the dorsal roots of L4-L5
Course runs medial to the femoral artery
Courses along the medial border of the psoas muscle
Courses under the inguinal ligament PREFERRED RESPONSE 5

Question 8

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

Explanation

DISCUSSION: A player who has an acute cervical disk herniation should not be allowed to return to play until the acute phase is over. Certain players with large herniations may require surgery before returning to play to eliminate the risk of disk-related stenosis and cord compression.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, Klein GR, Silber JS: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-705.

Question 9

Which factor increases the success rate associated with all-inside lateral meniscal repair?

Explanation

DISCUSSION
Decreased patient age, neutral alignment, and a concomitant ACL tear are associated with improved success rates of meniscal repair. Meniscus tears on the contralateral side of the knee and articular cartilage defects are not associated with improved healing rates.
RESPONSES FOR QUESTIONS 5 THROUGH 6
Physical therapy and a home exercise program
Corticosteroid injection
Arthroscopic debridement
Microfracture
Osteochondral autograft transplantation (OAT)
Match the treatment above with the clinical scenario below

Question 10

A 56-year-old man has a chief complaint of leg weakness and inability to walk. Examination reveals 5 out of 5 motor strength in all lower extremity muscle groups tested and normal sensation to light touch in both lower extremities. The patient is slow in getting up from a seated position and has an unsteady wide-based

Explanation

The patient is having gait problems suspicious for spinal cord compression. MRI of the thoracic and cervical spine should be performed to evaluate for spinal cord compression. Reports of leg weakness in the absence of discrete motor weakness on manual testing, and the appearance of an unsteady wide-based gait are more consistent with myelopathy as a cause of the gait difficulty rather than lumbar stenosis. Although the MRI scan of the lumbar spine shows multilevel spinal stenosis that is mild to moderate, it does not clearly explain the patient's signs and symptoms. Electromyography and nerve conduction velocity studies of the lower extremities are unlikely to add significantly to the diagnosis. Epidural steroid injections are not indicated. Lumbar decompression is unlikely to help the patient because the source of the patient's problem does not originate in the lumbar spine. MRI of the brain could be considered as a secondary imaging study if the cervical and thoracic MRI scans fail to identify an obvious cause for gait instability.

Question 11

According to clinical and biomechanical studies, the most appropriate position for a headless scaphoid compression screw for repair of a scaphoid waist fracture is

Explanation

demonstrated significantly improved biomechanical stability with centrally placed long screws vs centrally placed short screws. The screw may be placed retrograde or antegrade. Although the screw position may be relatively parallel to the radial inclination as the shape of the scaphoid body follows the contour of the radial styloid, screw position should be assessed relative to the scaphoid’s own architecture. Placing the screw in a retrograde fashion can force the treating surgeon to start the screw eccentrically in an attempt to avoid the interference of the trapezium lying over the distal pole of the scaphoid. This may result in noncentral screw placement.

Question 12

A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most appropriate manner of immobilizing the elbow for this patient?

Explanation

Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore, the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the
forearm should be splinted in full supination.

Question 13

-The patient requests anatomic double-bundle ACL reconstruction. Compared with transtibial singlebundle ACL reconstruction, anatomic double-bundle ACL reconstruction is more likely to

Explanation

DISCUSSION FOR QUESTIONS 65 THROUGH 67
The radiograph shows a Segond fracture, an avulsion fracture involving the lateral capsular ligament.
This radiographic finding has been associated with ACL rupture in 75% to 100% of cases. Drilling the femoral tunnel through the anteromedial portal allows for independent access to the native femoral attachment. Fiber orientation is more oblique than with a transtibial technique and more closely resembles that of the native ligament. Double-bundle reconstruction attempts to duplicate native ACL anatomy.Biomechanical studies have shown that double-bundle reconstruction more
closely reproduces normal knee kinematics; however, this technique does not offer a clear advantage in terms of clinical outcomes.The iliotibial band inserts onto Gerdy’s tubercle. The popliteus tendon originates from the lateral femoral condyle. The lateral meniscus attaches near the intercondylar eminence at the anterior and posterior meniscal roots. Recent advances in ACL reconstruction focus on restoring the native ACL anatomy.Studies have determined that a knee flexion angle of 110 degrees is optimal to avoid blowout of the back wall and injury to the lateral structures while drilling.
Femoral tunnel length is typically shorter than with a transtibial approach and decreases with higher-flexion angles. Double-bundle reconstruction is associated with higher surgical costs because of the need for additional fixation and, in the case of allograft reconstruction, a second graft.

Question 14

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Explanation

Training increases turnover of type I collagen, promoting both synthesis and degradation of collagen and a net increase synthesis of type I collagen in tendon-related tissue. Strenuous endurance training has resulted in decreased collagen cross-links, suggesting increased collagen turnover, but decreased collagen maturation. In human studies, physical training results in increased turnover of collagen. Synthesis and degradation are elevated initially when beginning an exercise program, but degradation products decrease overall. It is not known if activity levels in humans affect the diameter of collagen fibrils or the cross-sectional area of tendons.

Question 15

A 19-year-old linebacker for a collegiate football team has had two episodes of bilateral arm tingling and weakness after tackling; the symptoms resolved after 30 minutes of rest. Three follow-up neurologic examinations have been normal. Cervical spine CT and MRI scans are shown in Figures 13a through 13c. What is the next best step in management?

Explanation

DISCUSSION: Cervical spinal stenosis is a contraindication to participation in collision and contact sports. Previously, the risks of permanent quadriparesis from cervical spinal stenosis were thought to be unclear and athletes with cervical spinal stenosis were often allowed to play contact sports. In 1996, Torg and associates reported that developmental narrowing of the cervical canal in a stable patient does not appear to predispose an individual to permanent catastrophic neurologic injury and therefore should not preclude an athlete from participation in contact sports. However, the current understanding is that the actual risks of permanent neurologic injury from cervical stenosis are significant. The Torg ratio was previously used for diagnosis but is more recently thought to be of low predictive value as reported by Cantu. Current methods for diagnosis of cervical spinal stenosis rely on MRI and CT. Current diagnosis is based on comparisons of measurements with normal values. A cervical canal of less than 13 mm is considered stenotic whereas a diameter of less than 10 mm is considered absolute stenosis as reported by Crowl and Kong. This patient has symptomatic stenosis and should not be cleared for contact sports. A neck roll will not prevent neurologic injury in the presence of cervical spinal stenosis. Electrodiagnostic studies are not likely to add any additional significant findings with central canal stenosis. Cervical traction is not of value in the long-term. Epidural steroid injections or a methylprednisolone dose pack are not of value in this situation.
REFERENCES: Torg JS, Naranja RJ Jr, Pavlov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Cantu RC: The cervical spinal stenosis controversy. Clin Sports Med 1998;17:121-126. Crowl AC, Kong JF: Cervical Spine, in Johnson DL, Mair SD (eds): Clinical Sports Medicine. Philadelphia, PA, Mosby Elsevier, 2006, pp 143-149.

Question 16

A 13-year-old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examination. AP and lateral radiographs are shown in Figures 1a and 1b. Management should consist of

Explanation

DISCUSSION: The patient has a displaced intra-articular tibial tuberosity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Nondisplaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation.
REFERENCES: McKoy BE, Stanitski CL: Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003;34:397-403.
Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355.

Question 17

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

Explanation

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

Question 18

A 43-year-old man has had right groin pain for the past 3 months. A radiograph, CT scan, and biopsy specimen are shown in Figures 18a through 18c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographic appearance of the lesion is lytic with calcifications in the supra-acetabular region. The CT scan shows bone destruction and periosteal reaction, which rules out an enchondroma. The histologic appearance is that of cellular cartilage, with a high cytoplasmic:nuclear ratio and basophilic appearance to the cytoplasm; these findings rule out chordoma and metastatic renal cell carcinoma. In addition, chordomas are most frequently found in the sacrum and base of the skull. Because there is no high-grade spindle cell component to suggest dedifferentiation, the most likely diagnosis is chondrosarcoma.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 71-92.

Question 19

A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).

Explanation

DISCUSSION
The indication for anatomic TSA is end-stage glenohumeral arthritis with an intact rotator cuff. For the 62-year-old man, his radiographs reveal osteoarthritis, and his MR image shows an intact rotator cuff. Although humeral head replacement has historically been employed for this disorder, pain relief is not as reliable as with TSA, and the revision rate is higher. rTSA is generally reserved for patients with a nonfunctional rotator cuff.
For this 58-year-old patient with a full-thickness rotator cuff tear, preserved motion, and weakness in forward elevation, a rotator cuff repair is the most appropriate treatment. In the absence of degenerative changes, shoulder hemiarthroplasty or anatomic TSA is not indicated. Although indications for rTSA continue to evolve, well-compensated range of motion and a medium-sized rotator cuff tear in a younger patient are not among them.
rTSA is an emerging treatment for comminuted proximal humerus fractures in elderly patients. Although hemiarthroplasty has been a traditional treatment, current evidence suggests rTSA more reliably restores range of motion, and this 78-year-old patient's CT scan shows a small and comminuted greater tuberosity fragment that is unlikely to heal. ORIF is another option, but the CT scan also shows a small humeral head fragment that suggests osteopenia, making fixation more tenuous and likely less reliable.
A common problem associated with hemiarthroplasty for glenohumeral osteoarthritis is symptomatic glenoid degeneration that necessitates revision. This 55-year-old patient’s images reveal this is the case, although his infection workup is negative. His examination findings suggest an intact subscapularis repair. With a functioning rotator cuff and symptomatic glenoid arthritis, a conversion to anatomic TSA is indicated. In the absence of a functioning rotator cuff in an older patient, an rTSA is a better option.
This 72-year-old patient has classic symptoms and radiographs of cuff tear arthropathy. For patients with massive rotator cuff tear and glenohumeral arthritis, neither anatomic TSA nor rotator cuff repair is indicated. Hemiarthroplasty has historically been indicated for cuff tear arthropathy, but rTSA outcomes for this disorder have been superior and are now the preferred option.
Comminuted proximal humerus fractures in young, active patients are treated primarily with ORIF. The absence of glenohumeral arthritis removes anatomic TSA as a possibility, and concerns about implant longevity in younger, active patients such as this 40-year-old laborer contraindicate rTSA. Hemiarthroplasty is still employed in 3- and 4-part fractures but is generally reserved for subacute presentations or dislocations in which the humeral head is dysvascular and unlikely to survive. In this acute setting, a fixation procedure is preferred.
The 71-year-old patient who has had 2 failed rotator cuff repairs has an MR image that reveals another recurrent tear that is retracted to the glenoid. Her examination findings reveal classic signs
of a decompensated rotator cuff tear with pseudoparalysis and weakness in forward elevation. Although infection is a concern in the setting of multiply failed rotator cuff repair, the workup is negative in this scenario. Because this patient has a dysfunctional rotator cuff and has failed previous attempts at repair, a conversion to rTSA is the better option. In the absence of degenerative changes, hemiarthroplasty and anatomic TSA are not indicated.
The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes. Anatomic TSA is also reasonable but not an optimal option considering the normal glenoid condition. rTSA is not a consideration when a young patient’s MR images reveal an intact rotator cuff.
RECOMMENDED READINGS
Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: longterm results. J Shoulder Elbow Surg. 1997 Nov-Dec;6(6):495-505. PubMed PMID: 9437598. View Abstract at PubMed
Chalmers PN, Slikker W 3rd, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014 Feb;23(2):197-204. doi: 10.1016/j.jse.2013.07.044. Epub 2013 Sep 27. PubMed PMID: 24076000. View Abstract at PubMed
Groh GI, Wirth MA. Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. J Shoulder Elbow Surg. 2011 Jul;20(5):778-82. doi: 10.1016/j.jse.2010.09.014. Epub 2011 Jan 13. PubMed PMID: 21232989. View Abstract at PubMed
Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007 May-Jun;16(3 Suppl):S27-32. Epub 2006 Nov 16. PubMed PMID: 17113317. View Abstract at PubMed
Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg. 2014 Mar;23(3):395-400. doi: 10.1016/j.jse.2013.07.047. Epub 2013 Oct 12. PubMed PMID: 24129052. View Abstract at PubMed

Question 20

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Explanation

DISCUSSION: If the patient’s medical condition and prognosis remain good in the presence of significant and progressive neurologic deficit from cord compression, then the most reliable means of restoring function is via surgical decompression and fusion. Decompression should be directed toward the compressing structure (eg, anteriorly if the compression is from the anterior side). This procedure can be done via a posterolateral technique, such as costotransversectomy in some cases.
REFERENCE: Fardin DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 123-133.

Question 21

During spinal deformity surgery, which of the following is the most specific early indicator of an intraoperative injury to the spinal cord? Review Topic

Explanation

Transcranial motor-evoked potentials provide the most specific early indicator of an intraoperative spinal cord injury. Somatosensory-evoked potentials are routinely used but do not have the sensitivity and specificity of motor-evoked potentials. EMG evaluations are routinely used for root evaluation following pedicle screw placement. BAERs are typically used in monitoring brain surgery.

Question 22

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Explanation

Advanced glycation end-products (AGEs) are found in aging and osteoarthritis (OA) and result in increased articular cartilage stiffness and increased brittleness.
AGEs are produced from spontaneous nonenzymatic glycation of proteins when sugars (glucose, fructose, ribose) react with lysine or arginine residues. Because of the low turnover, cartilage is susceptible to AGEs accumulation. The accumulation of AGEs has been thought to play a role in the development of OA of the knee and ankle.
Li et al. reviewed age-related changes in cartilage. They state that with aging, there is excessive collagen cross-linking increases cartilage stiffness, while shortening/degradation of aggrecan leads to loss of sugar side chains and water-binding ability, while increased levels of AGEs are associated with a decline in anabolic activity. There is also increased chondrocyte death and/or apoptosis.
Anderson et al. reviewed the relationship between osteoarthritis and aging. They state that knee cartilage thins with aging (especially on the femoral and patellar sides, suggesting a gradual loss of cartilage matrix. AGEs formation leads to modification of type II collagen by cross-linking of collagen molecules, increasing stiffness and brittleness and increasing susceptibility to fatigue failure.
Incorrect Answers:

Question 23

Figures 24a through 24c show the coronal T 1 -weighted, T 2 -weighted fat-saturated, and T 1 -weighted fat-saturated gadolinium MRI scans of the proximal thigh of a 52-year-old woman who reports a mass in the medial thigh and groin area. She notes that the fullness has grown in size over the course of many months. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T₂-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 24

Lipohemarthrosis of the knee is most likely secondary to which of the following?

Explanation

DISCUSSION: Lipohemarthrosis is formed when an intraarticular fracture occurs and can be detected with arthrocentesis or imaging such as xray, MRI, ultrasound, or CT. It is most commonly seen with occult tibial plateau fractures but can be associated with any intra-articular fractures. Up to three layers are visible on an MRI (fat/serum/cellular parts of blood), and this separation may take up to 3 hours to appear after injury. An example of hemarthrosis as seen on CT is shown in Illustration A. The referenced article by Ahn et al is a review of MRI findings in intraarticular knee injuries. They note that detection of lipohemarthrosis on an MRI is very sensitive and specific for intraarticular fracture. The referenced article by Schick et al reports that MRI can be as sensitive as arthrocentesis in detecting lipohemarthrosis (occult fracture).

Question 25

Embolic material generated during total knee arthroplasty (TKA) shown in Figure 29 is composed of which of the following substances?

Explanation

DISCUSSION: Emboli are created during TKA. Usually there is an increased incidence with the use of intramedullary rods that disrupt the marrow contents. These are not fat emboli per se. They are material composed of fat cells and marrow that act like pulmonary emboli to obstruct small arterioles in the lung. They are different from free fat emboli that are seen in fractures and that lead to chemical injury to the lung rather than obstructive injury.
REFERENCES: Markel DC, Femino JE, Farkas P, et al: Analysis of lower extremity embolic material after total knee arthroplasty in a canine model. J Arthroplasty 1999;14:227-232.
Pell AC, Christie J, Keating JF, et al: The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing: A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 1993;75:921-925.
McGrath BJ, Hsia J, Boyd A, et al: Venous embolization after deflation of lower extremity tourniquets. Anesth Analg 1994;78:349-353.

Question 26

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectional
instability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 27

A 72-year-old female sustains a displaced intracapsular femoral neck fracture. Which of the following is TRUE regarding the long term differences between possible treatment options for this injury?

Explanation

Elderly patients with femoral neck fractures (FNF) undergoing total hip arthroplasty (THA) are less likely to require reoperation than those undergoing internal fixation.
Intracapsular FNF are common in elderly patients after a fall from standing height. Treatment depends on physiological age and displacement (Garden's classification). For displaced fractures, physiologically young patients are treated with internal fixation while physiologically old patients are treated with either hemiarthroplasty (debilitated, less active patients) or THA (more active patients, those with acetabular
disease or preexisting inflammatory arthritis).
Chammout et al. retrospectively compared the long term (17 years) results of THA (cemented both component) and ORIF (2 cannulated screws) in elderly patients (>65 years). They found no difference in mortality. But hip scores were higher and pain was better in the THA group, while reoperation rates were higher in the ORIF group. Walking speed was initially faster in the THA group, but later did not differ between groups. They recommend THA for elderly patients with displaced FNF.
Rogmark et al. prospectively compared closed reduction and internal fixation (CRIF) with arthroplasty (combining hemiarthroplasty and THA) at 2 years in elderly patients (>70 years). Failure rates were higher, pain was worse, and walking was more impaired after CRIF. They recommend arthroplasty for patients >70 with FNF.

Question 28

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Explanation

Revision anterior exposure within 2 weeks of total disk replacement incurs relatively little additional morbidity because adhesion formation is minimal. Surgeons should have a low threshold for revising implants that are clearly dangerously malpositioned or show early migration within this 2-week window. Beyond this time period, a revision strategy must be individualized to the particular clinical situation. A posterior fusion with instrumentation with or without a laminectomy is currently the most effective salvage procedure.

Question 29

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

Explanation

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,

an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 30

A 12-year-old male sustains a ulnar fracture with an associated posterior-lateral radial head dislocation. After undergoing closed reduction, the radiocapitellar joint is noted to remain non-concentric. What is the most likely finding?

Explanation

DISCUSSION: In pediatric Monteggia fractures the annular ligament is commonly interposed in the radiocapitellar joint. Tan et al reviewed their treatment of 35 children with Type I and Type III Monteggia fractures. All radial heads were explored and the interposed annular ligament was stretched out of the joint space. They noted that none of the patients has any recurrent dislocation or subluxation. Bado initially described and classified Monteggia fractures. The most common injury pattern is an extension type 1 with anterior radial head dislocation and apex anterior ulnar shaft fracture. The apex of the ulna fracture determines the direction of the radial head subluxation or dislocation. Adults typically require ORIF of the ulna. These fractures in children are often treated non-operatively with closed reduction if the ulna fracture is transverse and stable. Type III is the one most commonly associated with irreducibility of the radial head because of interposition of the annular ligament. The incidence of posterior interosseous nerve injury is high with this lesion. The nerve deficit usually completely resolves rapidly and spontaneously. Ring et al in their review stress the importance of an anatomic reduction of the ulna to restore the reduction of the radial head

Question 31

Examination of a 6-year-old boy who sustained a displaced Salter-Harris type II fracture of the distal radius reveals 35 degrees of volar angulation. A satisfactory reduction is obtained with the aid of a hematoma block. At the 10-day follow-up examination, radiographs show loss of reduction and 35 degrees of volar angulation. Management should now consist of

Explanation

DISCUSSION: In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would

be damaged.
REFERENCES: Dimeglio A: Growth in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 33-62.
Waters PM: Forearm and wrist fractures, in Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 251-258.

Question 32

A 69-year-old man sustains a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in Figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changes in the emergency department. Clinical pictures taken in the office are shown in Figures 27c through 27e. What is the most appropriate management of this soft-tissue wound?

Explanation

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 33

Osteonecrosis of the femoral head after intramedullary nailing in children is thought to be the result of injury to the

Explanation

DISCUSSION: All of these are possible explanations for the development of osteonecrosis following intramedullary nailing in children. However, the lateral ascending cervical artery, which supplies the epiphysis, is much more vulnerable to injury in children because it lies in the trochanteric fossa.
REFERENCES: Buckley SL: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop 1997;338:60-73.
Rockwood CA, Wilkins KE, Beaty JH: Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, p 1214.

Question 34

Figures below show the radiographs obtained from a 19-year-old woman with a 3-year history of progressive hip pain in the left groin with activity, which is unresponsive to activity modification and physical therapy. Examination reveals normal range of motion, with pain on anterior impingement testing. What treatment is associated with the best long-term results?

Explanation

DISCUSSION:
This patient has symptomatic femoroacetabular impingement as well as clinical and radiographic signs of acetabular retroversion, including a cross-over sign, ischial spine sign, and posterior wall sign bilaterally. Good midterm to long-term outcomes have been reported with reverse (anteverting) Bernese periacetabular osteotomy (PAO). In patients with less retroversion, open or arthroscopic rim trimming with labral refixation have shown good short-term results, but longer-term results have yet to be fully delineated. Isolated hip arthroscopy and labral repair would not be indicated without addressing the retroversion deformity. Femoral varus rotational osteotomy plays no role in the treatment of this pathology. Open surgical dislocation with rim trimming could be considered in patients with less deformity, but some studies have shown inferior long-term results compared with reverse PAO.

Question 35

A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient? Review Topic

Explanation

The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.

Question 36

Patients with which of the following primary carcinomas have the shortest overall survival rate after a solitary metastasis to bone?

Explanation

DISCUSSION: The median survival of patients after discovery of bone metastasis from primary lung carcinoma is shorter compared with other primary sites.
REFERENCE: CA, January/February 2000, vol 50, no. 1 (Cancer Statistics).

Question 37

A 56-year-old man who underwent a left total hip arthroplasty 8 years ago is seen following a fall from a standing height. A radiograph obtained at 2 years postoperatively is shown in Figure 55a and a current radiograph obtained in the emergency department is shown in Figure 55b. On further questioning, he reports pain in this thigh for the past 3 years that has been increasing in intensity. Appropriate management at this time includes which of the following?

Explanation

DISCUSSION: The patient has a Vancouver type B2 periprosthetic femoral fracture with a loose, cementless femoral component. Radiographs show subsidence of the femoral component and the patient reports pain in the thigh for several years prior to the fall. When the femoral component is loose, revision is mandated to treat both the loose component and the fracture. Nonsurgical management is associated with a high risk of medical complications related to extended recumbency as well as a high rate of malunion and nonunion. Cementless femoral component revision has been shown to fare better than cemented femoral components, particularly for treating periprosthetic fractures of the femur.
REFERENCES: Masri BA, Meek RM, Duncan CP: Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;420:80-95.
Springer BD, Berry DJ, Lewallen DB: Treatment of periprosthetic femoral fractures following total hip
arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85:2156-2162. Question 56
A 62-year-old woman who underwent a primary total knee arthroplasty under a combined spinal-epidural anesthetic presents 5 hours postoperatively with severe pain in the extremity that is unresponsive to narcotic pain medication. A tourniquet was used during the procedure. On examination, the patient is unable to dorsiflex or plantar flex the foot and the pulses appear to be asymmetric. What is the next most appropriate step in management?
Discontinuation of the epidural and serial neurologic exams
Loosening of the surgical bandages and elevation of the extremity
MRI of the spine to evaluate for an epidural hematoma
Return to the operating room for angiography and vascular bypass
Return to the operating room for angiography, vascular bypass, and four-compartment fasciotomy PREFERRED RESPONSE: 5
DISCUSSION: The patient has clinical evidence of vascular injury and compartment syndrome. An emergent
vascular consult and a return to the operating room for an angiogram and revascularization are needed. In these situations, thrombectomy alone is often not sufficient and a bypass is typically required. A four-compartment fasciotomy should be done following revascularization of the extremity.
REFERENCES: Calligaro KD, Dougherty MJ, Ryan S, et al: Acute arterial complications associated with total hip and knee arthroplasty. J Vase Surg 2003;38:1170-1177.
Smith DE, McGraw RW, Taylor DC, et al: Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg 2001;9:253-257.
Ninomiya JT, Dean JC, Goldberg VM: Injury to the popliteal artery and its anatomic location in total knee
arthroplasty. J Arthroplasty 1999;14:803-809.

Question 38

A 42-year-old college professor reports persistent pain at the hypothenar eminence 9 months after falling from his bicycle. Initial radiographs were reportedly normal. Use of a wrist splint for the last 2 months has failed to provide relief. A radiograph obtained by his primary care physician prior to referral is seen in Figure 31. What is the most appropriate treatment?

Explanation

DISCUSSION: The oblique radiograph of the wrist reveals a displaced fracture of the pisiform that usually occurs following a direct blow or sudden contraction of the flexor carpi ulnaris tendon. Persistent pain secondary to pisotriquetral incongruity and degenerative arthritis warrants pisiform excision, which does not compromise wrist flexion strength. Pisiform fractures are usually missed on routine radiographic views. An oblique or carpal tunnel view can be helpful in visualizing the pisotriquetral joint.
REFERENCE: Fleege MA, Jebson PJ, Renfrew DL, et al: Pisiform fractures. Skeletal Radiol 1991;20:169-172.

Question 39

Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Explanation

Injuries to underlying vascular structures associated with clavicle fractures require exploration and stabilization. Brachial plexus injuries recover spontaneously in two thirds of patients. Displaced and segmental fractures may undergo closed reduction. Open treatment of clavicle fractures have been discouraged secondary to technical difficulties and nonunion. A floating shoulder (displaced clavicle and scapular neck fractures is an indication for ORIF but not humeral neck fracture.)

Question 40

A 32-year-old man sustains a forceful inversion injury while playing soccer. Examination reveals tenderness in the lateral hindfoot and midfoot region with associated ecchymosis and swelling. Radiographs show proximal migration of the os peroneum. Active eversion is still present. These findings indicate disruption of the

Explanation

DISCUSSION: The os peroneum is an accessory ossicle located within the peroneus longus tendon. It is typically located at the level of the cuboid groove in the lateral hindfoot and midfoot region. Proximal migration of the os peroneum indicates disruption of the peroneus longus tendon and is an important clue to diagnosis. This unusual condition can cause chronic lateral ankle pain, and surgical repair may be indicated. Active eversion indicates that the peroneus brevis is clinically intact. Disruption of the extensor digitorum brevis, plantar fascia, or syndesmosis would have no effect on the position of the os peroneum.
REFERENCES: Thompson FM, Patterson AH: Rupture of the peroneus longus tendon: Report of three cases. J Bone Joint Surg Am 1989;71:293-295.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.

Question 41

An eversion mechanism of injury is associated with which of the following ankle conditions?

Explanation

DISCUSSION: A fracture of the anterior colliculus is typically the result of an eversion mechanism resulting in a bony avulsion of the deltoid ligament from the anterior colliculus of the medial malleolus. An inversion ankle injury typically involves ligamentous damage to the lateral ligaments of the ankle to include the anterior talofibular ligament and calcaneofibular ligament. Acute and particularly chronic ankle sprains also can have associated injuries. The inversion mechanism has been implicated in osteochondral and transchondral talar dome lesions, producing splits in the peroneus tendons, and in the development of meniscoid and soft-tissue impingement lesions in the anterolateral ankle. An inversion mechanism can also stretch the superficial peroneal nerve, leading to pain and paresthesias along its distribution.
REFERENCES: Casillas MM: Ligament injuries of the foot and ankle in the athlete, in DeLee JC, Drez D, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2323-2357.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 233-245.

Question 42

A baseball player has had diffuse scapular soreness for the past 8 weeks. He reports that it began insidiously over several days and gradually has become worse. He denies any history of trauma. Examination reveals drooping of the shoulder, with lateral winging of the scapula at rest. He is otherwise neurologically intact. What is the best course of action?

Explanation

DISCUSSION: Lateral scapular winging is characteristic of trapezius palsy, whereas medial scapular winging is characteristic of long thoracic nerve palsy. During sports activity, injury to the spinal accessory nerve is rare but may occur with blunt or stretching trauma. Patients often report an asymmetric neckline, drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination.
REFERENCES: Wiater JM, Bigliani LU: Spinal accessory nerve injury. Clin Orthop 1999;368:5-16.
Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop 1999;368:17-27.
Mariani PP, Santoriello P, Maresca G: Spontaneous accessory nerve palsy. J Shoulder Elbow Surg 1998;7:545-546.
Porter P, Fernandez GN: Stretch-induced spinal accessory nerve palsy: A case report. J Shoulder Elbow Surg 2001;10:92-94.
Cohn BT, Brahms MA, Cohn M: Injury to the eleventh cranial nerve in a high school wrestler. Orthop Rev 1986;15:59-64.

Question 43

78A B Figures 78a and 78b are the emergency department radiographs of an 83-year-old woman who tripped and braced herself against a wall; this was followed by shoulder pain. Which intervention would provide optimal treatment for this patient?

Explanation

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
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
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430. View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 44

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Explanation

DISCUSSION: Radiographic fusion success rates are best described as slightly rather than substantially improved. Hospital stay and time to fusion also are not substantially decreased. Use of BMP does eliminate the need for autograft harvest for anterior lumbar interbody fusion/cage. The need for postoperative bracing is not altered based on graft choice. Early studies of posterolateral fusion applications appear to show a greater potential benefit of rhBMP-2 over autograft. Not all BMP formulations perform the same with regard to safety and effectiveness. Other osteoinductive proteins in clinical trials (BMP-7, GDF-5) will require individual analysis of these properties.
REFERENCE: Burkus JK, Gornet MF, Dickman CA, et al: Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 2002;15:337-349.

Question 45

Which of the following pelvic injury types has the highest reported mortality rate?

Explanation

mechanism injuries all have lower mortality rates than APC injuries.

OrthoCash 2020

Question 46

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Explanation

Marfan syndrome is a challenging disease for the orthopaedic surgeon. Most problems of joint laxity, acetabular protrusio, and minor scoliosis curves are treated nonsurgically. Pseudarthrosis of the tibia is not seen in Marfan syndrome; it is more common in patients with neurofibromatosis (NF-1). Treating kyphosis is risky for vertebral subluxation. Rapidly progressive scoliosis in immature patients is associated with higher surgical complications, but surgery is indicated. Overcorrection is associated with significant cardiovascular complications and should be avoided.

Question 47

.A 22-year-old collegiate baseball pitcher has had posterior shoulder pain with decreased throwing velocity and accuracy over the past several months. Examination of the abducted shoulder in the supine position reveals 120 degrees of external rotation, 40 degrees of internal rotation on the throwing side, 100 degrees of external rotation, and 70 degrees of internal rotation on the nonthrowing side. The remainder of the clinical examination is unremarkable. An MRI scan shows a small partial articular-sided infraspinatus tear. Initial treatment should consist of

Explanation

Question 48

What is the most common surgical cause of the foot deformity shown in Figure 9?

Explanation

DISCUSSION: The radiograph shows a hallux varus deformity. Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both. It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection.
REFERENCES: Donley BG: Acquired hallux varus. Foot Ankle Int 1997;18:586-592.
Myerson MS, Komenda GA: Results of hallux varus correction using an extensor brevis tenodesis. Foot Ankle Int 1996;17:21-27.

Question 49

A 14-year-old girl reports a 3-week history of anterior thigh pain and a palpable mass after sustaining a soccer-related injury. Examination reveals a tender, firm mass in the midportion of the rectus femoris. MRI scans are shown in Figures 39a through 39c. What is the most appropriate management? Review Topic

Explanation

The history, examination, and MRI scan findings are consistent with a midsubstance partial rupture of the rectus femoris muscle. This is an injury masquerading as a “pseudo tumor.” The lack of an appreciable mass effect on the T1-weighted MRI scan, the defined fluid signal on the T2-weighted scans, and the lack of significant contrast enhancement after gadolinium are all most consistent with injury rather than a neoplasm. Most of these injuries respond to nonsurgical management; a few will benefit from late debridement and repair if symptoms fail to resolve in 3 to 6 months. The treatment of choice is nonsurgical management with a follow-up MRI scan to verify that the findings are resolving.

Question 50

Figure 6 shows the radiograph of a 14-year-old baseball player who felt a pop and had an immediate onset of pain in his elbow after a hard throw from the outfield. The best course of action should be to

Explanation

DISCUSSION: The valgus stress at the elbow caused by throwing strains the medial collateral ligament. The medial epicondyle, on which the ligament inserts, is the last ossification center to fuse to the distal humerus, and acute avulsion of the medial epicondyle can occur in adolescents. If the elbow is allowed to heal in a displaced position, valgus instability and loss of elbow extension may result. Valgus instability is especially problematic for the throwing athlete. Surgical treatment with rigid internal fixation is the treatment of choice for displaced medial epicondyle avulsion fractures. Valgus instability is prevented, and the rigid fixation allows for early range of motion.
REFERENCES: Case SL, Hennrikus WL: Surgical treatment of displaced medial epicondyle fractures in adolescent athletes. Am J Sports Med 1997;25:682-686.
Woods GW, Tullos HS: Elbow instability and medial epicondyle fractures. Am J Sports Med 1977;5:23-30.

Question 51

Figures below depict the radiographs obtained from a 76-year-old woman who comes to the emergency department after experiencing a fall. She is an unassisted community ambulator with a history of right hip pain. What is the most appropriate surgical treatment for this fracture?

Explanation

DISCUSSION:
This patient has pre-existing right hip osteoarthritis. The most correct option for the treatment of this active patient is a right total hip arthroplasty. Hemiarthroplasty would not address the patient's pain from osteoarthritis, and open reduction and internal fixation would not fix the femoral head issue or the
osteoarthritis.

Question 52

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 53

A 38-year-old man has an enlarging left paraspinal soft-tissue mass. Based on the MRI scans and biopsy specimens shown in Figures 32a through 32e, what is the most likely diagnosis?

Explanation

DISCUSSION: Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist

of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications.
REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.
Spear MA, Jennings LC, Mankin HJ, et al: Individualizing management of aggressive fibromatoses. Int J Radiat Oncol Biol Phys 1998;40:637-645.

Question 54

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 55

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

Explanation

DISCUSSION: In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.
REFERENCES: Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.
Dellaero DT, Levin LS: Compartment syndrome of the hand: Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-408.

Question 56

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they want to “get the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared with nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 57

A 25-year-old tennis player has shoulder pain and weakness to external rotation. MRI scans are shown in Figures 16a and 16b. What is the most likely cause of his weakness?

Explanation

DISCUSSION: The MRI scans show a paralabral cyst, which is most commonly associated with labral tears. Compression of the suprascapular nerve results in weakness of the supraspinatus and/or infraspinatus depending on the level of compression.
REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Inokuchi W, Ogawa K, Horiuchi Y: Magnetic resonance imaging of suprascapular nerve palsy.

J Shoulder Elbow Surg 1998;7;223-227.

Question 58

A 61-year-old right-hand-dominant woman falls down the stairs, resulting in a left anteroinferior dislocation and noncomminuted greater tuberosity fracture. A closed glenohumeral reduction with intravenous sedation is performed in the emergency department. After reduction, the greater tuberosity fragment remains displaced by 2 mm. What is the most appropriate treatment?

Explanation

Greater tuberosity fractures and rotator cuff tears associated with a traumatic dislocation are more commonly seen in women >60 years. Greater tuberosity fractures that are displaced <5 mm in the general population and
<3 mm in laborers and professional athletes can be treated successfully without surgery. Early passive range
of motion is important to avoid stiffness.

Question 59

Thoracic disk herniations are most frequently found in what area of the spine?

Explanation

DISCUSSION: Although thoracic disk herniations have been reported at all levels of the thoracic spine, more than two thirds are found at T9-T12, which is the more mobile lower third of the thoracic region.
REFERENCES: Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864.
Bohlman HH, Zdeblick TA: Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 1988;70:70-77.

Question 60

The majority of severe cervical spine injuries occurring in contact sports evolve during axial loading and flexion of the cervical spine. At what minimum degree of flexion does axial loading place the cervical spine at risk during contact sports?

Explanation

DISCUSSION: The paravertebral musculature, the intervertebral disks, and the normal lordotic curvature of the cervical spine can absorb much of the imparted energy of collision. However, when the neck is flexed approximately 30 degrees, the normal lordotic curvature is flattened and the forces applied to the vertex of the head are directed at a straight segmented column. In this situation, the cervical spine is less able to absorb the applied force. With mounting axial load, compressive deformation occurs within the intervertebral disks, causing angular deformation and buckling. The spine will fail in flexion, with resultant fracture, subluxation, or dislocation. A rotatory component added to axial compression can cause concomitant extension, rotation, and shear injury patterns. The National Football Head and Neck Injury Registry has made two recommendations to the NCAA Football Rules Committee to minimize the risk of such injuries: (1) No player should intentionally strike an opponent with the crown or top of the helmet; and (2) No player should deliberately use his helmet to butt or ram an opponent.
REFERENCES: Thomas BE, McCullen GM, Yuan HA: Cervical spine injuries in football players. J Am Acad Orthop Surg 1999;7:338-347.
Torg JS, Truex R Jr, Quedenfeld TC, Burstein A, Spealman A, Nichols C III: The National Football Head and Neck Injury Registry: Report and conclusions 1978. JAMA 1979;241:1477-1479.

Question 61

A 10‘/2-year-old boy sustained the injury shown in Figure 72 when he fell out of a tree. This is a closed, neurologically intact injury and the patient has no head injury or loss of consciousness. He weighs 115 pounds and is otherwise healthy. What is the optimal treatment option for this injury?

Explanation

DISCUSSION: Although flexible intramedullary nails are a good treatment alternative for femoral shaft fractures in older children, patients weighing more than 100 pounds have a higher incidence of complications that include bending of the nails. Therefore, transtrochanteric solid intramedullary nail fixation is most likely the best option for this patient. Using a greater trochanteric entry point avoids the piriformis fossa and the possibility of osteonecrosis. External fixation is not a good alternative for this patient because of the transverse nature of the fracture. External fixation of this fracture pattern has been associated with a high refracture rate. Traction and casting can be performed but results in a lengthy hospital stay and a very large cast in an overweight 10-year-old child.
REFERENCES: Flynn JM, Schwend RM: Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;12:347-359.
Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295-1301.

Figure 71a Figure 71b Figure 71c Figure 71d

Question 62

A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Explanation

There are many causes of rickets and osteomalacia. Renal osteodystrophy is a common complication of chronic renal failure and is one of the most common causes of osteomalacia. Pure osteomalacia is caused by the aluminum in phosphate binders used to treat hyperphosphatemia in renal failure. Desferoxamine is an effective chelator of aluminum in patients with biopsy documented aluminum-associated osteomalacia. Pure osteomalacia also can be caused by hypophosphatemia. The other choices are part of the mechanism of bone changes in renal osteodystrophy.

Question 63

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

Explanation

Question 64

A 26-year-old man has had a 2-year history of pain and stiffness after sustaining a comminuted olecranon fracture. Treatment at the time of injury consisted of open reduction and internal fixation with tension band wiring. Examination reveals motion of 45 degrees to 110 degrees and pain throughout the arc of motion. Resisted flexion and extension are painful. Forearm rotation is normal. Radiographs are shown in Figure 51. Treatment should consist of

Explanation

DISCUSSION: The patient has posttraumatic arthritis of the elbow; therefore, the treatment of choice is hardware removal and soft-tissue releases with splinting to avoid recurrence of contractures. The combination of pain and stiffness in an elbow that has sustained significant joint surface damage renders it unresponsive to simple soft-tissue releases and heterotopic bone excision. Joint distraction and interposition arthroplasty offer the possibility of maintaining motion and relieving pain as a later salvage procedure. Joint replacement should not be performed in young, active, strong individuals because the prosthesis will fail quickly and complications will develop. Synovectomy and radial head excision are not indicated.
REFERENCES: Morrey BF: Distraction arthroplasty: Clinical applications. Clin Orthop 1993;293:46-54.
O’Driscoll SW: Elbow arthritis: Treatment options. J Am Acad Orthop Surg 1993;1:106-116.

Question 65

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

Explanation

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

Question 66

A patient has pain 2 years after undergoing a metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with a prognosis if this patient is having a reaction to metal debris?

Explanation

Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on- polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor- functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Question 67

A year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Postreduction CT is shown in 2 through What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 68

A 57-year-old man has had a 2-week history of neck pain. He has no history of radiating symptoms, and has no complaints of numbness or paresthesias. There was no trauma associated with the onset of the pain. Figure 26 shows the MRI scan initially obtained by his family physician. What should the patient be told regarding the prevalence of the MRI findings in his age group? Review Topic

Explanation

The MRI findings reveal age-related degenerative changes in the cervical spine, which is a very common finding in the adult population. Boden and associates evaluated cervical spine MRI findings on 63 asymptomatic subjects, and found that the prevalence of having at least one degenerative disk was approximately 57% in those older than age 40 years.

Question 69

Figure 12 shows the radiograph of a 15-year-old boy with cerebral palsy who has pain at the first metatarsophalangeal joints. He is a community ambulator. Management consisting of accommodative shoes has failed to provide relief. What is the treatment of choice?

Explanation

DISCUSSION: While other surgeries have provided some success, first metatarsophalangeal joint arthrodesis has the highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy. The recurrence rate is unacceptably high with the other procedures listed above. In contrast, neurologically normal children are amenable to osteotomies and soft-tissue procedures.
REFERENCES: Davids JR, Mason TA, Danko A, et al: Surgical management of hallux valgus deformity in children with cerebral palsy. J Pediatr Orthop 2001;21:89-94.
Jenter M, Lipton GE, Miller F: Operative treatment for hallux valgus in children with cerebral palsy. Foot Ankle Int 1998;19:830-835.

Question 70

What is the dominant component of articular cartilage extracellular matrix by weight?

Explanation

DISCUSSION: Articular cartilage is a highly organized viscoelastic material, and load transmission depends on the specific composition of the extracellular matrix. Articular cartilage is devoid of neural, lymphatic, and blood vessel tissue. The extracellular matrix consists of water, proteoglycans, and collagen. Water comprises most of the wet weight (65% to 80%). Type II collagen comprises 95% of the collagen. The collagen and proteoglycan (keratan sulfate and chondroitin sulfate) matrix and its high water content are responsible for the mechanical properties of the articular cartilage.
REFERENCES: Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Inst Course Lect 1998;47:487-504.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 3-18.

Question 71

Which of the following lesions most closely resembles Ewing’s sarcoma histologically?

Explanation

DISCUSSION: Ewing’s sarcoma is characterized by small round blue cells. Lesions with a similar appearance include lymphoma, primitive neuroectodermal tumor, rhabdomyosarcoma, small cell lung tumor, and metastatic neuroblastoma. Karyotyping, immunohistochemistry, and electron microscopy can help differentiate these lesions.
REFERENCE: Wold LE, McLeod RA, Sim FH, Unni KK: Atlas of Orthop Pathology. Philadelphia, PA, WB Saunders, 1990.

Question 72

A 9-month-old nonambulatory girl is seen in the emergency department with a fracture of her right forearm. The mother says she fell from the changing table yesterday and continues to cry and not use her right arm. Radiographs are shown in Figure 31. Treatment should consist of which of the following? Review Topic

Explanation

The occurrence of a forearm fracture in a 9-month-old child has a greater than 50% chance that the injury is due to child abuse. It is mandatory to report this to child protective services unless there is some compelling reason that it is definitely not child abuse. In addition, a skeletal survey should be requested to look for other injuries. A bone scan would show other injuries, but a skeletal survey is a more
efficient way to evaluate for other fractures. A MRI of the brain is not indicated unless fundoscopic examination reveals an abnormality.

Question 73

Rickets can be best characterized by which of the following radiographic changes in children?

Explanation

Rickets is a condition of inadequate mineralization of osteoid and cartilage at the growing ends of bone in children. It is associated with a nutritional deficiency in children that affects open physes, as opposed to osteomalacia which is a deficiency in people with closed growth plates. There are classic radiographic findings and disorders that mimic rickets. Classic findings are widened physes related to widening of the physis from accumulation of nonmineralized osteoid and cartilage, irregular metaphyses, and loss of definition of the zone of provisional calcification. The changes are seen predominantly in the bones with greatest growth (tibia, distal femur, distal radius) and rarely seen in slower growing bones such as the tubular bones in the hand. Widening of the anterior ribs, the rachitic rosary, may be seen. Hyperparathyroidism with accumulation of fibrous tissue in the metaphyses can produce lucencies that may appear similar to the nonmineralized osteoid of rickets. Hyperparathyroidism has erosion around the edge of the growth plate. There are punched out lesions and resorption subperiosteally. Rounded epiphyses and marked separation of the epiphysis and metaphysis are the classic differentiation of Jansen syndrome, a dominantly inherited metaphyseal chondrodysplasia. Sclerotic metaphyseal ends are similar to rickets, but with maturation, the spaces fill with irregular calcification classic to Jansen syndrome. Sclerotic of the vertebra, or "rugger jersey" spine, is typical of renal osteodystrophy.

Question 74

Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?

Explanation

DISCUSSION: The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.
REFERENCE: Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Question 75

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. What is the most appropriate treatment?

Explanation

A 20-year-old division 1 collegiate football player presents with an acute left ankle injury. He states that as he was carrying the football, his left foot became trapped under another player while his body was rotated inward, causing a hyperexternal rotation moment to his ankle. He was unable to return to the game secondary to pain and inability to bear weight. Radiographs did not show any fracture. An external rotation stress radiograph is shown in Figure 1. In comparison to screw fixation, suture button fixation of this injury has demonstrated what clinical
outcomes? 16
A. Decreased American Orthopaedic Foot and Ankle Society (AOFAS) scores at 2- year follow-up
B. Slower return to work
C. Increased rate of hardware removal
D. Decreased rate of syndesmotic malreduction
The clinical vignette demonstrates an unstable left ankle syndesmotic injury, also known as a “high ankle sprain”. The distal tibiofibular syndesmosis comprises five structures: the anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, the interosseous membrane, the interosseous ligament, and the inferior transverse ligament.
This injury commonly occurs secondary to a forced external rotation motion of the foot. Stable grade 1 strains without diastasis on stress radiographs can be treated with a period of non-weight bearing followed by physical therapy. Unstable injuries, grade 2 and 3, which demonstrate diastasis on external rotation stress radiographs, are commonly treated operatively. Fixation constructs commonly include screw fixation, suture button fixation, or a hybrid combination technique. Naqvi and associates demonstrated more accurate syndesmotic reduction with suture button fixation versus screw fixation. Syndesmotic malreduction has been shown to be an important independent predictor of decreased clinical outcomes. Andersen and associates demonstrated higher AOFAS scores and diminished syndesmotic widening at radiographic follow-up at 2 years with suture button fixation. In a systematic review, Zhang and associates demonstrated higher AOFAS scores, diminished need for implant removal (3.7% vs 40.2%), diminished implant failure, and lower rates of malreduction (1% vs 12%). Thornes and associates demonstrated a faster return to work following suture button fixation versus screw fixation.
21- A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious deformity on his radiographs. What structures were
compromised during his excision? 17
A. Anterior and superior acromioclavicular joint ligaments
B. Posterior and superior acromioclavicular joint ligaments
C. Conoid ligament
D. Trapezoid ligament
The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.
22- Figures 1 and 2 are the T2-weighted MRI scans of a 54-year-old woman with medial knee pain and catching of 6 months’ duration. What treatment option is most likely to be associated with a favorable outcome?
A. Physical therapy
B. Meniscal repair
C. Meniscectomy
D. Reconstruction
The MRI scans reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root 18
repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.
22- A 24-year-old semiprofessional baseball player has noted increasing medial elbow pain for the past 2 months. This has been associated with a concomitant loss in velocity and control. He denies pain, numbness, or tingling in the hand or digits. Examination demonstrates medial elbow tenderness and swelling. Elbow range of motion is full. There is pain with milking maneuver and valgus stress test. Tinel’s sign is negative over the cubital tunnel, and there is no ulnar nerve subluxation. His MRI scan is shown in Figure 1. After thorough discussion, the player elects to undergo surgical intervention. What surgical variable has been associated with inferior outcomes?
A. Use of palmaris autograft
B. Ulnar nerve transposition
C. Muscle-splitting approach
D. Use of a docking technique
The information and image provided describe a throwing athlete with a complete tear of his ulnar collateral ligament (UCL) of the elbow. Numerous techniques have been described for UCL reconstruction, and at this time, optimal graft choice and fixation methods have not been established. Most studies show no.
major differences in outcome between gracilis autograft palmaris autograft, and allograft. Similarly, no clear advantage has been established when comparing use of bone tunnels with interference screws, tunnels with a docking technique, modified docking techniques, and combination

Question 76

Figures 86a through 86c are the radiographs and biopsy specimen of a 14-year-old boy who has had left knee pain for 4 weeks. What is the most likely diagnosis?

Explanation

Question 77

A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year. The pain is worse with weight bearing and is better with rest and the use of an ankle brace. What findings are shown on the MRI scans shown in Figures 18a through 18c?

Explanation

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath. This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.
REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction). Foot Ankle Clin 1997;2:241-260.
Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle 1992;13:208-214.

Question 78

Figure 1 shows a radiograph obtained from an active 30-year-old man who sustained an injury to his ring finger 1 week earlier. The most appropriate treatment is

Explanation

EXPLANATION:

Figure 1 reveals evidence of an intra-articular distal phalanx fracture with a distal interphalangeal (DIP) joint dorsal subluxation. This injury is unstable and requires surgical management for an active individual. Volar distal phalanx fractures are often associated with flexor digitorum profundus avulsion injuries, which are addressed concomitantly. This injury was treated with ORIF of the intra-articular fracture, pinning of the DIP joint, and repair of an avulsed flexor digitorum profundus tendon with a button on the dorsal nail plate, as shown in Figure 2. Splint immobilization would not maintain a reduction of this unstable injury. The terminal tendon is not injured in this patient but is often injured in a dorsal distal phalanx fracture with a volar dislocation. Arthrodesis of the DIP is a salvage procedure and would not be considered acutely.

Question 79

Which of the following radiographic views best assesses anterior coverage of the dysplastic hip?

Explanation

DISCUSSION: Anterior coverage of the hip may be best estimated by the anterior center edge angle of Lequesne and de Seze (analogous to Wiberg’s angle), which is measured on the well-defined faux profil view. Evaluation with CT scans also has been described.
REFERENCES: Klaue K, Wallin A, Ganz R: CT evaluation of coverage and congruency of the hip prior to osteotomy. Clin Orthop 1988;232:15-25.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.

Question 80

A 25-year-old left hand-dominant man has severe left shoulder pain after being involved in a high-speed motor vehicle accident. Examination reveals that he is unable to move the left shoulder. His neurovascular status is intact in the entire left upper extremity. A radiograph is shown in Figure 19. What is the most appropriate surgical management of this injury?

Explanation

DISCUSSION: In this young patient, every attempt must be made to retain the native proximal humerus; therefore, open reduction and internal fixation should be attempted of both the articular segment and tuberosities to the humeral shaft. This is best accomplished through an open approach. Shoulder arthroplasty should be reserved for the elderly and for failed internal fixation.
REFERENCES: Ko JY, Yamamoto R: Surgical treatment of complex fractures of the proximal humerus. Clin Orthop Relat Res 1996;327:225-237.
Aschauer E, Resch H: Four-part proximal humeral fractures: ORIF, in Warner JP, Iannotti JP, Flatow EL (eds): Complex and Revision Problems in Shoulder Surgery, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 289-309.

Question 81

A 21-year-old professional ballet dancer reports a painful popping sensation over her right hip joint. Examination reveals that symptoms are reproduced with hip flexion and external rotation. Which of the following studies will best confirm the diagnosis? Review Topic

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.

Question 82

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

Explanation

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation; this must be avoided by careful attention to initial resting position and station of the knee.

Question 83

Long-term alendronate (Fosamax) use for osteoporosis has been associated with which of the following?

Explanation

Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency
fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with uterine cancer or a detached retina.

Question 84

.Figures 75a through 75d are the radiograph, CT scan, bone scan, and biopsy of a 45-year-old man who has had a several-month history of progressive pain in his right hip and groin region. Based on these images and histology, what is the most appropriate treatment?

Explanation

Question 85

A 75-year-old woman notes a slowly enlarging mass in the right anterior thigh. Her medical history is significant only for hypertension. An MRI scan of her thigh is shown in Figures 60a through 60d. Which of the following surgical margins is the most appropriate for removal of this lesion?

Explanation

DISCUSSION: The patient has a large deep anterior thigh mass that has imaging characteristics of mature fat. Intramuscular lipomas are effectively treated with marginal resections with very low recurrence rates. Large lipomas often have small amounts of intralesional signal changes frequently representing trapped muscle fibers and do not necessitate more extensive margins.
REFERENCES: Gaskin CM, Helms CA: Lipomas, lipoma variants, and well-differentiated liposarcomas (atypical lipomas): Results of MRI evaluations of 126 consecutive fatty masses. Am J Roentgenol 2004;182:733-739.
Rozental TD, Khoury LD, Donthineni-Rao R, et al: Atypical lipomatous masses of the extremities: Outcome of surgical treatment. Clin Orthop Relat Res 2002;398:203-211.

Question 86

Figures 40a and 40b show the pre- and postoperative radiographs of an 82-year-old woman with bilateral hip pain who has had staged total hip arthroplasties. To minimize potential injury to the sciatic nerve at the time of surgery, the surgeon should

Explanation

DISCUSSION: To improve hip biomechanics and secure more suitable bone for acetabular fixation, the true acetabulum is often resurfaced in patients who have developmental dysplasia of the hip, thus lowering the hip center and lengthening the leg. Acute lengthening of more than 3 cm will place excessive tension on the sciatic nerve and require a femoral shortening to avoid sciatic nerve injury. The other maneuvers will not relieve sciatic nerve tension because of

limb lengthening.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 430-431.
Sanchez-Sotelo J, Berry DJ, Trousdale RT, et al: Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options. J Am Acad Orthop Surg 2002;10:334-344.

Question 87

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Explanation

DISCUSSION: The PCL is a nonisometric structure with nonuniform tension during knee motion, with maximum tension at 90° of flexion. While the posteromedial PCL fibers have been found to be the most isometric, the anterolateral fibers represent the bulk of the ligament. Studies have suggested that anterior placement of the femoral tunnel is superior to placement in an isometric position. The anterolateral bundle tightens as the knee flexes; therefore, it is optimal to tension the graft at 90° of flexion.
REFERENCES: Harner CD, Xerogeanes JW, Livesay GA, et al: The human posterior cruciate ligament complex: An interdisciplinary study. Ligament morphology and biomechanical evaluation. Am J Sports Med 1995;23:736-745.
Burns WC II, Draganich LF, Pyevich M, Reider B: The effect of femoral tunnel position and graft tensioning technique on posterior laxity of the posterior cruciate ligament-reconstructed knee. Am J Sports Med 1995;23:424-430.

Question 88

Figures 25a and 25b are the radiographs of a 63-year-old man who had right total hip arthroplasty (THA) 4 months ago. Progressive stiffness began 2 months after surgery, and he now reports pain only after prolonged physical activity. His examination reveals normal gait and painless range of motion with flexion of 70 degrees, extension of 0 degrees, internal rotation of 20 degrees, external rotation of 20 degrees, abduction of 10 degrees, and adduction of 10 degrees. His erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are within defined limits. Physical therapy has produced no benefit. What is the most appropriate next step?

Explanation

DISCUSSION
This patient presents with HO 4 months after undergoing THA. Symptomatic HO may complicate nearly 7% of primary THA cases. Improvement in pain is expected within 6 months, and most patients will not need surgical treatment. Surgical excision may be warranted for symptomatic patients after full maturation of the HO, usually 6 to 18 months after the surgery. Patients can be followed with repeated serum alkaline phosphatase levels, which are elevated initially and should return to normal upon maturation of HO. Alternatively, a bone scan can show decreased activity once the HO has matured. Twenty-five milligrams of indomethacin 3 times daily for 6 weeks or 1 dose of irradiation at 700 to 800 Gy is effective in the prevention of HO, not for the treatment of established HO.
RESPONSES FOR QUESTIONS 26 THROUGH 29
Minimum inhibitory concentration (MIC)
Minimum bactericidal concentration (MBC)
Antiobiotic susceptibility
Antibiograms
Antimicrobial resistance
Spectrum of coverage
Match the description below with the appropriate response above.

Question 89

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 90

A 20-year-old man involved in a motor vehicle accident is brought to the emergency department with a C6-7 unilateral facet dislocation. His neurologic examination reveals a focal left-sided C7 nerve root palsy. He is awake and cooperative with questioning and has no other obvious traumatic injuries. What is the most appropriate treatment at this time? Review Topic

Explanation

In the patient who is neurologically intact or has an incomplete injury from a cervical facet dislocation, a closed reduction with weighted tong traction is appropriate when the patient is awake, alert, and cooperative. Although there is a risk that a cervical facet dislocation could occur with an underlying cervical disk herniation, Vaccaro and associates have shown that closed reduction can be safely carried out in the awake, responsive patient. Closed reduction can be performed in the emergency department with traction with skull tongs or a halo ring. A slow stepwise application of weight is added until a reduction is achieved. Any worsening of the neurologic status of the patient requires immediate termination of the closed reduction and further diagnostic imaging before proceeding with further treatment.

Question 91

Figures 1 through 3 show the clinical photographs obtained from a 45-year-old woman who is right-hand dominant. She has pain in the left ring proximal interphalangeal (PIP) joint that gets worse during lifting or gripping activities. On examination, she has PIP range of motion of 15° to 50° with laxity of the radial collateral ligament and tenderness around the joint. The flexor and extensor tendons are intact. She has rotational malalignment when making a composite fist. Radiographs reveal end-stage arthritis at the PIP joint. She elects to move forward with surgery and undergoes arthroplasty. What component of the examination is essential to determine which implant arthroplasty—silicone or surface replacement—is best?

Explanation

EXPLANATION:
This patient has end-stage arthritis in conjunction with ligament insufficiency. The treatment for arthritis is arthroplasty or fusion. Given that her ring finger is affected, arthroplasty is recommended to preserve motion and grip. Two types of arthroplasties are available: silicone and surface replacement. The prerequisites are the same for both and include good bone stock, good sensibility of the joint, adequate soft-tissue coverage, and normally functioning tendons. Adequate collateral ligaments are required for surface replacement arthroplasty. This patient has a deficiency of the radial collateral ligament, evidenced by her clinical examination. Thus, silicone arthroplasty is the recommended option for joint replacement in this patient.

Question 92

The use of bisphosphonates in children with osteogenesis imperfecta is becoming more widely accepted as treatment to improve quality of life and to decrease the risks of fracture. What is the mechanism by which bisphosphonates work?

Explanation

The mechanism by which bisphosphonates act is by inhibiting osteoclasts. One mechanism of bisphosphonates is to cause osteoclast apoptosis. Another mechanism of bisphosphonates is to disrupt the cytoskeleton of osteoclasts, resulting in loss of the ruffled border. The uncoupling of bone resorption and bone formation with decreased bone resorption results in increased bone mineralization. This translates into fewer fractures in patients with osteogenesis imperfecta and improved quality of life.

Question 93

An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play?

Explanation

DISCUSSION: Infectious mononucleosis commonly affects adolescents and young adults. It is a febrile illness accompanied by acute pharyngitis. Splenomegaly may occur and predispose the athlete to splenic rupture. Splenic rupture has been reported in nonathletes as well as in patients with normal-sized spleens. Clinical evidence supports a return to all sports 4 weeks after the onset of symptoms provided that the spleen has returned to normal size.
REFERENCES: Auwaerter PG: Infectious mononucleosis: Return to play. Clin Sports Med 2004;23:485-497.
Kinderknecht JJ: Infectious mononucleosis and the spleen. Curr Sports Med Rep
2002;1:116-120.

Question 94

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

Explanation

DISCUSSION: The radiograph shows a faux profil view of the hip. The primary purpose of this view is to evaluate anterior coverage of the femoral head.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Lequesne M, deSez S: Le faux profil du bassin: Nouvelle incidence radiographique pour l’etude de la hance. Son utilite dans les dysplasies et les differentes coxopathies. Rev Rhum Mal Osteoartic 1961;28:643.

Question 95

Figure 7 is the MR image of a 43-year-old man who has left shoulder pain with a traumatic rotator cuff tear after a fall. An examination reveals active forward elevation at 120 degrees and positive Yergason and lift-off test results. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

DISCUSSION

Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 96

Figures 52a and 52b show the radiographs of a left proximal femoral lesion noted serendipitously following minor trauma to the left hip. The patient has no thigh pain and is fully active without limitation. What is the most likely diagnosis of this bony lesion?

Explanation

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 97

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Explanation

Fixation of pelvic and acetabular fractures in pregnancy is not contraindicated. However, both maternal and fetal morbidity and mortality is increased in this patient subset. Factors shown to be associated with increased fetal mortality include: injury severity, mechanism of injury, and maternal hemorrhage. Surgical approach, fracture classification, fetal position, and the trimester of pregnancy have not been shown to affect fetal morbidity or mortality.

Question 98

Figures 19a through 19c show radiographs of the cervical spine of an asymptomatic patient with Down syndrome who wants to participate in a Special Olympics running event. The neurologic examination is normal. Management should consist of

Explanation

DISCUSSION: An atlanto-dens interval (ADI) of up to 4 mm in children is considered normal. Children with Down syndrome have increased ligamentous laxity, with atlantoaxial instability occurring in as many as 15% to 20% of patients. These patients are at risk for catastrophic injury following minor trauma and should be routinely screened for instability, generally beginning when the patient starts to walk. Patients with an ADI of greater than 5 mm should avoid contact sports and high-risk activities such as gymnastics, diving, the high jump, and the butterfly stroke. The American Academy of Pediatrics Committee of Sports Medicine and Fitness guidelines recommend that lateral views of the cervical spine in neutral, flexion, and extension should be obtained in all children with Down syndrome who wish to participate in sports. Patients with normal radiographs and examinations do not need repeat radiographs, although some authors suggest that instability increases with age, and therefore recommend repeat radiographs every 5 years. Cervical spine fusion in patients with Down syndrome has a high rate of complications and should be performed only on patients with symptoms and evidence of myelopathy.
REFERENCES: American Academy of Pediatrics Committee of Sports Medicine and Fitness: Atlantoaxial instability in Down syndrome. Pediatrics 1995;96:151-154.
Copley LA, Dormans JP: Cervical spine disorders in infants and children. J Am Acad Orthop Surg 1998;6:204-214.
Tredwell SJ, Newman DE, Lockitch G: Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 1990;10:602-606.

Question 99

Which component is most common to both simple and complex elbow dislocations?

Explanation

DISCUSSION: Elbow dislocations are classified as either simple (no associated fracture) or complex (associated fracture). The goal of treatment is a stable joint that tolerates early motion. The initial range of motion is the stable arc found on postreduction examination. Studies have demonstrated a better outcome when simple elbow dislocations are treated non-surgically rather than with surgical repair. Simple elbow dislocations usually have an excellent outcome (return of functional range of motion with normal strength). A loss of terminal extension is the most common sequelae.

Question 100

Which factor should most influence a patient's decision to have surgery for adult scoliosis if he or she is younger than age 50?

Explanation

DISCUSSION
In a retrospective review of 137 patients treated surgically and 153 patients treated nonsurgically for adult scoliosis, Bess and associates found that surgical treatment for patients younger than 50 years of age was driven by increased coronal plane deformity, and surgical treatment for older patients was mandated by pain and disability. They also concluded that age, comorbidities, and sagittal balance did not influence treatment decisions.
RECOMMENDED READINGS
Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2186-90. PubMed PMID: 19752704.View Abstract at PubMed
Anderson DG, Albert T, Tannoury C. Adult scoliosis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:331-338.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Surgical reconstruction
Rest, followed by physical therapy
Splinting in 15 degrees of flexion
Primary repair
Arthroscopic debridement, followed by bracing in full extension for 4 weeks

Correct Answer: Surgical reconstruction

Explanation:

Question 2:

- The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the

Options:

Oblique popliteal ligament
Lateral capsule
Popliteal tendon
Fibular collateral ligament
Posterior oblique ligament

Correct Answer: Lateral capsule

Explanation:

Question 3:

Figures 20a and 20b are the radiographs of a 19-year-old woman who was involved in a motor vehicle accident. What mechanism of injury is most consistent with the injury?

Options:

Vertical shear
External rotation
Sagittal translation
Lateral compression
Anterior posterior compression

Correct Answer: Lateral compression

Explanation:

Question 4:

Options:

Posterior tibial tendinitis
Tarsal tunnel syndrome
Os trigonum impingement syndrome
Insertional tendinitis of the Achilles tendon
Osteochondritis dissecans of the talus

Correct Answer: Os trigonum impingement syndrome

Explanation:

Question 5:

Options:

Complex regional pain syndrome
Wartenberg’s syndrome
Carpal tunnel syndrome
Palmar cutaneous nerve injury
C7 radiculopathy

Correct Answer: Palmar cutaneous nerve injury

Explanation:

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 6:

A 36-year-old skier sustains a grade III posterior cruciate ligament (PCL) tear. Where will increased contact pressures develop over time?

Options:

Ligament of Humphrey
Patellar ligament
Quadriceps tendon
Lateral compartment
Medial compartment

Correct Answer: Medial compartment

Explanation:

Question 7:

What approach should be chosen for the injury seen in Figure 67? Review Topic

Options:

Stoppa
Hardinge
Ilioinguinal
Watson Jones
Kocher-Langenbeck

Correct Answer: Kocher-Langenbeck

Explanation:

Question 8:

Options:

until his symptoms resolve and the MRI findings return to normal.
until his symptoms resolve and his physical examination findings return to normal.
until he undergoes surgical decompression.
until he undergoes surgical decompression and fusion.
again because it is considered a career-ending injury.

Correct Answer: until his symptoms resolve and his physical examination findings return to normal.

Explanation:

Question 9:

Which factor increases the success rate associated with all-inside lateral meniscal repair?

Options:

Concomitant anterior cruciate ligament (ACL) reconstruction
Concomitant medial meniscus repair
Older patient age
Varus knee alignment

Correct Answer: Concomitant anterior cruciate ligament (ACL) reconstruction

Explanation:

Question 10:

Options:

Electromyography and nerve conduction velocity studies of bilateral lower extremities
Multilevel lumbar laminectomy
MRI of the thoracic and cervical spine
MRI of the brain
Epidural steroid injections

Correct Answer: MRI of the thoracic and cervical spine

Explanation:

Question 11:

According to clinical and biomechanical studies, the most appropriate position for a headless scaphoid compression screw for repair of a scaphoid waist fracture is

Options:

retrograde to protect the dorsal blood supply to the scaphoid.
retrograde eccentrically in the dorsal scaphoid to avoidtrapezium impingement.
deep and centrally placed, respecting the articular surface.
anterograde to protect the volar blood supply to the scaphoid.

Correct Answer: deep and centrally placed, respecting the articular surface.

Explanation:

EXPLANATION:
The position of a scaphoid screw for scaphoid fracture repair (Figure 1) is as critical as the position of a sliding hip screw for intertrochanteric fracture repair. Positioning the screw deep in the center of the densest portion of cancellous bone is beneficial for both of these fracture types.Trumble and associates have shown time to union for scaphoid nonunions to be decreased for centrally placed scaphoid screws. McCallister and associates documented improved biomechanical stability for scaphoid waist fractures repaired with a centrally placed screw vs an eccentrically placed screw. Dodds and associates
demonstrated significantly improved biomechanical stability with centrally placed long screws vs centrally placed short screws. The screw may be placed retrograde or antegrade. Although the screw position may be relatively parallel to the radial inclination as the shape of the scaphoid body follows the contour of the radial styloid, screw position should be assessed relative to the scaphoid’s own architecture. Placing the screw in a retrograde fashion can force the treating surgeon to start the screw eccentrically in an attempt to avoid the interference of the trapezium lying over the distal pole of the scaphoid. This may result in noncentral screw placement.

Question 12:

Options:

Sling for 3 days, with early active range of motion
Posterior splint for 5 to 7 days, forearm in full pronation
Posterior splint for 5 to 7 days, forearm in neutral
Posterior splint for 5 to 7 days, forearm in full supination

Correct Answer: Posterior splint for 5 to 7 days, forearm in full supination

Explanation:

Question 13:

-The patient requests anatomic double-bundle ACL reconstruction. Compared with transtibial singlebundle ACL reconstruction, anatomic double-bundle ACL reconstruction is more likely to

Options:

restore improved knee kinematics.
allow for earlier return to sports.
result in better clinical outcomes scores.
be associated with lower surgery cost.

Correct Answer: restore improved knee kinematics.

Explanation:

Question 14:

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Options:

Net decrease of type I collagen
Net increase of type I collagen
Increased diameter of collagen fibrils
Increased cross-sectional area of the tendon

Correct Answer: Net increase of type I collagen

Explanation:

Question 15:

Options:

The addition of a neck roll to the helmet and continuation of play
Electrodiagnostic studies
A series of epidural steroid injections, followed by a return to play
Methylprednisolone dose pack, followed by a return to play in 1 week
No further participation in football

Correct Answer: No further participation in football

Explanation:

Question 16:

Options:

MRI.
a long leg cast.
fasciotomy of the anterior compartment.
open reduction and internal fixation.
patellar advancement.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: The patient has a displaced intra-articular tibial tuberosity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Nondisplaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation.
REFERENCES: McKoy BE, Stanitski CL: Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003;34:397-403.
Zionts LE: Fractures around the knee in children. J Am Acad Orthop Surg 2002;10:345-355.

Question 17:

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

Options:

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

Correct Answer: Labral tear

Explanation:

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

Question 18:

A 43-year-old man has had right groin pain for the past 3 months. A radiograph, CT scan, and biopsy specimen are shown in Figures 18a through 18c. What is the most likely diagnosis?

Options:

Chordoma
Enchondroma
Dedifferentiated chondrosarcoma
Chondrosarcoma
Metastatic renal cell carcinoma

Correct Answer: Chondrosarcoma

Explanation:

Question 19:

A 35-year-old active woman with rheumatoid arthritis experiences right shoulder pain following an extended course of corticosteroids (Figures 96a and 96b).

Options:

Humeral head resurfacing/shoulder hemiarthroplasty
Anatomic total shoulder arthroplasty (TSA)
Reverse total shoulder arthroplasty (rTSA)
Rotator cuff repair
Open reduction and internal fixation (ORIF)

Correct Answer: Humeral head resurfacing/shoulder hemiarthroplasty

Explanation:

DISCUSSION
The indication for anatomic TSA is end-stage glenohumeral arthritis with an intact rotator cuff. For the 62-year-old man, his radiographs reveal osteoarthritis, and his MR image shows an intact rotator cuff. Although humeral head replacement has historically been employed for this disorder, pain relief is not as reliable as with TSA, and the revision rate is higher. rTSA is generally reserved for patients with a nonfunctional rotator cuff.
For this 58-year-old patient with a full-thickness rotator cuff tear, preserved motion, and weakness in forward elevation, a rotator cuff repair is the most appropriate treatment. In the absence of degenerative changes, shoulder hemiarthroplasty or anatomic TSA is not indicated. Although indications for rTSA continue to evolve, well-compensated range of motion and a medium-sized rotator cuff tear in a younger patient are not among them.
rTSA is an emerging treatment for comminuted proximal humerus fractures in elderly patients. Although hemiarthroplasty has been a traditional treatment, current evidence suggests rTSA more reliably restores range of motion, and this 78-year-old patient's CT scan shows a small and comminuted greater tuberosity fragment that is unlikely to heal. ORIF is another option, but the CT scan also shows a small humeral head fragment that suggests osteopenia, making fixation more tenuous and likely less reliable.
A common problem associated with hemiarthroplasty for glenohumeral osteoarthritis is symptomatic glenoid degeneration that necessitates revision. This 55-year-old patient’s images reveal this is the case, although his infection workup is negative. His examination findings suggest an intact subscapularis repair. With a functioning rotator cuff and symptomatic glenoid arthritis, a conversion to anatomic TSA is indicated. In the absence of a functioning rotator cuff in an older patient, an rTSA is a better option.
This 72-year-old patient has classic symptoms and radiographs of cuff tear arthropathy. For patients with massive rotator cuff tear and glenohumeral arthritis, neither anatomic TSA nor rotator cuff repair is indicated. Hemiarthroplasty has historically been indicated for cuff tear arthropathy, but rTSA outcomes for this disorder have been superior and are now the preferred option.
Comminuted proximal humerus fractures in young, active patients are treated primarily with ORIF. The absence of glenohumeral arthritis removes anatomic TSA as a possibility, and concerns about implant longevity in younger, active patients such as this 40-year-old laborer contraindicate rTSA. Hemiarthroplasty is still employed in 3- and 4-part fractures but is generally reserved for subacute presentations or dislocations in which the humeral head is dysvascular and unlikely to survive. In this acute setting, a fixation procedure is preferred.
The 71-year-old patient who has had 2 failed rotator cuff repairs has an MR image that reveals another recurrent tear that is retracted to the glenoid. Her examination findings reveal classic signs
of a decompensated rotator cuff tear with pseudoparalysis and weakness in forward elevation. Although infection is a concern in the setting of multiply failed rotator cuff repair, the workup is negative in this scenario. Because this patient has a dysfunctional rotator cuff and has failed previous attempts at repair, a conversion to rTSA is the better option. In the absence of degenerative changes, hemiarthroplasty and anatomic TSA are not indicated.
The indications for hemiarthroplasty continue to narrow, but it is still a consideration for young patients with unipolar shoulder degeneration. In this 35-year-old patient, her MR image shows avascular necrosis in the humeral head, and her arthroscopy suggests arthritic change only on the humeral side with an uncompromised glenoid. To best treat young and active patients, a hemiarthroplasty that articulates with healthy glenoid cartilage can provide good pain relief and functional outcomes. Anatomic TSA is also reasonable but not an optimal option considering the normal glenoid condition. rTSA is not a consideration when a young patient’s MR images reveal an intact rotator cuff.
RECOMMENDED READINGS
Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: longterm results. J Shoulder Elbow Surg. 1997 Nov-Dec;6(6):495-505. PubMed PMID: 9437598.
View
Abstract at PubMed
Chalmers PN, Slikker W 3rd, Mall NA, Gupta AK, Rahman Z, Enriquez D, Nicholson GP. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg. 2014 Feb;23(2):197-204. doi: 10.1016/j.jse.2013.07.044. Epub 2013 Sep 27. PubMed PMID: 24076000.
View Abstract at PubMed
Groh GI, Wirth MA. Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. J Shoulder Elbow Surg. 2011 Jul;20(5):778-82. doi: 10.1016/j.jse.2010.09.014. Epub 2011 Jan 13. PubMed PMID: 21232989.
View Abstract at PubMed
Orfaly RM, Rockwood CA Jr, Esenyel CZ, Wirth MA. Shoulder arthroplasty in cases with avascular necrosis of the humeral head. J Shoulder Elbow Surg. 2007 May-Jun;16(3 Suppl):S27-32. Epub 2006 Nov 16. PubMed PMID: 17113317.
View Abstract at PubMed
Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, Romeo AA, Nicholson GP. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg. 2014 Mar;23(3):395-400. doi: 10.1016/j.jse.2013.07.047. Epub 2013 Oct 12. PubMed PMID: 24129052.
View Abstract at PubMed

Question 20:

Figure 10 shows the MRI scan of a 56-year-old woman with metastatic breast cancer who now reports progressive paraparesis. Her general health remains good. Treatment should consist of

Options:

posterior spinal fusion for stabilization, followed by radiation therapy of the anterior tumor.
radiation therapy and a brace.
chemotherapy, then reevaluation.
anterior corpectomy and stabilization.
laminectomy.

Correct Answer: anterior corpectomy and stabilization.

Explanation:

Question 21:

During spinal deformity surgery, which of the following is the most specific early indicator of an intraoperative injury to the spinal cord? Review Topic

Options:

Somatosensory-evoked potentials
Transcranial motor-evoked potential monitoring
Transcutaneous electroencephalogram neuromonitoring
Stimulus-evoked transpedicular electromyography (EMG)
Brainstem auditory-evoked responses (BAERs)

Correct Answer: Transcranial motor-evoked potential monitoring

Explanation:

Question 22:

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Options:

Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness
Increased AGES is characteristic of osteoarthritis and results in increased articular cartilage stiffness
Increased AGES is characteristic of unresurfaced patellar cartilage after total knee arthroplasty and results in articular cartilage thinning
Increased AGES is characteristic of rheumatoid arthritis and results in synovial thickening
Increased AGES is characteristic hemarthrosis and results in articular cartilage staining

Correct Answer: Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness

Explanation:

Question 23:

Options:

Malignant fibrous histiocytoma
Liposarcoma
Synovial cell sarcoma
Leiomyosarcoma
Clear cell sarcoma

Correct Answer: Liposarcoma

Explanation:

DISCUSSION: The images show a complex, lobular lesion of the thigh that has signal characteristics that follow fat. The size of the lesion, the areas of stranding within the mass, along with mild uptake on the gadolinium sequences and the mild edema within the lesion on the T
2
-weighted image make liposarcoma the most likely diagnosis and simple intramuscular lipoma far less likely. All other diagnoses listed would not follow fat characteristics shown on the MRI sequences.
REFERENCE: Sanders TG, Parsons TW: Radiographic imaging of musculoskeletal neoplasia. Cancer Control 2001;8:221-231.

Question 24:

Lipohemarthrosis of the knee is most likely secondary to which of the following?

Options:

Seronegative monoarticular arthritis
Patellar tendon rupture
Medial meniscus tear
Medial patellofemoral ligament rupture
Occult fracture

Correct Answer: Seronegative monoarticular arthritis

Explanation:

Question 25:

Embolic material generated during total knee arthroplasty (TKA) shown in Figure 29 is composed of which of the following substances?

Options:

Fat only
Fat and air
Fat and marrow
Fat and cement
Fat and bone

Correct Answer: Fat and marrow

Explanation:

DISCUSSION: Emboli are created during TKA. Usually there is an increased incidence with the use of intramedullary rods that disrupt the marrow contents. These are not fat emboli per se. They are material composed of fat cells and marrow that act like pulmonary emboli to obstruct small arterioles in the lung. They are different from free fat emboli that are seen in fractures and that lead to chemical injury to the lung rather than obstructive injury.
REFERENCES: Markel DC, Femino JE, Farkas P, et al: Analysis of lower extremity embolic material after total knee arthroplasty in a canine model. J Arthroplasty 1999;14:227-232.
Pell AC, Christie J, Keating JF, et al: The detection of fat embolism by transoesophageal echocardiography during reamed intramedullary nailing: A study of 24 patients with femoral and tibial fractures. J Bone Joint Surg Br 1993;75:921-925.
McGrath BJ, Hsia J, Boyd A, et al: Venous embolization after deflation of lower extremity tourniquets. Anesth Analg 1994;78:349-353.

Question 26:

Options:

Abrasion arthroplasty of the anterior glenoid rim
Posterior capsular advancement into a Hill-Sachs defect
Repair of an inferior glenohumeral ligament detachment
Repair of an unstable SLAP tear
Closure of the rotator interval

Correct Answer: Closure of the rotator interval

Explanation:

Question 27:

A 72-year-old female sustains a displaced intracapsular femoral neck fracture. Which of the following is TRUE regarding the long term differences between possible treatment options for this injury?

Options:

Patients undergoing total hip arthroplasty are more likely to experience persistent pain than those undergoing internal fixation
Patients undergoing total hip arthroplasty are less likely to require reoperation than those undergoing internal fixation
There is no difference in functional outcome scores between internal fixation and total hip arthroplasty
Patients undergoing internal fixation perform activities of daily living better than those undergoing total hip arthroplasty
Mortality rates are higher following total hip arthroplasty than internal fixation

Correct Answer: Patients undergoing total hip arthroplasty are less likely to require reoperation than those undergoing internal fixation

Explanation:

Question 28:

Up to what time frame are the risks minimized in anterior revision disk replacement surgery? Review Topic

Options:

3 days
1 week
10 days
2 weeks
6 weeks

Correct Answer: 2 weeks

Explanation:

Question 29:

Options:

open reduction and exchange humeral nailing.
a custom orthosis and an external bone stimulator.
removal of the humeral nail and external fixation.
removal of the humeral nail and plate fixation with bone grafting.
open bone grafting and an internal bone stimulator.

Correct Answer: removal of the humeral nail and plate fixation with bone grafting.

Explanation:

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,
an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 30:

Options:

Lateral ulnar collateral ligament disruption
Anterior band of the medial collateral disruption
Posterior band of the medial collateral ligament disruption
Annular ligament interposition
Anconeus muscle interposition

Correct Answer: Lateral ulnar collateral ligament disruption

Explanation:

Question 31:

Options:

acceptance of the malalignment and continued cast immobilization.
repeat closed reduction with the aid of IV morphine and midazolam.
repeat closed reduction with the aid of IV ketamine.
repeat closed reduction with the patient under general anesthesia.
gentle open reduction with smooth cross-pin fixation.

Correct Answer: acceptance of the malalignment and continued cast immobilization.

Explanation:

DISCUSSION: In a 6-year-old child with a physeal fracture, the healing response 10 days after injury is so advanced that manipulation would have to be very forceful to be successful. A forceful manipulation in a patient this age increases the risk of early growth arrest and a significant disability because 80% of the growth of the radius comes from the distal physis. Because of the large contribution of growth from the distal radial physis and the angulation being in the plane of wrist motion, the potential for remodeling of this fracture is great. It is highly probable that this fracture will completely remodel in 1 to 2 years of growth. In this patient, even a “gentle” open reduction would probably require enough force that the physis would
be damaged.
REFERENCES: Dimeglio A: Growth in pediatric orthopaedics, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 33-62.
Waters PM: Forearm and wrist fractures, in Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 251-258.

Question 32:

Options:

Continue wet-to-dry dressing changes until the wound heals by secondary intention.
Perform a volar advancement flap (ie, Moberg flap).
Perform a V-Y advancement flap.
Perform a thenar flap.
Perform a cross-finger flap to the ring finger.

Correct Answer: Continue wet-to-dry dressing changes until the wound heals by secondary intention.

Explanation:

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 33:

Osteonecrosis of the femoral head after intramedullary nailing in children is thought to be the result of injury to the

Options:

artery within the ligamentum teres.
medial femoral circumflex artery.
lateral ascending cervical artery.
lateral femoral circumflex artery.
intraosseous blood supply.

Correct Answer: lateral ascending cervical artery.

Explanation:

Question 34:

Options:

Hip arthroscopy with labral repair
Reverse periacetabular osteotomy
Varus rotational osteotomy
Open surgical dislocation with rim trimming

Correct Answer: Reverse periacetabular osteotomy

Explanation:

Question 35:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis until the fracture has healed
Anterior corpectomy with strut grafting and placement of an anterior plate spanning L1 to L3
Anterior corpectomy with strut grafting, followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation from T11 to L4
L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Correct Answer: L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Explanation:

Question 36:

Patients with which of the following primary carcinomas have the shortest overall survival rate after a solitary metastasis to bone?

Options:

Prostate
Breast
Thyroid
Lung
Renal cell

Correct Answer: Lung

Explanation:

Question 37:

Options:

Nonsurgical management with the use of a cast-brace
Nonsurgical management with skeletal traction
Open treatment with a locked plate with or without strut allograft
Revision of the femoral component to a cemented femoral component that bypasses the fracture site by two cortical diameters
Revision of the femoral component to a cementless femoral component that bypasses the fracture site by at least two cortical diameters

Correct Answer: Revision of the femoral component to a cementless femoral component that bypasses the fracture site by at least two cortical diameters

Explanation:

Question 38:

Options:

Continued splint immobilization for 6 weeks
Pisiform excision
Hook of hamate excision
Open reduction and internal fixation with bone grafting
Lunotriquetral arthrodesis

Correct Answer: Pisiform excision

Explanation:

DISCUSSION: The oblique radiograph of the wrist reveals a displaced fracture of the pisiform that usually occurs following a direct blow or sudden contraction of the flexor carpi ulnaris tendon. Persistent pain secondary to pisotriquetral incongruity and degenerative arthritis warrants pisiform excision, which does not compromise wrist flexion strength. Pisiform fractures are usually missed on routine radiographic views. An oblique or carpal tunnel view can be helpful in visualizing the pisotriquetral joint.
REFERENCE: Fleege MA, Jebson PJ, Renfrew DL, et al: Pisiform fractures. Skeletal Radiol 1991;20:169-172.

Question 39:

- Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Options:

Injury to the subclavian artery
Injury to the brachial plexus
Segmental fracture
100% displacement
Associated displaced surgical neck fracture of the humerus

Correct Answer: Injury to the subclavian artery

Explanation:

Question 40:

Options:

extensor digitorum brevis.
plantar fascia.
peroneus brevis.
peroneus longus.
syndesmosis.

Correct Answer: peroneus longus.

Explanation:

Question 41:

An eversion mechanism of injury is associated with which of the following ankle conditions?

Options:

Peroneal tendon splits
Osteochondral talar dome fracture
Superficial peroneal nerve palsy
Anterolateral soft-tissue impingement
Fracture of the anterior colliculus

Correct Answer: Fracture of the anterior colliculus

Explanation:

Question 42:

Options:

Immediate MRI of the brain
Electromyography and nerve conduction velocity studies
Physical therapy and observation
Lyme titer
Psychiatric consultation

Correct Answer: Electromyography and nerve conduction velocity studies

Explanation:

Question 43:

Options:

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

Correct Answer: - Early mobilization with physical therapy initiated within 2 weeks

Explanation:

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
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
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430.
View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 44:

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Options:

Substantially improved radiographic fusion success rate
Substantially decreased time to fusion healing
Substantially decreased hospital stay
Elimination of autograft harvest
Elimination of need for postoperative bracing

Correct Answer: Elimination of autograft harvest

Explanation:

Question 45:

Which of the following pelvic injury types has the highest reported mortality rate?

Options:

Anterior posterior compression (APC) III injury
Lateral compression (LC) III injury
Transverse-posterior wall acetabular fracture
Vertical Shear
Combined mechanical injury (CMI) Corrent answer: 1 Anterior posterior compression (APC) injuries have the highest mortality rates of the fracture patterns listed. APC injuries have high rates of concomitant thoracic and abdominal visceral injuries leading to the highest rates of mortality among pelvic fractures. Lateral compression (LC) fractures have particularly high incidences of associated brain and head injury with lower mortality than APC injuries. Overall, as the grade of pelvic ring injury increases the rates of associated injuries increases, regardless of exact mechanism of injury. The overall mortality rate for any pelvic trauma is roughly 15%, with APC III mortality around 37%, and overall APC mortality rates around 26%. LC of any grade has an estimated mortality around 13%. Vertical shear and CMI have estimated mortality of 25% and 17.1%, respectively. The lowest mortality rates are following acetabular fractures with estimates around 1.5%. Dalal et al retrospectively reviewed 340 trauma patients with pelvic injuries to analyze organ injury, resuscitative requirements, and outcomes. They found the highest mortality rates were in APC III and that more severe APC injuries had greater organ damage and mortality. They conclude that the mechanical force type and classification of injury are predictors of organ injury pattern, resuscitation needs, and mortality. Eastridge et al reviewed 1,014 injured pedestrians for pelvic injuries, associated injuries, and relationship of treatments to outcomes. They found the highest mortality rates were associated with APC III and LC III injuries patterns at 50%. They conclude that pelvic fractures are a sign of significant energy imparted on the body and severity of associated injuries lead to the high rates of morbidity and mortality. Illustration A and B show an APC III and LC III injury, respectively. Incorrect Answers:

Correct Answer: Lateral compression (LC) III injury

Explanation:

mechanism injuries all have lower mortality rates than APC injuries.
OrthoCash 2020

Question 46:

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Options:

Kyphosis
Ankle instability
Protrusio acetabula
Progressive scoliosis
Pseudarthrosis of the tibia

Correct Answer: Progressive scoliosis

Explanation:

Question 47:

Options:

arthroscopic rotator cuff repair.
arthroscopic anterior capsulorrhaphy.
arthroscopic selective posterior capsular release.
selective posterior rotator cuff strengthening.
posterior capsular stretching with scapular stabilization.

Correct Answer: posterior capsular stretching with scapular stabilization.

Question 48:

What is the most common surgical cause of the foot deformity shown in Figure 9?

Options:

Medial tibial sesamoid subluxation
Overcorrection of the intermetatarsal angle
Excessive postoperative dressing application
Excessive medial eminence resection
Excessive lateral soft-tissue release and lateral sesamoidectomy

Correct Answer: Excessive lateral soft-tissue release and lateral sesamoidectomy

Explanation:

Question 49:

Options:

Incision and drainage of the abscess
Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks
Open biopsy
Hematoma evacuation and musculotendinous repair
Primary wide resection followed by radiation therapy

Correct Answer: Nonsteroidal anti-inflammatory drugs, physical therapy, and a repeat MRI scan in 6 to 8 weeks

Explanation:

Question 50:

Options:

obtain stress radiographs of the elbow.
obtain an MRI scan of the elbow.
apply a splint and initiate early range-of-motion exercises.
apply a cast in 90° of flexion for 4 weeks.
perform open reduction and internal fixation.

Correct Answer: perform open reduction and internal fixation.

Explanation:

Question 51:

Options:

Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement
Open reduction and internal fixation

Correct Answer: Cemented unipolar hemiarthroplasty B. Cemented bipolar hemiarthroplasty C. Total hip replacement

Explanation:

Question 52:

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 53:

A 38-year-old man has an enlarging left paraspinal soft-tissue mass. Based on the MRI scans and biopsy specimens shown in Figures 32a through 32e, what is the most likely diagnosis?

Options:

Fibromatosis
Well-differentiated liposarcoma
Synovial sarcoma
Schwannoma
Malignant fibrous histiocytoma

Correct Answer: Fibromatosis

Explanation:

DISCUSSION: Fibromatosis is a benign but aggressive fibrous lesion that principally arises from the connective tissue of muscle and the overlying fascia. The peak incidence is between the ages of 25 and 35 years. Most patients have a deep-seated, firm, poorly circumscribed mass that has grown insidiously and causes little or no pain. MRI is helpful in diagnosing the lesion and in assessing the extent of disease prior to surgical intervention. Histologically, the lesion is poorly circumscribed and infiltrates the surrounding tissue. The lesion appears bland with uniform spindle cells separated by abundant collagen, with little or no cell-to-cell contact. Despite its bland microscopic appearance, the tumor frequently behaves in an aggressive manner. These lesions do not metastasize but have a high incidence of recurrence. Treatment options consist
of surgical resection, radiation therapy, chemotherapeutic protocols, hormone modulation, and/or anti-inflammatory medications.
REFERENCES: Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 309-337.
Spear MA, Jennings LC, Mankin HJ, et al: Individualizing management of aggressive fibromatoses. Int J Radiat Oncol Biol Phys 1998;40:637-645.

Question 54:

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 55:

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

Options:

Clenched fist
Intrinsic minus posturing
Pain with passive stretch
Compression of the superficial arch
Pallor

Correct Answer: Intrinsic minus posturing

Explanation:

DISCUSSION: In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.
REFERENCES: Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.
Dellaero DT, Levin LS: Compartment syndrome of the hand: Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-408.

Question 56:

Options:

increased laxity.
increased risk for graft failure.
no differences in long-term results.
lower Knee Injury and Osteoarthritis Outcome Score (KOOS).

Correct Answer: no differences in long-term results.

Explanation:

Question 57:

A 25-year-old tennis player has shoulder pain and weakness to external rotation. MRI scans are shown in Figures 16a and 16b. What is the most likely cause of his weakness?

Options:

Supraspinatus tear
Infraspinatus tear
Suprascapular nerve compression
C5 radiculopathy
Subacromial impingement

Correct Answer: Suprascapular nerve compression

Explanation:

DISCUSSION: The MRI scans show a paralabral cyst, which is most commonly associated with labral tears. Compression of the suprascapular nerve results in weakness of the supraspinatus and/or infraspinatus depending on the level of compression.
REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Inokuchi W, Ogawa K, Horiuchi Y: Magnetic resonance imaging of suprascapular nerve palsy.
J Shoulder Elbow Surg 1998;7;223-227.

Question 58:

Options:

Open reduction internal fixation with transosseous sutures
Arthroscopic fixation using a suture bridge technique
Nonsurgical treatment with early passive range of motion
Nonsurgical treatment with sling immobilization for 4 weeks

Correct Answer: Nonsurgical treatment with early passive range of motion

Explanation:

Question 59:

Thoracic disk herniations are most frequently found in what area of the spine?

Options:

C7-T2
T2-T5
T5-T8
T9-T12
T12-L1

Correct Answer: T9-T12

Explanation:

Question 60:

Options:

15 degrees
30 degrees
45 degrees
60 degrees
75 degrees

Correct Answer: 30 degrees

Explanation:

Question 61:

Options:

Immediate spica casting
Flexible intramedullary nail placement
Traction and casting
External fixation
Solid intramedullary nail fixation via the greater trochanter

Correct Answer: Solid intramedullary nail fixation via the greater trochanter

Explanation:

Question 62:

- A form of renal osteodystrophy that is characterized by pure osteomalacia is caused by

Options:

Secondary hyperparathyroidism
Phosphate retention secondary to uremia
Insufficient renal synthesis of 1, 25 dihydroxy vitamin D
Aluminum deposition in bone from oral phosphate binders
Persistent acidosis aggravating the negative calcium balance

Correct Answer: Aluminum deposition in bone from oral phosphate binders

Explanation:

Question 63:

Options:

Ulnar
Radial
Axillary
Median
Musculocutaneous

Correct Answer: Musculocutaneous

Question 64:

Options:

excision of heterotopic bone.
hardware removal and elbow joint release with splinting.
semiconstrained total elbow arthroplasty.
distraction arthroplasty.
synovectomy and radial head excision.

Correct Answer: hardware removal and elbow joint release with splinting.

Explanation:

Question 65:

Options:

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

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

Explanation:

Question 66:

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
MRI with metal artifact reduction sequence (MARS) D. CT of pelvis

Correct Answer: MRI with metal artifact reduction sequence (MARS) D. CT of pelvis

Explanation:

Question 67:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 68:

Options:

Less than 10%
20% to 25%
50% to 60%
75% to 80%
Greater than 95%

Correct Answer: 50% to 60%

Explanation:

Question 69:

Options:

Custom-molded night orthotics
Double osteotomy of the first metatarsals
Crescentic osteotomy of the first metatarsals
Distal realignment (modified McBride)
First metatarsophalangeal joint arthrodeses

Correct Answer: First metatarsophalangeal joint arthrodeses

Explanation:

DISCUSSION: While other surgeries have provided some success, first metatarsophalangeal joint arthrodesis has the highest overall success rate compared to other surgeries in ambulatory and nonambulatory children with cerebral palsy. The recurrence rate is unacceptably high with the other procedures listed above. In contrast, neurologically normal children are amenable to osteotomies and soft-tissue procedures.
REFERENCES: Davids JR, Mason TA, Danko A, et al: Surgical management of hallux valgus deformity in children with cerebral palsy. J Pediatr Orthop 2001;21:89-94.
Jenter M, Lipton GE, Miller F: Operative treatment for hallux valgus in children with cerebral palsy. Foot Ankle Int 1998;19:830-835.

Question 70:

What is the dominant component of articular cartilage extracellular matrix by weight?

Options:

Water
Collagen
Keratan sulfate
Chondroitin sulfate
Nerve and lymphatic tissue

Correct Answer: Water

Explanation:

Question 71:

Which of the following lesions most closely resembles Ewing’s sarcoma histologically?

Options:

Metastatic neuroblastoma
Osteosarcoma
Osteomyelitis
Fibrous dysplasia
Fracture healing

Correct Answer: Metastatic neuroblastoma

Explanation:

Question 72:

Options:

Closed reduction and a long arm cast
Closed reduction, a long arm cast, and a skeletal survey
Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services
Closed reduction and a long arm cast, a bone scan, and referral to child protective services
Closed reduction and a long arm cast, MRI of the brain, and a referral to child protective services

Correct Answer: Closed reduction, a long arm cast, a skeletal survey, and a referral to child protective services

Explanation:

Question 73:

Rickets can be best characterized by which of the following radiographic changes in children?

Options:

Narrowed physes
Widening of the ribs anteriorly
Rounded epiphyses
Punched out metaphyseal defects with subperiosteal resorption
Sclerotic bands in the upper and lower margins of each vertebra

Correct Answer: Widening of the ribs anteriorly

Explanation:

Question 74:

Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?

Options:

Teres major
Latissimus dorsi
Short head of the biceps
Pectoralis major
Subscapularis

Correct Answer: Pectoralis major

Explanation:

DISCUSSION: The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.
REFERENCE: Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Question 75:

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. What is the most appropriate treatment?

Options:

Arthroscopic or open reduction and internal fixation
Arthroscopic loose body removal
Activity restriction for up to 9 months
Subchondral drilling The MRI reveals an osteochondritis dissecans (OCD) lesion that is unstable and has a large osseous component. OCDs are acquired lesions of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged, and the normal articular surface restored whenever possible. In this patient, the fragment is unstable and therefore stabilization of the fragment with internal fixation would be the best treatment option.

Correct Answer: Arthroscopic loose body removal

Explanation:

Question 76:

Figures 86a through 86c are the radiographs and biopsy specimen of a 14-year-old boy who has had left knee pain for 4 weeks. What is the most likely diagnosis?

Options:

Chondroblastoma
Chondrosarcoma
Parosteal osteosarcoma
Osteoblastoma
Osteosarcoma

Correct Answer: Osteosarcoma

Question 77:

Options:

The flexor digitorum longus tendon is ruptured.
The posterior tibial tendon has a normal appearance.
The posterior tibial tendon has a physiologic amount of fluid in its sheath.
The posterior tibial tendon is completely ruptured and retracted (type III tear).
The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Correct Answer: The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Explanation:

Question 78:

Figure 1 shows a radiograph obtained from an active 30-year-old man who sustained an injury to his ring finger 1 week earlier. The most appropriate treatment is

Options:

open reduction and internal fixation (ORIF).
a mallet splint.
repair of the terminal tendon.
arthrodesis.

Correct Answer: open reduction and internal fixation (ORIF).

Explanation:

EXPLANATION:
Figure 1 reveals evidence of an intra-articular distal phalanx fracture with a distal interphalangeal (DIP) joint dorsal subluxation. This injury is unstable and requires surgical management for an active individual. Volar distal phalanx fractures are often associated with flexor digitorum profundus avulsion injuries, which are addressed concomitantly. This injury was treated with ORIF of the intra-articular fracture, pinning of the DIP joint, and repair of an avulsed flexor digitorum profundus tendon with a button on the dorsal nail plate, as shown in Figure 2. Splint immobilization would not maintain a reduction of this unstable injury. The terminal tendon is not injured in this patient but is often injured in a dorsal distal phalanx fracture with a volar dislocation. Arthrodesis of the DIP is a salvage procedure and would not be considered acutely.

Question 79:

Which of the following radiographic views best assesses anterior coverage of the dysplastic hip?

Options:

AP of the hip
Obturator oblique
Lauenstein lateral
Faux profil
Pelvic inlet

Correct Answer: Faux profil

Explanation:

Question 80:

Options:

Arthroscopic reduction and fixation
Percutaneous pinning
Open reduction and internal fixation
Hemiarthroplasty with tuberosity reconstruction
Reverse shoulder arthroplasty

Correct Answer: Open reduction and internal fixation

Explanation:

DISCUSSION: In this young patient, every attempt must be made to retain the native proximal humerus; therefore, open reduction and internal fixation should be attempted of both the articular segment and tuberosities to the humeral shaft. This is best accomplished through an open approach. Shoulder arthroplasty should be reserved for the elderly and for failed internal fixation.
REFERENCES: Ko JY, Yamamoto R: Surgical treatment of complex fractures of the proximal humerus. Clin Orthop Relat Res 1996;327:225-237.
Aschauer E, Resch H: Four-part proximal humeral fractures: ORIF, in Warner JP, Iannotti JP, Flatow EL (eds): Complex and Revision Problems in Shoulder Surgery, ed 2. Philadelphia, PA, Lippincott Williams & Wilkins, 2005, pp 289-309.

Question 81:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 82:

Options:

positive Lachman test, normal posterior drawer, positive pivot shift.
positive Lachman test, positive posterior drawer, negative pivot shift.
normal Lachman test, positive posterior drawer, positive pivot shift.
normal Lachman test, positive posterior drawer, negative pivot shift.

Correct Answer: normal Lachman test, positive posterior drawer, negative pivot shift.

Explanation:

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation;
this must be avoided by careful attention to initial resting position and station of the knee.

Question 83:

Long-term alendronate (Fosamax) use for osteoporosis has been associated with which of the following?

Options:

Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures

Correct Answer: Diaphyseal femoral insufficiency fractures

Explanation:

Question 84:

Options:

Wide resection
Curetting and bone grafting
Percutaneous cementation and radiotherapy
Chemotherapy and radiotherapy DISCUSSION.. The imaging (which includes a clear chest CT scan) demonstrates a lytic periacetabular lesion with internal matrix production and a cellular cartilage lesion on histology, diagnostic for a chondrosarcoma with negative staging. Wide excision with limb salvage is appropriate for a lesion without evidence of neurovascular encasement. Although used for select low-grade cartilage lesions in the extremity, curettage is not indicated for pelvic chondrosarcomas. Radiation and chemotherapy are not used in the treatment of conventional chondrosarcoma.

Correct Answer: Wide resection

Question 85:

Options:

Radical
Wide
Marginal
Intralesional
Contaminated

Correct Answer: Marginal

Explanation:

DISCUSSION: The patient has a large deep anterior thigh mass that has imaging characteristics of mature fat. Intramuscular lipomas are effectively treated with marginal resections with very low recurrence rates. Large lipomas often have small amounts of intralesional signal changes frequently representing trapped muscle fibers and do not necessitate more extensive margins.
REFERENCES: Gaskin CM, Helms CA: Lipomas, lipoma variants, and well-differentiated liposarcomas (atypical lipomas): Results of MRI evaluations of 126 consecutive fatty masses. Am J Roentgenol 2004;182:733-739.
Rozental TD, Khoury LD, Donthineni-Rao R, et al: Atypical lipomatous masses of the extremities: Outcome of surgical treatment. Clin Orthop Relat Res 2002;398:203-211.

Question 86:

Options:

perform a femoral shortening.
perform a sciatic neurolysis.
release the piriformis tendon.
avoid use of posterior acetabular retractors.
apply postoperative abduction bracing.

Correct Answer: perform a femoral shortening.

Explanation:

DISCUSSION: To improve hip biomechanics and secure more suitable bone for acetabular fixation, the true acetabulum is often resurfaced in patients who have developmental dysplasia of the hip, thus lowering the hip center and lengthening the leg. Acute lengthening of more than 3 cm will place excessive tension on the sciatic nerve and require a femoral shortening to avoid sciatic nerve injury. The other maneuvers will not relieve sciatic nerve tension because of
limb lengthening.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 430-431.
Sanchez-Sotelo J, Berry DJ, Trousdale RT, et al: Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options. J Am Acad Orthop Surg 2002;10:334-344.

Question 87:

A 23-year-old soccer player sustains a grade III complete posterior cruciate ligament (PCL) tear after colliding with another player. In reconstructing the PCL, it is optimal to reconstruct the

Options:

anterolateral bundle and tension the graft at 10° of flexion.
anterolateral bundle and tension the graft at 90° of flexion.
posteromedial bundle and tension the graft at 10° of flexion.
posteromedial bundle and tension the graft at 45° of flexion.
posteromedial bundle and tension the graft at 90° of flexion.

Correct Answer: anterolateral bundle and tension the graft at 90° of flexion.

Explanation:

Question 88:

Options:

25 mg of indomethacin 3 times daily for 6 weeks
1 dose of irradiation at 800 Gy
Surgical excision of heterotypic ossification (HO)
Reevaluation in 6 months

Correct Answer: Reevaluation in 6 months

Explanation:

Question 89:

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Options:

Female athletes with valgus knee alignment and small femoral notch width
Female athletes with valgus knee alignment and large ACL width
Male athletes with valgus knee alignment and small ACL width
Male athletes with varus knee alignment and small femoral notch width

Correct Answer: Female athletes with valgus knee alignment and small femoral notch width

Explanation:

DISCUSSION
ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been proven to increase risk for ACL tears.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 90:

Options:

Further imaging studies, including MRI
An awake closed reduction with Gardner-Wells traction with neurologic examination
Immobilization in a halo skeletal fixation for definitive treatment
Closed reduction under general anesthesia
Immediate open reduction and internal fixation in the surgical suite

Correct Answer: An awake closed reduction with Gardner-Wells traction with neurologic examination

Explanation:

Question 91:

Options:

Preoperative range of motion
Flexor tendon integrity
Rotational malalignment
Collateral ligament stability

Correct Answer: Collateral ligament stability

Explanation:

Question 92:

Options:

Inhibits osteoclasts
Stimulates osteoblasts
Increases gastrointestinal absorption of calcium
Decreases renal excretion of calcium
Acts as a transcription factor to increase production of type I collagen

Correct Answer: Inhibits osteoclasts

Explanation:

Question 93:

An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play?

Options:

Full participation once symptoms resolve
Full participation once the splenomegaly resolves
Full participation 4 weeks after the onset of symptoms regardless of the size of the spleen
Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen
No participation for 8 weeks

Correct Answer: Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen

Explanation:

Question 94:

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

Options:

the anterior column of the acetabulum.
the acetabular rim.
the os acetabulae.
anterior coverage of the femoral head.
femoral anteversion.

Correct Answer: anterior coverage of the femoral head.

Explanation:

Question 95:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

DISCUSSION
Video 7 for reference
The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove.
The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 96:

Options:

Chondroblastoma
Enchondroma
Giant cell tumor
Fibrous dysplasia
Osteoblastoma

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: The radiographs reveal a geographic lesion of the proximal femur with the classic “ground glass” appearance noted in fibrous dysplasia. This intramedullary lesion is modestly expansile, demonstrates some minimal cortical thinning, and has no aggressive features. Chondroblastoma, giant cell tumor, and osteoblastoma are more lytic in appearance, and the location is not typical for giant cell tumor or chondroblastoma. While enchondroma may be considered, the uniform ground glass appearance, lack of punctuate mineralization, and distinct margination of the lesion make that diagnosis less likely.
REFERENCE: Parsons TW: Benign bone tumors, in Fitzgerald R Jr, Kaufer H, Malkani A (eds): Orthopaedics. Philadelphia, PA, Mosby International, 2002, pp 1027-1035.

Question 97:

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Options:

Fetal position
Surgical approach
Mechanism of injury
Fracture classification
Trimester of pregnancy

Correct Answer: Mechanism of injury

Explanation:

Question 98:

Options:

an MRI scan.
fusion from the occiput to C2.
fusion of C1-C2.
application of a cervical collar and no participation in any sports.
periodic follow-up examinations and no contact sports.

Correct Answer: periodic follow-up examinations and no contact sports.

Explanation:

Question 99:

Which component is most common to both simple and complex elbow dislocations?

Options:

radial head fracture
radial neck fracture
loss of terminal extension
coronoid tip fracture
coronoid base fracture

Correct Answer: radial head fracture

Explanation:

Question 100:

Which factor should most influence a patient's decision to have surgery for adult scoliosis if he or she is younger than age 50?

Options:

Increasing coronal plane deformity
Increasing pain
Increasing sagittal balance
Invasiveness of the surgical procedure

Correct Answer: Increasing coronal plane deformity

Explanation:

DISCUSSION
In a retrospective review of 137 patients treated surgically and 153 patients treated nonsurgically for adult scoliosis, Bess and associates found that surgical treatment for patients younger than 50 years of age was driven by increased coronal plane deformity, and surgical treatment for older patients was mandated by pain and disability. They also concluded that age, comorbidities, and sagittal balance did not influence treatment decisions.
RECOMMENDED READINGS
Bess S, Boachie-Adjei O, Burton D, Cunningham M, Shaffrey C, Shelokov A, Hostin R, Schwab F, Wood K, Akbarnia B; International Spine Study Group. Pain and disability determine treatment modality for older patients with adult scoliosis, while deformity guides treatment for younger patients. Spine (Phila Pa 1976). 2009 Sep 15;34(20):2186-90. PubMed PMID: 19752704.
View
Abstract at PubMed
Anderson DG, Albert T, Tannoury C. Adult scoliosis. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:331-338.

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

Orthopedic Surgery Board Review MCQs: Trauma, Sports Medicine & Nerve | Part 57

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 57

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index