Orthopedic Board Review MCQs: Foot, Spine, Trauma | Part 63

About This Board Review Set

This is Part 63 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 63

This module focuses heavily on: Foot, Fracture, Tendon.

Sample Questions from This Set

Sample Question 1: A 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuri...

Sample Question 2: During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?...

Sample Question 3: Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic...

Sample Question 4: What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?...

Sample Question 5: The use of posting (a wedge added to the medial or lateral side of an insole) is useful to balance forefoot or hindfoot malalignment. Assuming normal subtalar joint pronation, what is the maximum amount of recommended hindfoot posting?...

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 7-year-old boy sustains an acute injury to the distal radial metaphysis, along with a completely displaced Salter-Harris type I fracture of the ulnar physis, as shown by the arrows in Figure 12. After satisfactory reduction of both injuries, what is the major concern?

Explanation

DISCUSSION: While injury of the distal radial metaphysis is a rather common occurrence, the incidence of physeal arrest is only about 4% to 5% of patients. While injury of the distal physis of the ulna is rare, the incidence of physeal arrest is greater than 50% in fractures of this structure. These patients need to be followed closely both clinically and radiographically to look for the signs of distal ulnar/physeal arrest such as loss of the prominence of the ulna and ulnar deviation of the hand. Radiographically, progressive shortening of the ulna is observed.
REFERENCES: Nelson OA, Buchanan JR, Harrison CS: Distal ulnar growth arrest. J Hand Surg Am 1984;9:164-170.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, pp 632-635.

Question 2

During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?

Explanation

DISCUSSION: The flexor hallucis longus tendon provides the best, most direct route of transfer for filling Achilles tendon gaps. The tendon lies lateral to the neurovascular structures, making it safe for harvest and providing a direct route for transfer into the calcaneus without crossing these important structures. The flexor hallucis longus tendon also has muscle belly that extends distal on the tendon itself, often beyond the actual tibiotalar joint. When the tendon is transferred, this muscle belly brings excellent blood supply to the anterior portion of the reconstruction.
REFERENCES: Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.
Wapner K, Pavlock GS, Hecht PJ, Naselli F, Walther R: Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle Int 1993;14:443-449.

Question 3

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Explanation

The weight-bearing potential of bone is influenced by the ratio of cortical to cancellous bone. The area of the spinal anatomy that has the highest ratio is the pedicles of the thoracic spine. This is followed by the lumbar pedicles. The vertebral bodies have a lower ratio than the pedicles, with the sacrum having the very lowest ratio.

Question 4

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 5

The use of posting (a wedge added to the medial or lateral side of an insole) is useful to balance forefoot or hindfoot malalignment. Assuming normal subtalar joint pronation, what is the maximum amount of recommended hindfoot posting?

Explanation

DISCUSSION: Generally, patients cannot tolerate more than 5 degrees of hindfoot posting.
REFERENCES: Donatelli RA, Hurlbert C, Conaway D, et al: Biomechanics foot orthotics: A retrospective study. J Orthop Sports Phys Ther 1988;10:205-212.
Michaud TM: Foot Orthoses and Other Forms of Conservative Foot Care. Baltimore, MD, Williams & Wilkins, 1993, pp 61-65, 186.
Root MC, Orien WP, Weed JH: Normal and Abnormal Function of the Foot. Los Angeles, CA, Clinical Biomechanics Corporation, 1977, vol 2, pp 29-33.

Question 6

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

Explanation

DISCUSSION:
This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

Question 7

A 13-year-old boy has had pain and swelling in his ankle for the past several months. Based on the radiograph, MRI scan, and biopsy specimen shown in Figures 77a through 77c, what is the best course of action?

Explanation

DISCUSSION: Chondroblastomas are benign cartilage lesions frequently seen in adolescents or young adults. They are found in the epiphyseal or apophyseal regions of bones. The radiograph shows a radiolucent lesion with mineralization and a well-marginated rim of reactive bone. The lesion is composed of sheets of immature chondroblasts (polygonal cells with a clear, bluish cytoplasm and a small round central nucleus). In some regions, classic “chicken-wire” matrix calcifications and a “cobblestone” pattern of cell arrangement may be seen. Treatment consists of curettage and bone grafting.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 247-264.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 8

A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago. Examination now reveals recent onset erythema, warmth, and swelling of the midfoot. Radiographs are shown in Figures 23a through 23d. What is the most likely reason for the swelling of the foot?

Explanation

DISCUSSION: A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.
REFERENCE: Connolly JF, Csencsitz TA: Limb threatening neuropathic complications from ankle fractures in patients with diabetes. Clin Orthop 1998;348:212-219.

Question 9

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

Explanation

DISCUSSION
This patient sustained an eccentric contracture (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors have the highest
potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed.
The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared to the 2-incision technique. The most troubling complication for most surgeons is the development of a PIN palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABC nerve injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button.
Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The EIP is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC followed by the ECU, EDQ, and, finally, the EIP.
RESPONSES FOR QUESTIONS 26 THROUGH 27
Anterior tibial artery
Posterior tibial artery
Superficial peroneal nerve
Deep peroneal nerve
Match the neurovascular structure at risk (listed above) with the compartment undergoing fasciotomy (listed below).

Question 10

A 35-year-old female runner reports progressive vague aching pain involving her midfoot. Her pain is most notable when running. She denies specific injury. Examination reveals minimal swelling and localized tenderness over the dorsal medial midfoot and navicular. Radiographs and an MRI scan are shown in Figures 37a through 37c. What is the most appropriate management?

Explanation

DISCUSSION: A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called “N spot”) in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified.
REFERENCES: Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.
Coughlin M: Tarsal navicular stress fractures. Tech Foot Ankle Surg 2002;1:112-122.

Question 11

A 22-year-old woman has had progressive upper extremity weakness for the past several years. History reveals no pain in her neck or shoulders. Examination reveals scapular winging of both shoulders and weakness in external rotation. She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness. She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling. A clinical photograph is shown in Figure 14. What is the most likely diagnosis?

Explanation

DISCUSSION: Progressive weakness is a common sign with a large differential diagnosis. Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy. Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness. The weakness is usually bilateral, and scapular winging is common. If the scapular winging becomes pronounced, elevation of the shoulder can be affected. In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated. Duchenne muscular dystrophy is typically severe and progressive. The other diagnoses are not compatible with the history or the physical findings.
REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.
Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up. J Bone Joint Surg Am 1993;75:372-376.

Question 12

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

Explanation

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

Question 13

03 A 37 year-old woman with thoracic back pain has had hemoptysis and dyspnea for the past month. A thoracic spine radiograph shows a compression fracture of T-9 and a mass in the right lung. What is the best course of action?

Explanation

Here is an algorithm from OKU 6 Tumors of the Spine pp 723-736

This question gives you the history, skips right over physical exam and goes into plain films. With this patient’s history of hemoptysis and dyspnea and a lung mass, the next steps in this patients work-up would include the competion of initial work-up, metastatic work-up, then pre-operative planning. Goals of treatment are to 1) protect or restore neurologic function, 2) control pain,

Question 14

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 15

A 16-year-old high school football player who sustained an acute forceful dorsiflexion ankle injury reported that he felt a pop and then noted immediate swelling over the lateral malleolus. Examination 24 hours later reveals moderate swelling and tenderness along the lateral malleolus. The external rotation, squeeze, anterior drawer, and talar tilt tests are negative. Subluxation of the peroneal tendons is palpable over the peroneal groove of the fibula. Radiographs reveal a small cortical avulsion off the distal rim of the fibula. The stress views show no instability. Initial management for this injury should include

Explanation

DISCUSSION: The patient has an acute peroneal tendon dislocation. The evaluation for syndesmotic injury and lateral ankle instability is negative. The cortical avulsion off the distal tip of the lateral malleolus, a rim fracture, is characteristic of peroneal tendon dislocations. The sensation of apprehension or frank subluxation of the peroneal tendons with active dorsiflexion of the foot while the foot is held in plantar flexion confirms the diagnosis. Based on these findings, initial management should consist of cast immobilization and protected weight bearing. If a recurrent or chronic condition develops, surgery is the most reliable treatment option.
REFERENCES: Arrowsmith SR, Fleming LL, Allman FL: Traumatic dislocations of the peroneal tendons. Am J Sports Med 1983;11:142-146.
Marti R: Dislocation of the peroneal tendons. Am J Sports Med 1977;5:19-22.

Question 16

A 59-year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Question 17

-Figure is the radiograph of a 55-year-old veteran who developed avascular necrosis after a traumatic hip dislocation. He was treated with hemiarthroplasty 10 years ago and also has posttraumatic stress disorder and chronic pain. He has had multiple spinal surgeries and takes 30 mg of methadone daily. He now has severe groin pain and is unable to ambulate. Laboratory studies showed a C-reactive protein level of 0.2 mg/L (reference range, 0-3 mg/L), erythrocyte sedimentation rate of 50 mm/h (reference range, 0-20 mm/h), hip aspiration of 500/mm3 white blood cell count, 50% polynucleated cells, 30%monocytes, and 20% lymphocytes What is the most likely cause of his hip pain?

Explanation

Question 18

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Explanation

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 19

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Explanation

The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.

Question 20

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

Explanation

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

Question 21

A 16-year-old girl injured her hip in a fall. Radiographs are shown in Figures 14a and 14b. She denies any history of pain prior to the fall and is currently asymptomatic. A bone scan, MRI scan, and biopsy specimens are shown in Figures 14c through 14f. What is the most likely diagnosis?

Explanation

DISCUSSION: Although the classic radiographic appearance of fibrous dysplasia is one of a central metaphyseal lesion with ground glass matrix, it is not unusual to see either a more radiodense-appearing lesion or a more peripheral location. The histologic finding of spicules of woven bone without osteoblastic rimming in a bland fibrous background is diagnostic of fibrous dysplasia. The imaging studies could be consistent with low-grade osteosarcoma, osteoblastoma, or osteomyelitis, but all have a very different histologic picture. Observation is indicated in the absence of symptoms, impending fracture, or deformity. Fibrous dysplasia most commonly occurs in the proximal femur.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 30-43.
DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation, and treatment.

J Bone Joint Surg Am 2005;87:1848-1864.

Question 22

The space available for the cord is an important determinant in neurologic recovery. Recent analysis suggests that the most reliable radiographic predictor for neurologic recovery after surgery in patients with rheumatoid arthritis and paralysis is a preoperative

Explanation

DISCUSSION: Boden and associates’ recent article presents significant evidence that patients with rheumatoid arthritis, neurologic deterioration, and C1-2 instability are more likely to improve after surgery if the posterior alanto-odontoid interval is greater than 10 mm preoperatively. The accepted safe range for the posterior atlanto-odontoid interval is 14 mm. This measurement is believed to better represent the space available for the cord than the anterior alanto-odontoid interval.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 273-279.
Boden SD, Dodge LD, Bohlman HH, Rechtine GR: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Wattenmaker I, Concepcion M, Hibberd P, Lipson S: Upper airway obstruction and perioperative management of the airway in patients managed with posterior operations on the cervical spine for rheumatoid arthritis. J Bone Joint Surg Am 1994;76:360-365.

Question 23

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

Explanation

The instantaneous axis of rotation is the axis about which each vertebral segment rotates, but is theoretical depending on how it is defined, and varies depending on multiple factors. It is not a fixed point but can move depending on the position of the spine, and it is affected by degenerative conditions, fractures, injuries, and other anatomic changes of the spine. There are three axes of movement with 6 degrees of freedom (rotation and translation movements about each axis).

Question 24

Which of the following patients is considered the most appropriate candidate for selective dorsal rhizotomy?

Explanation

DISCUSSION: While other surgical and nonsurgical options exist for management of spasticity, the criteria originally laid out by Peacock and associates describe the most appropriate candidate for rhizotomy as a patient with spastic diplegia who is between the ages of 4 to 8 years and has a stable gait pattern that is limited by lower extremity spasticity. Rhizotomy is not recommended in patients with athetosis because of unpredictable results. In addition, rhizotomy should be avoided in nonambulatory patients with spastic quadriplegia because it is associated with significant spinal deformities.
REFERENCES: Peacock WJ, Arens LJ, Berman B: Cerebral palsy spasticity: Selective posterior rhizotomy. Pediatr Neurosci 1987;13:61-66.
Oppenheim WL: Selective posterior rhizotomy for spastic cerebral palsy: A review. Clin Orthop 1990;253:20-29.
Mooney JF III, Millis MB: Spinal deformity after selective dorsal rhizotomy in patients with cerebral palsy. Clin Orthop 1999;364:48-52.

Question 25

A 13-year-old girl sustained an isolated midshaft left femoral fracture in a motor vehicle accident. The fracture was treated with a rigid, antegrade intramedullary nail placed through the piriformis fossa. The fracture healed uneventfully, as shown in Figure 46a; however, at 12 months postoperatively she now reports left hip pain. A current AP radiograph and MRI scan are shown in Figures 46b and 46c. What complication occurred in this patient? Review Topic

Explanation

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis.

Question 26

Which of the following changes occur in the spinal cord and the spinal canal when the cervical spine moves from neutral to full flexion?

Explanation

DISCUSSION: The spinal cord and spinal canal undergo dynamic changes during neck flexion and extension. In neck flexion, the spinal cord initially unfolds and then undergoes elastic deformation with full flexion; the spinal canal lengthens. This may explain the presence of Lhermitte’s sign as the cord is pulled anteriorly over an anterior osteophyte or disk, generating a compressive force on the spinal cord. During neck extension, the spinal cord relaxes (folding like an accordion) and the spinal canal shortens.
REFERENCES: Breig A: Biomechanics of the Central Nervous System: Some Basic Normal and Pathologic Phenomena. Stockholm, Sweden, Almquist and Wiksell, 1960.
Ghanayem AJ, Zdeblick TA, Panjabi MM: Biomechanics of nonacute cervical spine trauma, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 103-105.

Question 27

During total hip arthroplasty, what characteristic of irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene should provide a more wear-resistant construct than traditional gamma- irradiated (2.5-4 Mrad)-in-air polyethylene mated with the same head?

Explanation

DISCUSSION:
Highly cross-linked polyethylene makes material resistant to adhesive wear. Abrasive wear from third bodies does not decrease wear. The fatigue strength of such material is inferior to that of traditional polyethylene, and its resistance to creep is the same, if not lower, than that of traditional polyethylene.

Question 28

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Explanation

DISCUSSION: Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage.
REFERENCES: Holton PD, Mader J, Nelson CL, Osmon DR, Patzakis MJ: Antibiotics for the practicing orthopaedic surgeon. Instr Course Lect 2000;341:36-42.
Wilkins J, Patzakis M: Choice and duration of antibiotics in open fractures. Orthop Clin North Am 1991;22:433-437.

Question 29

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 30

What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?

Explanation

DISCUSSION
Humphreys and associates in a retrospective review of TLIF vs PLIF found fusion rates, surgical time, and length of hospital stay were similar with both procedures. The only benefits associated with TLIF were less blood loss and preservation of the paraspinal muscle sleeve. Manos and associates in a cadaver study found no difference in the volume of disk material evacuated or the area of endplate exposed in either procedure.
RECOMMENDED READINGS
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001 Mar 1;26(5):567-71. PubMed PMID: 11242386. View Abstract at PubMed
Manos R, Sukovich W, Weistroffer J: Transforaminal lumbar interbody fusion: Minimally invasive versus open disc excision and endplate preparation. Presented at the 12th International Meeting of Advanced Spine Techniques, Banff, Alberta, Canada, July 7-9, 2005.

Question 31

Which of the following is an advantage of using blocking screws for tibial nailing?

Explanation

DISCUSSION: Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. There are no studies as of yet that find a blocking screw to decrease nail failure.
Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.
In a later clinical study, Krettek found that after using blocking screws, tibial healing was evident radiologically at a mean of 5.4 months with a decreased rate of malunions.
Ricci also found that blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.

Question 32

Figures 1 and 2 show the radiographs obtained from a 68-year-old morbidly obese man who underwent left total hip replacement 7 years ago and did well, with no symptoms prior to the current presentation. He recently rose from a seated position and felt a pop in the hip, with immediate pain and inability to bear weight. Any pressure on the left foot now produces a painful, grinding sensation with loss of left hip stability. What is the best next step?

Explanation

DISCUSSION:
The modular femoral stem has fractured. Changing the liner to a constrained design is not warranted at this time based on the information provided. Revision of the acetabular implant is appropriate because of the potential for damage to the existing cup from metal debris and femoral implant contact and to convert from a metal-on-metal articulation. Nonsurgical management would not provide pain relief or improvement; revision of the total hip arthroplasty is recommended. The implant failed in a short time, and retention of the femoral stem is not recommended because of the concern for failure with only a neck exchange. A dual-mobility bearing may be a good option if the surgeon plans to retain the acetabular component. Extended trochanteric osteotomy is a useful technique for the removal of a well-fixed femoral implant. In this patient, femoral stem removal without
osteotomy would be difficult due to the fracture of the implant’s femoral neck and the
inability to gain purchase for extraction.

Question 33

A 14-year-old boy is seen for back pain. Radiographic evaluation reveals a grade III isthmic spondylolisthesis. What measurement is most useful in predicting the likelihood of progression?

Explanation

DISCUSSION: Slip angle has been shown to be highly predictive of the risk for increased slippage in patients with spondylolisthesis. None of the other radiographic parameters listed has been shown to be predictive of the risk for increased slippage.
REFERENCES: Huang RP, Bohlman HH, Thompson GH, et al: Predictive value of pelvic incidence in progression of spondylolisthesis. Spine 2003;28:2381-2385.
Mac-Thiong JM, Wang Z, de Guise JA, et al: Postural model of sagittal spino-pelvic alignment and its relevance for lumbosacral developmental spondylolisthesis. Spine 2008;33:2316-2325.

Figure 22a Figure 22b

Question 34

Which of the following clinical findings is most often seen with the MRI scan findings shown in Figures 19a through 19c? Review Topic

Explanation

The MRI scans show a large superior labral cyst. Impingement of the cyst on the suprascapular nerve is implied by the visible atrophy of the infraspinatus muscle as seen in Figure 19c. Clinically, this is manifested by atrophy of the posterior aspect of the shoulder inferior to the scapular spine. The suprascapular nerve provides only motor function and does not provide any sensory function to the shoulder girdle; therefore, sensory deficits will not be present in this patient.

Question 35

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. 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, observation for 1 year would not be appropriate.
The psoas is the anatomic structure that runs anterior to the acetabulum. The femoral neurovascular structures are at risk if the retractor is placed anterior and inferior to the psoas tendon.
The patient develops a foot drop 2 days after surgery. As a result, it can be assumed that the nerve was not injured directly during the surgical procedure. Although MR imaging or a CT scan 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 decreased by flexing the surgical knee and positioning the bed flat.

Question 36

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

Explanation

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have

shown some healing response with callus formation, but these techniques are not successful

in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions

of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 37

A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding. Review Topic

Explanation

A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 38

Figure 7 shows the radiograph of an otherwise healthy 65-year-old man who injured his right dominant shoulder while skiing 18 months ago. He did not seek treatment at the time of the injury. He now reports intermittent soreness when playing golf but has no other limitations. Examination reveals full range of motion and no tenderness, but he has slight pain with a crossed arm adduction stress test. He is neurologically intact. Initial management should consist of

Explanation

DISCUSSION: The radiograph shows a displaced type II distal clavicle fracture with nonunion. Because the patient’s symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation. Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy. If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Craig EV: Fractures of the clavicle, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 428-482.

Question 39

A 20-year-old football player has immediate pain in the midfoot and is unable to bear weight after an opposing player lands on the back of his plantar flexed foot. AP and lateral radiographs are shown in Figures 4a and 4b. Management should consist of

Explanation

DISCUSSION: The history and radiographs indicate a Lisfranc fracture-dislocation of the foot. The radiographs show the classic “fleck sign,” which is an avulsion of the Lisfranc ligament from the base of the second metatarsal. Most authors recommend open reduction and internal fixation of this injury. Closed reduction can be attempted, but anatomic reduction is unlikely because of the interposed bone fragments and soft tissues. Standard radiographs are not reliable in identifying 1 to 2 mm of subluxation of the tarsometatarsal joint. The tarsometatarsal joint has a poor tolerance to even mild subluxation, and the resulting decrease in joint contact area increases the likelihood of posttraumatic arthritis. Open reduction with the joint visible allows more anatomic reduction and internal fixation of larger osteochondral fragments or excision of smaller interposed fragments.
REFERENCES: Bellabarba C, Sanders R: Dislocations of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 2, pp 1539-1558.
Murphy GA: Fractures and dislocations of the foot, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby, 1998, vol 2, pp 1956-1960.

Question 40

Figures below demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. A further work-up reveals elevations in serum cobalt and chromium levels and fluid collections surrounding the hip on MRI with MARS. Revision THA is recommended. The most common complication following revision of a failed metal-on- metal hip arthroplasty is

Explanation

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

Question 41

Intramembranous ossification during fracture repair is characterized by absence of which of the following elements?

Explanation

DISCUSSION: Intramembranous ossification occurs through the direct formation of bone without the formation of a cartilaginous intermediate. Clinically, both intramembranous and endochondral ossification occur simultaneously during fracture healing; however, the latter is characterized by the differentiation and maturation of chondrocytes, vascular invasion of a hypertrophic cartilage matrix, and bone formation. Collagens type II and X are cartilage specific and would be characteristic of endochondral ossification, not intramembranous ossification.
REFERENCES: Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.
Buckwalter JA, Einhorn TA, Bolander ME: Healing of the musculoskeletal tissues, in Rockwood CA Jr, Green DP, Bucholz RW, et al (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 261-276.

Question 42

A 36-year-old man sustains blunt chest trauma, an open right femur fracture, and a closed left tibia fracture following a high-speed MVC. Upon presentation to the emergency room, blood pressure is 80/40, HR 135, and urine output is .4 cc/kg/hr. Fluids and blood products are administered, and the patient is transferred to the ICU for further care. Which of the following indicates adequate resuscitation has been achieved?

Explanation

DISCUSSION: Of the following variables, only a normal gastric mucosal pH (>7.3) is associated with restoration of tissue oxygenation.
Shock is an abnormality of the circulatory system that results in inadequate organ perfusion and tissue oxygenation. This leads to anaerobic metabolism with the development of lactic acidosis and oxygen debt. Shock is either classified as compensated or uncompensated. Compensated shock exists when there is evidence of ongoing inadequate tissue perfusion despite the normalization of blood pressure, heart rate, and urine output. Uncompensated shock occurs when there is inadequate tissue perfusion and abnormal blood pressure, heart rate, and urine output. Thus, a patient may have normal vital signs but still be in a state of compensated shock that requires additional resuscitation.
Porter et al. review the optimal end points of resuscitation in trauma patients. They conclude that using traditional end points such as blood pressure, urine output and heart rate, may leave up to 85% of patients in "compensated" shock. They urge the use of lactate, base deficit, and gastric intramucosal pH as appropriate end points of resuscitation.
Roberts et al. discuss various aspects of damage control orthopaedics in the multiply injured trauma patient. Although they do not discuss the end points for resuscitation, they note that they presence of shock is a clinical parameter associated with adverse outcomes in the trauma patient.
Incorrect answers:

Question 43

The artery of Adamkiewicz (arteria radicularis, arteria magna) is most commonly found on the

Explanation

DISCUSSION: Approximately 75% of people have the artery on the left side between T9 and T11. Its relevance to iatrogenic spinal cord problems is still uncertain.
REFERENCES: Stambaugh J, Simeone F: Vascular complication in spine surgery, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1715.
Lazorthes G: Arterial vascularization of the spinal cord. J Neurosurg 1971;35:253-262.

Question 44

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who has elbow pain after falling from a ladder onto an outstretched hand. Examination reveals elbow pain, swelling, limited motion, and normal neurologic function. A pathognomonic radiographic feature of this injury is a

Explanation

Discussion: Coronal shear fractures of the distal end of the humerus are rare. Failure to recognize the fracture pattern can lead to poor patient outcomes secondary to poor surgical decision making. The double arc sign is considered a pathognomonic finding on the lateral elbow radiograph seen in Figure 2. This is created by the subchondral bone of the capitellum and lateral trochlear ridge. Excessive internal rotation of the fracture fragment or a subpar lateral radiograph can make recognition of this sign difficulty
Ideal visualization of the fragment during surgery is provided through a laterally based elbow approach (Kaplan or Kocher) with the patient in the supine position. Extension of the approach can be accomplished by releasing the lateral collateral ligament origin, which must be repaired to prevent post-operative instability. Posterior comminution and lateral column impaction are occasionally seen. When present, a posterior approach with an olecranon osteotomy is considered an alternative, but still does not allow ideal visualization of the anterior articular cartilage or safe angles for anterior to posterior screw placement. Therefore, the posterior approach not the preferred approach.
Headless screws are useful because this is typically a partial articular injury and screw orientation is ideally from anterior to posterior. The anterior entry of the screw should be buried beneath the articular cartilage margin.

Question 45

What is the most common cause for poor outcomes in patients who undergo total shoulder arthroplasty?

Explanation

DISCUSSION: In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.
REFERENCES: Chin PY, Sperling JW, Cofield RH, et al: Complications of total shoulder arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 2006;15:19-22.
Hasan SS, Leith JM, Campbell B, et al: Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg 2002;11:431-441.

Question 46

A 10-year-old girl was thrown over the handlebars of her bicycle and landed directly on her left shoulder. She was treated with a figure-of-8 strap and analgesics. Follow-up examination 2 weeks later reveals that the lateral end of the clavicle is superiorly dislocated relative to the acromion. A radiograph of the shoulder shows calcification lateral to the coracoid process at the level of the acromion, and the clavicle is superiorly displaced. Management should consist of

Explanation

DISCUSSION: In adults, a direct blow on the acromion usually results in an acromioclavicular dislocation. In children, however, the usual injury from this mechanism is a physeal fracture of the lateral clavicle. The clavicular shaft fragment, analogous to the metaphyseal portion of a physeal fracture, herniates through the periosteum, leaving the distal periosteal sleeve in contact with the lateral (distal) physeal fragment. The treatment of choice is immobilization until the patient is pain-free.
REFERENCES: Falstie-Jensen S, Mikkelsen P: Pseudodislocation of the acromioclavicular joint. J Bone Joint Surg Br 1982;64:368-369.
Havranek P: Injuries of the distal clavicular physis in children. J Pediatr Orthop 1989;9:213-215.

Question 47

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

Explanation

DISCUSSION: Thoracic pedicles typically are angled 25 degrees medially at T₁ so the

starting point is more lateral. T₂ angles about 15 degrees, and then the pedicles average about

5 to 7 degrees down to T10. At T11 and 12, the angulation is minimal.
REFERENCES: Weinstein L: Pediatric Spine Principles and Practice. New York, NY, Raven Press, 1994, pp 1659-1681.
Lenke LG, Orchowski J: Segmental posterior spinal instrumentation: Thoracic spine to sacrum, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 537-552.

Question 48

A patient undergoes a simple excision of a 3-cm superficial mass in the thigh at another institution. The final pathology reveals a leiomyosarcoma, without reference to the margins. What is the recommendation for definitive treatment?

Explanation

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,

a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 49

An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction?

Explanation

DISCUSSION: The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.
REFERENCES: Waters PM: Update on management of pediatric brachial plexus palsy.

J Pediatr Orthop B 2005;14:233-244.
Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am

2005;87:320-325.
Moukoko D, Ezaki M, Wilkes D, et al: Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86:787-793.

Question 50

A 35-year-old woman presents with an elbow injury which includes a coronoid fracture involving more than 50%, a comminuted radial head fracture, and an elbow dislocation. What is the most appropriate treatment?

Explanation

DISCUSSION: A terrible triad of the elbow includes dislocation of the elbow with associated fractures of the radial head and the coronoid process. Ring et al. stressed that these injuries are prone to complications and advised against resection of the radial head due to instability, and instead recommended a radial head replacement if too comminuted for ORIF. Coronoid fractures compromise elbow stability as well and require open reduction and internal fixation as with the lateral collateral ligament. McKee et al. showed stable elbows in 34/36 with mean Mayo elbow score of 88 when the standard protocol of coronoid ORIF, radial head repair/replacement, and LCL repair were employed.

Question 51

The anterior approach to the hip (iliofemoral or Smith-Peterson) puts which of the following anatomic structures at greatest risk?

Explanation

(SBQ12SP.36) What is the most common type of cause and type of peripheral nerve injury detected by electrophysiologic monitoring during anterior cervical spine surgery? Review Topic
Brachial plexopathy following shoulder taping and application of countertraction
Brachial plexopathy on neck extension for surgical access
Spinal cord injury on neck extension for surgical access
Ulnar neuropathy due to tightly wrapped or malpositioned upper extremities
Cerebral hypoperfusion due to elevation of the head of the bed PREFERRED RESPONSE 1
(SBQ12TR.83) A 45-year-old male sustains the fracture seen in Figure A. He is scheduled for open reduction and internal fixation using the Smith-Peterson approach. After dissection through the superficial intermuscular plane, a moderate amount of bleeding is noted in the surgical field. What vessel was likely injured?

Ascending branch of the lateral femoral circumflex artery
Medial femoral circumflex artery
Obturator artery
Superficial external pudendal artery
Femoral vein

Question 52

When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as

Explanation

DISCUSSION: The ratio of scapulothoracic to glenohumeral motion with elevation has been shown to vary depending on what portion of elevation is examined, how much load is on the arm, and the technique used to measure increments of elevation. However, almost every study shows that the ratio of scapulothoracic to glenohumeral motion is 1:2 for the contributions over a full range of elevation to 170 degrees. In the first 30 degrees of elevation, there is significant variability in the ratio, and there may be significant variability up to around 60 degrees.
REFERENCES: Inman VT, Saunders JR, Abbott LC: Observations of the function of the shoulder joint. Clin Orthop 1996;330:3-12.
Freedman L, Munro RH: Abduction of the arm in the scapular plane: Scapular and glenohumeral movements. J Bone Joint Surg Am 1966;18:1503.

Question 53

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

Explanation

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

Question 54

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities including walking. Examination reveals a grade 3+ Lachman with a soft endpoint, varus laxity at 30 degrees, and a positive dial test at 30 degrees that dissipates at 90 degrees of knee flexion. He has mild medial joint line tenderness. When walking, there is a slight varus thrust. What treatment is most likely to lead to a successful outcome? Review Topic

Explanation

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.
(SBQ12SP.35) A 16-year-old male football player is tackled into the ground during a game. He comes to the sideline with unilateral upper extremity pain, burning dysesthesias, and muscle weakness. Several minutes later, his symptoms resolve. In this scenario, what muscles are most likely to be affected? Review Topic
Deltoid and biceps
Triceps
Wrist flexors
Finger flexors
Interossei
This patient presents with a 'burner' or 'stinger,' a transient unilateral neurapraxia that most commonly involves the biceps, deltoid and rotator cuff muscles.
Hypotheses for the mechanism of neurapraxia in stingers include nerve root compression in the neural foramen as a result of extension and compression, traction on the brachial plexus or a direct blow to the plexus. C5-C6 is the most commonly involved level, indicating root injury or upper trunk brachial plexus injury. Unilateral and transient symptoms are required for diagnosis. Bilateral 'stinger' symptoms of numbness, tingling, and weakness are consistent with cervical spinal cord neurapraxia. Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine.
Shannon et al. review burner syndrome in athletes. They emphasize that criteria for return to play are based on a complete and thorough neurologic and physical exam. Normal strength and sensation in both upper extremities as well as a normal cervical spine exam (including range of motion, compression, Spurling's, Adson's, and resistive head pressures) are required for return to play. Any positive findings mandate withdrawal of the player from competition.
Illustration A shows hypothesized areas of involvement by mechanism according to
Shannon et al. A, Extension-ipsilateral compression. B, Flexion-contralateral flexion (traction) or direct trauma.
Incorrect Answer Answer Answer
2:
3:
4:
Wrist Finger
Triceps
flexors flexors
C7 C7 C8

Question 55

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

Explanation

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

Question 56

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Explanation

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:

OrthoCash 2020

Question 57

Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with

Explanation

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.

J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. J Sports Med 1998;26:41-45.

Question 58

Which of the following is an indication for surgical management of a Weber type B distal fibular fracture?

Explanation

DISCUSSION: A widened medial clear space indicates instability caused by an associated tear of the deltoid ligament; therefore, nonsurgical management is not warranted. Weber type B distal fibular fractures without a deltoid tear have a medial clear space of < 4 mm, even under stress, and may be successfully treated nonsurgically. The presence of medial hindfoot ecchymosis and medial ankle tenderness is not fully indicative of medial soft-tissue instability; however, these findings may indicate a deltoid injury and should raise suspicion of an unstable fracture injury pattern. Stress testing is necessary to demonstrate the presence or absence of instability. A small amount of comminution is also cause for increased suspicion of an unstable pattern; however, it is not a direct contraindication when considering nonsurgical management. Two millimeters of fibular displacement without lateral shift of the talus is an acceptable position when considering nonsurgical management of Weber type B distal fibular fractures.
REFERENCES: Michelson JD, Magid D, Ney DR, et al, Examination of the pathologic anatomy of ankle fractures. J Trauma 1992;32:65-70.
Marsh JL, Saltzman CL: Ankle fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 2001-2090.

Question 59

Which of the following statements describing chordomas is false?

Explanation

DISCUSSION: Casali and associates provided a recent review of the treatment options for chordomas. These tumors are not radiosensitive; however, modern intensity modulated radiosurgery techniques may be of value. The combination of surgery and radiotherapy compared to surgery alone results in the same disease-free survival time. Complete surgical resection of the chondroma with clean margins offers the best survival; however, its location may make total removal impossible. Thus subtotal resection followed by radiotherapy results in better survival despite the tumor’s lack of radiosensitivity.
REFERENCE: Casali PG, Stacchiotti S, Sangalli C, et al: Chordoma. Curr Opin Oncol 2007;19:367-370.

Question 60

A 78-year-old man being seen for routine follow-up studies reports mild to moderate pain in his left arm. The patient has a history of lung cancer and severe heart disease. A radiograph and a bone scan are shown in Figures 36a and 36b. Treatment should consist of

Explanation

DISCUSSION: The patient has lung cancer metastatic to the left humerus that is mildly to moderately symptomatic. Radiographically, the lesion is small and is not associated with significant cortical destruction. Metastatic lesions in the upper extremity have a lower incidence of pathologic fracture than lesions in the lower extremity.
REFERENCE: Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.

Question 61

The superior glenohumeral ligament primarily restrains

Explanation

DISCUSSION: Several cutting studies have evaluated the primary static restraints and the role of the glenohumeral ligaments in providing static stability. With the arm at the side in adduction, the superior glenohumeral ligament and coracohumeral ligament are the primary restraints to inferior translation. The middle glenohumeral ligament functions with the arm in 45 degrees of abduction and resists anterior translation. The inferior glenohumeral ligament is the primary restraint to anterior translation at 90 degrees of abduction.
REFERENCES: Warner JJ, Deng XH, Warren RF, et al: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.
Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy Orthopaedic Surgeons, 1994, pp 165-177.

Question 62

Radiographs of a 12-year-old boy who has knee pain show a 2-cm osteochondral lesion of the lateral aspect of the medial femoral condyle. The fragments are not detached from the femur. Initial management should consist of

Explanation

DISCUSSION: For a pediatric patient without mechanical symptoms, initial management of an osteochondral defect lesion that is not detached should consist of casting in flexion. Failure to respond to several weeks or months of nonsurgical management may warrant surgical treatment.
REFERENCE: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 505-520.

Question 63

Figures 85a through 85c are the sagittal and axial CT scans and sagittal T2 MR image of a 21-year-old man who was thrown from his motocross bike earlier in the day. He now has significant low-back pain; however, he is neurologically intact and has no trouble voiding urine. A standing plain radiograph obtained the next day is shown in Figure 85d. Treatment should involve A B C D

Explanation

DISCUSSION
Disruption of the posterior ligamentous complex is an important determinant of the stability of a burst fracture. This patient is neurologically intact and his MR images do not reveal posterior ligamentous complex (PLC) disruption. The standing radiograph confirms that overall alignment is acceptably and relatively preserved. Nonsurgical treatment with or without a brace is acceptable in this scenario; however, the patient should not be cleared to resume full activity until fracture healing, which may be as long as 3 months after the date of injury. Anterior or posterior surgery should be reserved for patients with PLC disruption, neurological injury, or, in some cases, multiple trauma.
RECOMMENDED READINGS
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024. View Abstract at PubMed
Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. PubMed PMID: 16227897. View Abstract at PubMed
Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Lehman RA Jr, Anderson DG, Bono CM, Kuklo T, Oner FC. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005 Jun;18(3):209-15. PubMed PMID: 15905761.View Abstract at PubMed
RESPONSES FOR QUESTIONS 86 THROUGH 89
Proximal junctional kyphosis (PJK)
Adjacent segment degeneration
Intraoperative neurological injury
Postsurgical wound infection
Please select the complication listed above that most commonly is associated with a clinical scenario described below.

Question 64

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Explanation

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?
A. Inability to flex the distal interphalangeal joint of the index finger
B. Positive Froment’s sign
C. Weakness with wrist extension
D. Decreased capillary refill

Question 65

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

Explanation

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

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

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

Question 66

-Use of the shorter, anterior screw may result in

Explanation

Question 67

What is the most appropriate management at this time? Review Topic

Explanation

The CT scan reveals a right-sided lateral disk protrusion at L3-4 that has been symptomatic for more than 4 months despite appropriate nonsurgical management. Relative surgical indications include persistent radiculopathy despite an adequate trial of nonsurgical management, recurrent episodes of sciatica, persistent motor deficit with tension signs and pain, and pseudoclaudication caused by underlying stenosis. Whereas studies have shown improvement in patients with sciatica from a lumbar disk herniation treated either nonsurgically or surgically, those undergoing surgical treatment had an overall greater improvement of symptoms.

Question 68

A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?

Explanation

DISCUSSION: Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position.
REFERENCES: Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.
Ferretti A, De Carli A, Fontana M: Injury of the suprascapular nerve at the spinoglenoid notch: The natural history of infraspinatus atrophy in volleyball players. Am J Sports Med 1998;26:759-763.

Question 69

Which of the following statements best characterizes polymethylmethacrylate (PMMA) when it is used to secure joint components in bone and to distribute the forces evenly across the bone-implant interface?

Explanation

DISCUSSION: PMMA has no adhesive properties and can be more accurately described as grout than glue. It does not chemically bond to bone or implants; however, mechanical bonding is accomplished with porous or coated components and with cancellous bone. PMMA is approximately three times stronger in compression than in tension. Peak blood levels of monomer are usually seen approximately 3 minutes after the cement is placed. The monomer is cleared by the lungs. Associated hypotension is more closely related to diminished blood volume than to circulating monomer levels. High porosity decreases the tensile and fatigue properties of cement. Manually mixed cement may have porosity as high as 27%. Porosity may be reduced to less than 1% through vacuum mixing or centrifugation of the cement. When adding antibiotics to cement, the compressive and tensile forces are not appreciably decreased, but the overall fatigue strength may be reduced.
REFERENCES: Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby, 1998, pp 221-224.
Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 27-33.

Question 70

A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis? Review Topic

Explanation

The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow.

Question 71

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Explanation

Most thoracic disk herniations occur in the lower (caudal) third of the thoracic spine. This predilection may be related to the unique anatomic and biomechanical environment of that region. The 11th and 12th ribs do not join the rib cage anteriorly and do not form a true articulation with the transverse processes posteriorly. Furthermore, flexion and torsional forces tend to concentrate between T10 and L1.

Question 72

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Explanation

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 73

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Explanation

Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.

Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.

Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.

The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 74

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had

Explanation

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.

Question 75

Figures 46a through 46e show the radiographs of a 22-year-old man who injured his wrist in a motorcycle accident. He has no other injuries. What is the best course of action?

Explanation

DISCUSSION: The patient has a fracture-dislocation of the radiocarpal joint. Attached to the large radial styloid fragment are the extrinsic wrist ligaments to the carpus. This injury should be treated with open reduction and internal fixation of the styloid fracture. Radiolunate fusion or extrinsic ligament repair is suggested when the extrinsic ligaments are ruptured, resulting in ulnar translocation of the carpus.
REFERENCES: Dumontier C, Meyer ZU, Reckendorf G, et al: Radiocarpal dislocations: Classification and proposal for treatment: A review of twenty-seven cases. J Bone Joint Surg Am 2001;83:212.
Bilos ZJ, Pankovich AM, Yelda S: Fracture-dislocation of the radiocarpal joint: A clinical study of five cases. J Bone Joint Surg Am 1977;59:198-203.

Question 76

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 77

A 17-year-old boy underwent open reduction and internal fixation of a navicular fracture 5 days ago. A follow-up examination now reveals a tensely swollen foot with erythema and multiple skin bullae. The patient is febrile and has marked pain with palpation of the entire forefoot and hindfoot. What is the next step in management?

Explanation

DISCUSSION: Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%. Debridement of the bullae and observation are not indicated. Although elevation and close follow-up may be warranted early on, in this patient, surgical debridement is the next step.
REFERENCES: Ault MJ, Geiderman J, Sokolov R: Rapid identification of group A streptococcus as the cause of necrotizing fasciitis. Ann Emerg Med 1996;28:227-230.
McHenry CR, Piotrowski JJ, Pentrinic D, Malangoni MA: Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-563.

Question 78

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Explanation

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.View Abstract at PubMed

Question 79

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Explanation

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:

Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 80

Which structure is shown in Video 27? 27

Explanation

DISCUSSION
Video 27 shows the medial patellofemoral ligament running from the medial epicondyle of the femur to the medial portion of the patella. The posterior oblique ligament and the superficial medial collateral ligament run from medial epicondyle to the tibia.
RECOMMENDED READINGS
Babb JR, Detterline AJ, Noyes FR. AAOS Orthopaedic Video Theater. The Key to the Knee: A Layer-by-Layer Video Demonstration of Medial and Anterior Aatomy. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2009.
Hoppenfeld S, deBoer P. Surgical Exposures in Orthopedics. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:493-568.

Question 81

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Explanation

DISCUSSION: A positive jaw jerk reflex suggests that the problem is above the level of the pons. All of the other physical signs are exhibited in patients with cervical myelopathy. Although these signs also may be present in conditions affecting the brain, they do not help differentiate between a brain etiology and a cervical spine etiology. A jaw jerk reflex, however, is not present in patients with cervical myelopathy alone.
REFERENCES: Montgomery DM, Brower RS: Cervical spondylotic myelopathy: Clinical syndrome and natural history. Orthop Clin North Am 1992;23:487-493.
Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K: Myelopathy hand: New clinical signs of cervical cord damage. J Bone Joint Surg Br 1987;69:215-219.
An HS, Simpson JM: Surgery of the Cervical Spine. Baltimore, MD, Williams and

Wilkins, 1994.

Question 82

.The least gliding resistance for a flexor tendon laceration at the thumb palmar-digital crease as shown inFigure 75 can be achieved with

Explanation

Question.9 . A 42-year-old woman has the injury shown in Figures 78a and 78b. The decision to treat the ulnar styloid surgically is based upon which finding?

Patient age
Displacement of the radius fracture
Displacement of the ulnar styloid fracture
Position of the ulnar styloid after open reduction and internal fixation of the radius
Stability of the distal radioulnar joint after open reduction and internal fixation of the radius

Question 83

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

Explanation

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

Question 84

A 13-year-old boy has knee pain after sustaining a mild twisting injury while playing basketball 4 weeks ago. Radiographs and MRI scans are shown in Figures 24a through 24d, and biopsy specimens are shown in Figures 24e and 24f. Treatment should consist of

Explanation

DISCUSSION: The imaging studies and histology are consistent with high-grade osteosarcoma. The standard treatment for osteosarcoma is neoadjuvant chemotherapy combined with wide surgical resection that can be performed with amputation or limb salvage depending on characteristics unique to each tumor and each patient. In most patients, limb salvage surgery can be performed with reconstruction using allografts and/or megaprostheses. Osteosarcoma is poorly responsive to radiation therapy. Chemotherapy alone, in the absence of appropriate surgery, has not proven effective.
REFERENCES: Simon MA, Springfield DS: Surgery for Bone and Soft-Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 265-274.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 85

A 28-year-old anesthesia resident has aching pain in his dominant right forearm after injuring it while playing basketball 1 week ago. He reports that he is unable to perform regional anesthesia that requires manipulation of a needle. Examination reveals that he is unable to flex the interphalangeal joint of the thumb, and flexion of the distal interphalangeal joint of the index finger is weak. Management should consist of

Explanation

DISCUSSION: The patient has anterior interosseous nerve palsy. Initial management should consist of splinting followed by observation; surgical decompression may be required if there is no improvement in the functional deficit in 6 months. Anterior interosseous nerve palsy is classically described as an inability to flex the interphalangeal joint of the thumb because of flexor pollicis longus paralysis and a weakness or inability to flex the distal interphalangeal joint of the index finger because of weakness and/or paralysis of the flexor digitorum profundus to the index finger. There has been some controversy in the literature as to whether this represents a true peripheral compression neuropathy or neuritis. Recent recommendations have been to extend the period of observation from 3 to 6 months before surgical decompression, as most cases will resolve within 6 months.
REFERENCES: Miller-Breslow A, Terrono A, Millender LH: Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am 1990;15:493-496.
Stern PJ, Fassler PR: Anterior interosseous nerve compression syndrome, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, 1991, vol 2, pp 983-1002.

Question 86

What muscle is most often encountered during surgical approaches to C5-6?

Explanation

DISCUSSION: The omohyoid muscle crosses the surgical field from inferior lateral to anterior superior traveling from the scapula to the hyoid bone and may need to be transected. The posterior digastric crosses the field as well but higher near C3-4. The other muscles run longitudinally.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-56.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 87

A 75-year-old female with a longstanding history of brachial plexus palsy 2 . A 63-year-old male with a 6 month history of shoulder pain and inability to abduct past 30 degrees

Explanation

Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?

Immobilization in external rotation for 6 weeks Arthroscopic bony Bankart repair

Arthroscopic Remplissage procedure

Glenoid augmentation using coracoid transfer Glenoid augmentation using tricortical iliac crest graft
This patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.
Older (>20 years old), recreational athletes with minor glenoid bone loss (<20 % of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid.
Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.
Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.
Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.
Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.
Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss. Incorrect Answers:
A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?

Nonsynergistic action of the transferred muscle Fatty atrophy of the supraspinatus and infraspinatus Deficiency of the subscapularis

Absence of the coracoacromial ligament Deltoid weakness
A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer.
The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.
An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure?

Anchor fatigue and breakage Anchor pull out from bone

Suture rupture secondary to anchor eyelet abrasion Suture pull out from the repaired tissue

Infection
Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).
George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.
Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include highstrength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.
Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, singlerow configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 1215 mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing. Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.
Incorrect Responses
Biocomposite anchors exhibit high load-to-failure and result in fatigue failure less commonly than metal anchors.

A 32-year-old cross-training athlete awakens with severe left neck and shoulder pain after a day of intense upper body training. Aside from a recent viral illness, he is otherwise healthy. His pain improves, but two weeks later he notes significant left shoulder weakness. Examination reveals weakness of shoulder abduction, forward elevation and external rotation with the arm at his side. Radiographs are normal. Electromyography demonstrates 2+ positive sharp waves and fibrillations. Sensory nerve conduction studies show reduced amplitudes. MRI of the brain, cervical spine and shoulder are shown in Figures A-D, respectively. Which of the following is true of his prognosis?

Decompression will result in improved muscle strength and function.

The patient can expect a gradual return of muscle strength without long term functional deficits. Immunomodulators may decrease the number and severity of his relapses. 4 . Arthroscopic repair will result in the best functional outcomes given the patient's high activity level.

Question 88

A patient sustained the injuries shown in the radiographs and clinical photograph seen in Figures 10a through 10c. The neurovascular examination is normal. The first step in emergent management of the extremity injuries should consist of

Explanation

DISCUSSION: The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation.
REFERENCES: Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529.
Moed BR, WillsonCarr SE, Watson JT: Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am 2002;84:752-758.

Question 89

A 42-year-old patient undergoes resection of the medial clavicle for painful sternoclavicular degenerative joint disease. The postoperative course is complicated by an increase in symptoms, a medial bump, and subjective tingling in the digits. A clinical photograph and radiograph are shown in Figures 20a and 20b. What is the most appropriate procedure at this time?

Explanation

DISCUSSION: Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 90

Figures 26a through 26c show the MRI scans of a 47-year-old man who underwent arthroscopic shoulder surgery 6 months ago and continues to have pain despite a prolonged course of rehabilitation. Management should now consist of

Explanation

DISCUSSION: The MRI scans show an os acromiale of the mesoacromion type. This represents an unfused acromial apophysis. Pain is thought to be caused by either motion at the site or downward displacement of the anterior aspect of the acromion onto the rotator cuff, causing impingement. Most patients can be treated nonsurgically as they are usually asymptomatic. In those patients with persistent symptoms of pain and tenderness over the acromion, surgery consisting of rigid internal fixation and bone grafting has yielded satisfactory results. Excision may be a viable treatment option for the preacromion type.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Warner JP, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.
Sammarco VJ: Os acromiale: Frequency, anatomy, and clinical implications. J Bone Joint Surg Am 2000;82:394-400.

Question 91

In a hypothetical study, an investigator uses pedometers to determine that the 20 women in his activity study averaged 2.1 million steps per year, whereas the 20 men averaged 1.8 million. The p-value for this difference was 0.09. Which of the following is a correct interpretation of the outcome of this study?

Explanation

The p-value should be interpreted only as an indication of the level of uncertainty of the results observed in this study. That is, the p-value answers the specific question, "If, in general, there actually is no difference between the average activity levels of women and men, how often would one expect to obtain by chance a difference as large (or larger) than was observed in the present study?" If the p-value is very small, it is relatively unlikely that the observed difference occurred by chance. However, it is critical to realize that, because of its definition, a large p-value is not an indication that there probably is no difference in general. Therefore, it is not true that the study has shown that there is "statistically no difference" between the activity levels of women and men. Rather, a large p-value indicates a relative lack of certainty of whether the difference between the activity levels of women and men in general is much smaller or much larger than was observed in the present study. Furthermore, no matter how large the p-value, in the absence of other data (other studies), the difference observed between two randomly selected groups of subjects is the most reliable estimate of the magnitude of the actual difference between the full populations. In a study such as this, if the p-value is sufficiently small, the investigators may be relatively confident in concluding that the observed difference holds in general. In contrast, if the p-value is very large (say, 0.8), then the investigators are relatively uncertain about any conclusion - they are not highly certain that there is no difference in general. Put simply, contrary to the common misconception, observed differences are not shown to be real or false depending on whether the p-value is less than or greater than 0.05, or any other arbitrary value.

Question 92

Figures 47a and 47b show the CT scans of a patient who reports persistent pain in the sinus tarsi following a fall. The avulsion fracture fragment remains attached to what ligament?

Explanation

DISCUSSION: The bifurcate ligament bifurcates to connect the dorsal aspect of the anterior process of the calcaneus to both the cuboid and the navicular. Inversion injuries on the side of the foot can result in avulsion fractures (arrow) of the anterior process of the calcaneus.
REFERENCES: Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. New York, NY, Lippincott, 1993, p 192.
Robbins MI, Wilson MG, Sella EJ: MR imaging of anterosuperior calcaneal process fractures. Am J Roentgenol 1999;172:475-479.

Question 93

Which of the following best describes the relationship of the median nerve to the flexor carpi radialis tendon just proximal to the carpal canal?

Explanation

DISCUSSION: The median nerve has an intimate association with the palmaris longus and the flexor carpi radialis at the proximal aspect of the carpal canal. The median nerve lies just ulnar and dorsal to the flexor carpi radialis tendon.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.
Henry A: Extensile Exposure, ed 3. Edinburgh, UK, Churchill Livingstone, 1995, pp 100-107.

Question 94

A 35-year-old man sustained a 1-inch stab incision in his proximal forearm while trying to use a screwdriver 2 weeks ago. The laceration was routinely closed, and no problems about the incision site were noted. He now reports that he has been unable to straighten his fingers or thumb completely since the injury. Clinical photographs shown in Figures 30a and 30b show the man passively flexing the wrist. What is the most appropriate management?

Explanation

DISCUSSION: The clinical photographs indicate that the tenodesis effect of digit flexion with passive wrist extension and digit extension with passive wrist flexion is intact, indicating no discontinuity of the extensor or flexor tendons. The most likely injury is a laceration of the posterior interosseous nerve.
REFERENCE: Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 2069.

Question 95

Arthritic change in cartilage is characterized by which of the following findings?

Explanation

Experimental models of late-stage arthritis in animals demonstrated lower compressive modulus, higher permeability, and higher water content. There is proteoglycan loss within the matrix. A significant and progressive decrease in the tensile and shear modulus has been observed.

Question 96

Examination of a 5-year-old boy with amyoplasia shows a flexion contracture of 70° of the right knee. The active arc of motion is from 70° to 90°, and the opposite knee has a flexion contracture of 10°. Both hips are dislocated with flexion contractures of 10°, passive hip motion is from 10° to 90° of flexion, and the feet are plantigrade and easily braceable. Despite a daily stretching program, the parents and physical therapists note that it is increasingly difficult for him to walk because of the flexion contracture of the right knee. Management of the knee flexion contracture should now include

Explanation

DISCUSSION: Most children with amyoplasia are ambulatory and when a decrease in function occurs because of a severe contracture, it must be addressed. A radical posterior soft-tissue release, including the posterior knee capsule and often the collateral ligaments and the posterior cruciate ligament, is needed to obtain extension. After the age of 1 year, aggressive physical therapy will do little to correct a contracture. Botulinum toxin A is indicated for spasticity and is contraindicated with severe contractures. Supracondylar femoral extension osteotomy works well, but will remodel at an average rate of 1° per month, which is not considered ideal in a young patient. Gradual correction with a circular ring external fixator is an option, but a soft-tissue release will also most likely be needed for a contracture of this severity.
REFERENCES: Sarwark JF, MacEwen GD, Scott CI Jr: Amyoplasia (a common form of arthrogryposis). J Bone Joint Surg Am 1990;72:465-469.
DelBello DA, Watts HG: Distal femoral extension osteotomy for knee flexion contracture in patients with arthrogryposis. J Pediatr Orthop 1996;16:122-126.
Sells JM, Jaffe KM, Hall JG: Amyoplasia, the most common type of arthrogryposis: The potential for good outcome. Pediatrics 1996;97:225-231.

Question 97

A 23-year-old baseball pitcher reports pain in the posterior aspect of his dominant shoulder during the late cocking phase of throwing. With the dominant shoulder positioned in 90 degrees of abduction from the body and with the scapula stabilized, examination reveals 135 degrees of external rotation and 20 degrees of internal rotation. Examination of the opposite shoulder reveals 100 degrees of external rotation and 75 degrees of internal rotation. Both shoulders are stable on examination. Radiographs and MRI scans are unremarkable. What is the primary cause of his pain?

Explanation

DISCUSSION: Internal impingement of the shoulder is a leading cause of shoulder pain in the throwing athlete. The primary lesion in pathologic internal impingement is excessive tightening of the posterior band of the inferior glenohumeral ligament complex. To obtain an accurate assessment of true glenohumeral rotation, the scapula is stabilized during examination. A loss of 20 degrees or more of internal rotation, as measured with the shoulder positioned in 90 degrees of abduction, indicates excessive tightness of the posterior band of the inferior glenohumeral ligament complex.
REFERENCES: Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Spectrum of pathology. Part I: Pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420.
Meister K: Injuries to the shoulder in the throwing athlete. Part one: Biomechanics, pathophysiology, classification of injury. Am J Sports Med 2000;28:265-275.

Question 98

A 63-year-old man has a feeling of generalized clumsiness in his arms and hands, difficulty buttoning his shirt, and gradually worsening gait instability. During examination, his neck is gently passively flexed to end range while he is seated. The patient describes an electric shock-like sensation that radiates down the spine and into the extremities. This describes which of the following? Review Topic

Explanation

What is now referred to as Lhermitte sign was first described by Marie and Chatelin in 1917 to describe "transient 'pins and needles' sensations traveling the spine and limbs on flexion of the head" in some patients with head injuries. A positive test is indicated by the presence of electric-like sensation down the spine or extremities. It is associated with cervical spinal cord pathology from a wide variety of etiologies, including multiple sclerosis. Recent studies suggest that it has a low sensitivity and high specificity. Spurling's sign is elicited by axial compression of the tilted head. Jackson's sign is elicited by hyperextension of the cervical spine. Lasegue sign refers to the straight leg raise with dorsiflexion of the ankle for lumbar radiculopathy. Hoffmann sign is a pathologic reflex of the upper extremity, that is felt to be an indicator of cervical myelopathy.

Question 99

A 41-year-old man is involved in a high-speed motor vehicle crash and sustains a closed femoral midshaft fracture and a unilateral pulmonary contusion with a hemothorax, requiring placement of a chest tube. He has an initial blood pressure of 90/50 mm Hg. After receiving two liters of crystalloid, he has a blood pressure of 115/70 mm Hg and a heart rate of 90 bpm. He has normal mentation and does not require ventilator support. An arterial blood gas reveals that his delta base is

Explanation

The patient responded to crystalloid resuscitation and hemodynamic parameters and the base deficit indicate that he is adequately resuscitated for definitive fracture care. In a resuscitated patient, a reamed nail is not detrimental in the setting of a pulmonary injury and is favorable for fracture union. An unreamed nail has a higher nonunion rate than a reamed nail for femoral fractures. In a skeletally mature patient with a midshaft fracture, an intramedullary nail is preferred to open reduction and internal fixation. In an adult patient, skeletal traction should be considered only as a temporary treatment prior to surgical fixation of the femoral fracture.

Question 100

A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure

Explanation

Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.
Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.
Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. They
report 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.
Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.
OrthoCash 2020

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Loss of reduction of the ulnar physis
Loss of reduction of the radial metaphysis
Physeal arrest of the distal radius
Physeal arrest of the distal ulna
Osteonecrosis of the ulnar epiphysis

Correct Answer: Physeal arrest of the distal ulna

Explanation:

Question 2:

During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?

Options:

Flexor hallucis longus
Flexor digitorum longus
Peroneus longus
Posterior tibial
Quadratus planti

Correct Answer: Flexor hallucis longus

Explanation:

Question 3:

Which of the following areas of the vertebral segment has the highest ratio of cortical to cancellous bone? Review Topic

Options:

Thoracic vertebral bodies
Lumbar vertebral bodies
Sacrum
Pedicles of the lower lumbar spine
Pedicles of the thoracic spine

Correct Answer: Pedicles of the thoracic spine

Explanation:

Question 4:

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 5:

Options:

0 degrees
1 degrees to 2 degrees
Approximately 5 degrees
Approximately 10 degrees
10 degrees to 15 degrees

Correct Answer: Approximately 5 degrees

Explanation:

Question 6:

Options:

Open reduction and cerclage fixation of the fracture
Open reduction and revision of the femoral implant to a long cemented stem
Open reduction and revision of the femoral implant to a long fluted and tapered uncemented stem
Application of balanced traction followed by surgery after the ecchymosis has resolved

Correct Answer: Application of balanced traction followed by surgery after the ecchymosis has resolved

Explanation:

Question 7:

Options:

Observation
Curettage and bone grafting
Radiofrequency ablation
Radiation therapy
Wide resection

Correct Answer: Curettage and bone grafting

Explanation:

DISCUSSION: Chondroblastomas are benign cartilage lesions frequently seen in adolescents or young adults. They are found in the epiphyseal or apophyseal regions of bones. The radiograph shows a radiolucent lesion with mineralization and a well-marginated rim of reactive bone. The lesion is composed of sheets of immature chondroblasts (polygonal cells with a clear, bluish cytoplasm and a small round central nucleus). In some regions, classic “chicken-wire” matrix calcifications and a “cobblestone” pattern of cell arrangement may be seen. Treatment consists of curettage and bone grafting.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 247-264.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 8:

Options:

Infection
Charcot arthropathy
Delayed compartment syndrome
Deep venous thrombosis
Gout

Correct Answer: Charcot arthropathy

Explanation:

Question 9:

After the athlete undergoes the appropriate treatment of the postsurgical complication and recovers without further incident, which muscle most likely will be last to experience return of function?

Options:

Extensor indicis proprius (EIP)
Extensor digiti quinti (EDQ)
Extensor digitorum communis (EDC)
Extensor carpi ulnaris (ECU)

Correct Answer: Extensor indicis proprius (EIP)

Explanation:

Question 10:

Options:

Non-weight-bearing immobilization and CT
Walking boot and weight bearing as tolerated
Activity restrictions (avoidance of running) and repeat radiographs in 2 to 4 weeks
Activity restrictions and a bone scan
Surgical fixation

Correct Answer: Non-weight-bearing immobilization and CT

Explanation:

DISCUSSION: A high index of suspicion is required to identify a possible navicular stress fracture, especially in runners. High pain tolerance in the competitive athlete and often minimal swelling contribute to frequent delays in diagnosis. Localized tenderness over the dorsal navicular (so-called “N spot”) in a running athlete should alert the treating physician. In this patient, the radiographs are negative and the MRI scan shows marrow edema within the navicular. This could represent a stress reaction, stress fracture, or osteonecrosis. Appropriate management should include non-weight-bearing immobilization and obtaining a CT scan to determine if a fracture is present. Early surgical treatment may be considered but only if a fracture is identified.
REFERENCES: Lee A, Anderson R: Stress fractures of the tarsal navicular. Foot Ankle Clin 2004;9:85-104.
Coughlin M: Tarsal navicular stress fractures. Tech Foot Ankle Surg 2002;1:112-122.

Question 11:

Options:

Bilateral long thoracic nerve palsies
Central cervical disk herniation
Duchenne muscular dystrophy, adult onset
Fascioscapulohumeral dystrophy
Disuse atrophy as the result of deconditioning

Correct Answer: Fascioscapulohumeral dystrophy

Explanation:

Question 12:

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

Options:

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

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

Explanation:

Question 13:

Options:

Metastatic work-up
Physical therapy
Transpedicular biopsy
Thoracotomy with partial resection of the mass
T9 corpectomy with anterior column reconstruction 76.03

Correct Answer: Metastatic work-up

Explanation:

Here is an algorithm from OKU 6 Tumors of the Spine pp 723-736
This question gives you the history, skips right over physical exam and goes into plain films. With this patient’s history of hemoptysis and dyspnea and a lung mass, the next steps in this patients work-up would include the competion of initial work-up, metastatic work-up, then pre-operative planning. Goals of treatment are to 1) protect or restore neurologic function, 2) control pain,

Question 14:

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 15:

Options:

a lace-up ankle splint and progressive activities.
anatomic repair of the anterior talofibular and calcaneofibular ligaments.
Kirschner wire and tension band fixation of the cortical avulsion fracture off the fibula.
local ligament transfer and reconstruction of the lateral ankle ligaments.
protected weight bearing and a short leg cast for 6 weeks.

Correct Answer: protected weight bearing and a short leg cast for 6 weeks.

Explanation:

Question 16:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

Explanation:

Question 17:

Options:

Infection
Osteolysis
Acetabular protrusio
Loosening of implant
Complex regional pain syndrome

Correct Answer: Acetabular protrusio

Question 18:

With the arm abducted 90 degrees and fully externally rotated, which of the following glenohumeral ligaments resists anterior translation of the humerus?

Options:

Coracohumeral
Superior glenohumeral
Middle glenohumeral
Anterior band of the inferior glenohumeral ligament complex
Posterior band of the inferior glenohumeral ligament complex

Correct Answer: Anterior band of the inferior glenohumeral ligament complex

Explanation:

DISCUSSION: With the arm in the abducted, externally rotated position, the anterior band of the inferior glenohumeral ligament complex moves anteriorly, preventing anterior humeral head translation. Both the coracohumeral ligament and the superior glenohumeral ligament restrain the humeral head to inferior translation of the adducted arm, and to external rotation in the adducted position. The middle glenohumeral ligament is a primary stabilizer to anterior translation with the arm abducted to 45 degrees. The posterior band of the inferior glenohumeral ligament complex resists posterior translation of the humeral head when the arm is internally rotated.
REFERENCES: Harryman DT II, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.
Wang VM, Flatow EL: Pathomechanics of acquired shoulder instability: A basic science perspective. J Shoulder Elbow Surg 2005;14:2S-11S.

Question 19:

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Options:

Dorsal foot pain extending into the great toe
Foot pain extending along the lateral border of the foot
Pain extending into the foot in a stocking distribution
Anterior thigh and shin pain ending at the ankle
Lateral foot paresthesias

Correct Answer: Dorsal foot pain extending into the great toe

Explanation:

Question 20:

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

Options:

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

Correct Answer: Preservation of external rotation

Explanation:

Question 21:

Options:

Osteosarcoma
Fibrous dysplasia
Osteoblastoma
Ossifying fibroma
Osteomyelitis

Correct Answer: Fibrous dysplasia

Explanation:

DISCUSSION: Although the classic radiographic appearance of fibrous dysplasia is one of a central metaphyseal lesion with ground glass matrix, it is not unusual to see either a more radiodense-appearing lesion or a more peripheral location. The histologic finding of spicules of woven bone without osteoblastic rimming in a bland fibrous background is diagnostic of fibrous dysplasia. The imaging studies could be consistent with low-grade osteosarcoma, osteoblastoma, or osteomyelitis, but all have a very different histologic picture. Observation is indicated in the absence of symptoms, impending fracture, or deformity. Fibrous dysplasia most commonly occurs in the proximal femur.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 30-43.
DiCaprio MR, Enneking WF: Fibrous dysplasia: Pathophysiology, evaluation, and treatment.
J Bone Joint Surg Am 2005;87:1848-1864.

Question 22:

Options:

anterior alanto-odontoid interval of less than 9 mm.
anterior alanto-odontoid interval of greater than 9 mm.
posterior alanto-odontoid interval of greater than 10 mm.
posterior alanto-odontoid interval of greater than 12 mm.
posterior alanto-odontoid interval of greater than 14 mm.

Correct Answer: posterior alanto-odontoid interval of greater than 10 mm.

Explanation:

Question 23:

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

Options:

The IAR is calculated by movement around six different axes.
The IAR consists of potential movements or 12 degrees of freedom.
The IAR is fixed and consistent and is the axis about which each vertebral segment rotates.
The IAR can be derived from AP and lateral radiographs.
Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Correct Answer: Degenerative disease, fractures, and ligamentous injuries can affect the IAR.

Explanation:

Question 24:

Which of the following patients is considered the most appropriate candidate for selective dorsal rhizotomy?

Options:

Nonambulatory 2-year-old with spastic diplegia
Nonambulatory 2-year-old with spastic quadriplegia
Nonambulatory 12-year-old with spastic quadriplegia
Ambulatory 4-year-old with spastic diplegia
Ambulatory 9-year-old with hemiplegia and athetosis

Correct Answer: Ambulatory 4-year-old with spastic diplegia

Explanation:

Question 25:

Options:

Chondrolysis
Ischemic necrosis of the femoral head
Ischemic necrosis of the greater trochanter
Femoral neck fracture
Trochanteric overgrowth

Correct Answer: Ischemic necrosis of the femoral head

Explanation:

Question 26:

Which of the following changes occur in the spinal cord and the spinal canal when the cervical spine moves from neutral to full flexion?

Options:

The spinal cord relaxes and the spinal canal shortens.
The spinal cord undergoes elastic deformation and the spinal canal lengthens.
The spinal cord remains unchanged and the spinal canal lengthens.
The spinal cord remains unchanged and the spinal canal shortens.
Neither structure shows any predictable pattern of changes.

Correct Answer: The spinal cord undergoes elastic deformation and the spinal canal lengthens.

Explanation:

Question 27:

Options:

Resistance to adhesive wear B. Resistance to abrasive wear C. Resistance to fatigue wear
Resistance to creep

Correct Answer: Resistance to creep

Explanation:

Question 28:

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Options:

First-generation cephalosporin
Cephalosporin, penicillin, and quinolone
Cephalosporin and aminoglycoside
Quinolones
Synthetic penicillin and aminoglycoside

Correct Answer: Synthetic penicillin and aminoglycoside

Explanation:

Question 29:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

Question 30:

What is the most significant benefit of percutaneous transforaminal lumbar interbody fusion (TLIF) vs open posterior lumbar interbody fusion (PLIF)?

Options:

Preservation of the paraspinal muscle sleeve
Higher fusion rate
More measurable intraoperative blood loss
Improved ability to evacuate the disk space

Correct Answer: Preservation of the paraspinal muscle sleeve

Explanation:

DISCUSSION
Humphreys and associates in a retrospective review of TLIF vs PLIF found fusion rates, surgical time, and length of hospital stay were similar with both procedures. The only benefits associated with TLIF were less blood loss and preservation of the paraspinal muscle sleeve. Manos and associates in a cadaver study found no difference in the volume of disk material evacuated or the area of endplate exposed in either procedure.
RECOMMENDED READINGS
Humphreys SC, Hodges SD, Patwardhan AG, Eck JC, Murphy RB, Covington LA. Comparison of posterior and transforaminal approaches to lumbar interbody fusion. Spine (Phila Pa 1976). 2001 Mar 1;26(5):567-71. PubMed PMID: 11242386.
View Abstract at PubMed
Manos R, Sukovich W, Weistroffer J: Transforaminal lumbar interbody fusion: Minimally invasive versus open disc excision and endplate preparation. Presented at the 12th International Meeting of Advanced Spine Techniques, Banff, Alberta, Canada, July 7-9, 2005.

Question 31:

Which of the following is an advantage of using blocking screws for tibial nailing?

Options:

Decrease risk of nail breakage
Eliminate use of interlocking screws
Allow for larger nail use
Enhance construct stiffness
Decrease torsional rigidity

Correct Answer: Decrease risk of nail breakage

Explanation:

Question 32:

Options:

Revision of the acetabular implant to a constrained bearing with modular exchange of the femoral head and neck
Revision of the acetabular and femoral implants
Retention of the acetabular implant with modular exchange of the femoral head and neck
Revision of the femoral component alone with a new ceramic head

Correct Answer: Revision of the acetabular and femoral implants

Explanation:

Question 33:

A 14-year-old boy is seen for back pain. Radiographic evaluation reveals a grade III isthmic spondylolisthesis. What measurement is most useful in predicting the likelihood of progression?

Options:

Pelvic incidence
Slip angle
Sacral inclination
Lumbosacral joint angle
Sagittal rotation

Correct Answer: Slip angle

Explanation:

Question 34:

Which of the following clinical findings is most often seen with the MRI scan findings shown in Figures 19a through 19c? Review Topic

Options:

Atrophy of the lateral shoulder
Atrophy of the posterior shoulder
Sensory deficit of the lateral shoulder
Sensory deficit of the posterior shoulder
Sensory deficit of the anterior shoulder

Correct Answer: Atrophy of the posterior shoulder

Explanation:

Question 35:

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

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 degrees.
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 36:

Options:

external electrical stimulation.
external ultrasound stimulation.
implanted electrical stimulation.
closed reduction and percutaneous fixation.
open reduction and internal fixation with bone graft.

Correct Answer: open reduction and internal fixation with bone graft.

Explanation:

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have
shown some healing response with callus formation, but these techniques are not successful
in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions
of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson
NS
, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 37:

Options:

Numbness over dorsal aspect of the foot, weakness to gluteus medius
Numbness over plantar foot, weakness to his gastrocsoleus complex
Numbness over medial malleolus, and weakness to quadriceps
Numbness over medial calf, weakness in his EHL
Numbness over lateral malleolus, weakness to hip adduction

Correct Answer: Numbness over medial calf, weakness in his EHL

Explanation:

The MRI demonstrates a left paracentral L4/5 disc protrusion which leads to compression of the traversing (descending) left L5 nerve root. Numbness over the dorsal aspect of the foot and weakness to gluteus medius is consistent with a L5
radiculopathy.
While nerve root innervation shows some variability by patient, L5 is "characteristically" responsible for the sensation to the dorsal aspect of the foot, ankle dorsiflexion (tibialis anterior - along with L4), great toe extension (EHL), and hip abduction (gluteus medius).
Suri et al. reported on specific physical exam findings that significantly increased the likelihood of nerve root impingement at specific lumbar levels. They found: L2 was associated with decreased anterior thigh sensation. L3 was associated with a positive femoral stretch test. L4 was associated with a blunted patellar reflex, decreased medial ankle sensation or a positive crossed femoral stretch test. L5 was associated with was associated with decreased hip abductor strength.
Luri et al. reported 8-year follow up on the patients in the spine patient outcomes research trial who underwent surgical vs. conservative care for treatment of lumbar herniated disc. They found that patients who underwent surgical treatment had superior results that were maintained at 8 years compared to patients who underwent conservative management.
Figure A is an axial MRI at the L4/5 disc space that shows a left paracentral disc herniation compressing the descending L5 nerve root. Illustration A identifies the structures in the MRI image. Illustration B demonstrates the dermatome, reflex and motor function associated with the L4, L5 and S1 nerve root.
Incorrect Answers:
(SBQ13PE.102) An 26-year-old male presents to your office complaining of bilateral hip and low back pain. On physical examination, he has 10 degree bilateral hip flexion contractures. An AP pelvis radiograph is demonstrated in figure A. Which of the following findings is consistent with this patient's presentation?
Review Topic
A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 38:

Options:

excision of the distal clavicle.
open reduction and internal fixation with intramedullary partial threaded pins.
open reduction and internal fixation with a reconstruction plate, screws, and bone grafting.
bone grafting and use of heavy sutures to secure the clavicle to the coracoid.
observation and nonsteroidal anti-inflammatory drugs.

Correct Answer: observation and nonsteroidal anti-inflammatory drugs.

Explanation:

Question 39:

Options:

closed reduction and a non-weight-bearing cast.
closed reduction and a weight-bearing cast.
closed reduction and percutaneous pinning.
open reduction and casting.
open reduction and internal fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 40:

Options:

infection. B. instability. C. loosening.
periprosthetic fracture.

Correct Answer: periprosthetic fracture.

Explanation:

Question 41:

Intramembranous ossification during fracture repair is characterized by absence of which of the following elements?

Options:

Alkaline phosphatase
Osteonectin
Osteopontin
Collagen type I expression
Collagen type II expression

Correct Answer: Collagen type II expression

Explanation:

Question 42:

Options:

Systolic blood pressure > 120
Heart rate between 60-100
Urine output equals 0.4 cc/kg/hr
Gastric intramucosal pH of 7.4
Normal mentation

Correct Answer: Systolic blood pressure > 120

Explanation:

Question 43:

The artery of Adamkiewicz (arteria radicularis, arteria magna) is most commonly found on the

Options:

right side between T5 and T7.
right side between T9 and T11.
left side between T5 and T7.
left side between T9 and T11.
left side between L1 and L3.

Correct Answer: left side between T9 and T11.

Explanation:

Question 44:

Options:

radiocapitellar joint dislocation.
fat pad sign.
proximal radioulnar joint dislocation.
double arc sign.

Correct Answer: double arc sign.

Explanation:

Question 45:

What is the most common cause for poor outcomes in patients who undergo total shoulder arthroplasty?

Options:

Loosening of the humeral component
Loosening of the glenoid component
Infection
Brachial plexus injury
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.
REFERENCES: Chin PY, Sperling JW, Cofield RH, et al: Complications of total shoulder arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 2006;15:19-22.
Hasan SS, Leith JM, Campbell B, et al: Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg 2002;11:431-441.

Question 46:

Options:

supportive immobilization until the patient is pain-free.
coracoclavicular ligament repair.
open reduction and internal fixation of the acromioclavicular dislocation.
resection of the distal clavicle and Weaver and Dunn reconstruction.
open biopsy of the calcific mass.

Correct Answer: supportive immobilization until the patient is pain-free.

Explanation:

Question 47:

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

Options:

5 degrees medial at T 1 and T 2 ; 10 degrees from T3 to T10
5 degrees lateral at T 1 ; neutral at T 2 ; 5 degrees medial from T3 to T12
10 degrees medial from T1 to T10; 15 degrees medial at T11 and T12
10 degrees medial from T 1 to T12
25 degrees medial at T 1 ; 15 degrees at T 2 ; and 10 degrees medial from T3 to T10

Correct Answer: 25 degrees medial at T 1 ; 15 degrees at T 2 ; and 10 degrees medial from T3 to T10

Explanation:

DISCUSSION: Thoracic pedicles typically are angled 25 degrees medially at T
1
so the
starting point is more lateral. T
2
angles about 15 degrees, and then the pedicles average about
5 to 7 degrees down to T10. At T11 and 12, the angulation is minimal.
REFERENCES: Weinstein L: Pediatric Spine Principles and Practice. New York, NY, Raven Press, 1994, pp 1659-1681.
Lenke LG, Orchowski J: Segmental posterior spinal instrumentation: Thoracic spine to sacrum, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 537-552.

Question 48:

Options:

Repeat wide excision of the tumor bed
Observation
Radiation therapy to the tumor bed only
Chemotherapy
Radiation therapy and chemotherapy

Correct Answer: Repeat wide excision of the tumor bed

Explanation:

DISCUSSION: Treatment of patients with unplanned excision of soft-tissue sarcomas is challenging. If the margins are positive or unclear, the patient is best managed with repeat excision of the tumor bed, and radiation therapy if the repeat excision does not yield wide margins. In patients with no detectable tumor on physical examination or imaging after unplanned excision, some studies have shown that up to 35% of patients will have residual disease and a poorer local recurrence rate (22% versus 7%). Therefore, whenever feasible,
a reexcision of the tumor bed is recommended.
REFERENCE: Noria S, Davis A, Kandel R, et al: Residual disease following unplanned excision of soft-tissue sarcoma of an extremity. J Bone Joint Surg Am 1996;78:650-655.

Question 49:

Options:

Electromyography
MRI of the shoulder joint
MRI of the brain
Radiograph of the elbow
Aspiration of the right shoulder

Correct Answer: MRI of the shoulder joint

Explanation:

DISCUSSION: The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.
REFERENCES: Waters PM: Update on management of pediatric brachial plexus palsy.
J Pediatr Orthop B 2005;14:233-244.
Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am
2005;87:320-325.
Moukoko D, Ezaki M, Wilkes D, et al: Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86:787-793.

Question 50:

Options:

closed reduction and early range of motion
radial head resection and lateral collateral ligament reconstruction
radial head resection and coronoid open reduction internal fixation
radial head arthroplasty and coronoid open reduction internal fixation
radial head arthroplasty, coronoid open reduction internal fixation, and lateral collateral ligament repair

Correct Answer: closed reduction and early range of motion

Explanation:

Question 51:

The anterior approach to the hip (iliofemoral or Smith-Peterson) puts which of the following anatomic structures at greatest risk?

Options:

Femoral artery
Femoral nerve
Lateral femoral cutaneous nerve
Medial femoral circumflex artery
Obturator artery

Correct Answer: Femoral artery

Explanation:

(SBQ12SP.36) What is the most common type of cause and type of peripheral nerve injury detected by electrophysiologic monitoring during anterior cervical spine surgery?
Review
Topic
Brachial plexopathy following shoulder taping and application of countertraction
Brachial plexopathy on neck extension for surgical access
Spinal cord injury on neck extension for surgical access
Ulnar neuropathy due to tightly wrapped or malpositioned upper extremities
Cerebral hypoperfusion due to elevation of the head of the bed PREFERRED RESPONSE 1
(SBQ12TR.83) A 45-year-old male sustains the fracture seen in Figure A. He is scheduled for open reduction and internal fixation using the Smith-Peterson approach. After dissection through the superficial intermuscular plane, a moderate amount of bleeding is noted in the surgical field. What vessel was likely injured?
Ascending branch of the lateral femoral circumflex artery
Medial femoral circumflex artery
Obturator artery
Superficial external pudendal artery
Femoral vein

Question 52:

When elevating the arm, the ratio of scapulothoracic to glenohumeral motion over the total range of motion is best described as

Options:

1:2, and in the first 30 degrees the ratio is 1:5.
1:2, and in the first 30 degrees the ratio is variable.
2:1, and in the first 30 degrees the ratio is variable.
2:1, and in the first 30 degrees the ratio is 3:1.
highly variable and no definitive statement can be made about the ratios.

Correct Answer: 1:2, and in the first 30 degrees the ratio is variable.

Explanation:

Question 53:

Options:

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

Correct Answer: Diminished fatigue strength

Explanation:

Question 54:

Options:

Hamstring autograft
Revision ACL reconstruction and posterior cruciate ligament (PCL) reconstruction
Revision ACL reconstruction and posteromedial corner reconstruction
Revision ACL reconstruction and posterolateral corner reconstruction

Correct Answer: Hamstring autograft

Explanation:

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.
(SBQ12SP.35) A 16-year-old male football player is tackled into the ground during a game. He comes to the sideline with unilateral upper extremity pain, burning dysesthesias, and muscle weakness. Several minutes later, his symptoms resolve. In this scenario, what muscles are most likely to be affected?
Review Topic
Deltoid and biceps
Triceps
Wrist flexors
Finger flexors
Interossei
This patient presents with a 'burner' or 'stinger,' a transient unilateral neurapraxia that most commonly involves the biceps, deltoid and rotator cuff muscles.
Hypotheses for the mechanism of neurapraxia in stingers include nerve root compression in the neural foramen as a result of extension and compression, traction on the brachial plexus or a direct blow to the plexus. C5-C6 is the most commonly involved level, indicating root injury or upper trunk brachial plexus injury. Unilateral and transient symptoms are required for diagnosis. Bilateral 'stinger' symptoms of numbness, tingling, and weakness are consistent with cervical spinal cord neurapraxia. Return to play in contact sports is contraindicated with bilateral symptoms prior to MRI evaluation of the cervical spine.
Shannon et al. review burner syndrome in athletes. They emphasize that criteria for return to play are based on a complete and thorough neurologic and physical exam. Normal strength and sensation in both upper extremities as well as a normal cervical spine exam (including range of motion, compression, Spurling's, Adson's, and resistive head pressures) are required for return to play. Any positive findings mandate withdrawal of the player from competition.
Illustration A shows hypothesized areas of involvement by mechanism according to
Shannon et al. A, Extension-ipsilateral compression. B, Flexion-contralateral flexion (traction) or direct trauma.
Incorrect Answer Answer Answer
2:
3:
4:
Wrist Finger
Triceps
flexors flexors
C7 C7 C8

Question 55:

Options:

Thompson
Cotton
Squeeze
Anterior drawer

Correct Answer: Cotton

Explanation:

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

Question 56:

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Options:

Early post-operative knee range of motion
Delayed weightbearing
Short working length of the construct
Bridge plate fixation
Plate-screw density less than 0.5

Correct Answer: Plate-screw density less than 0.5

Explanation:

Question 57:

Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with

Options:

subglenoid dislocation.
subcoracoid dislocation.
fracture of the greater tuberosity.
fracture of the greater tuberosity and glenoid rim.
pediatric-age patients.

Correct Answer: fracture of the greater tuberosity and glenoid rim.

Explanation:

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.
J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. J Sports Med 1998;26:41-45.

Question 58:

Which of the following is an indication for surgical management of a Weber type B distal fibular fracture?

Options:

Medial hindfoot ecchymosis
Medial ankle tenderness
Widened medial clear space
Comminution
Two millimeters of fibular displacement

Correct Answer: Widened medial clear space

Explanation:

Question 59:

Which of the following statements describing chordomas is false?

Options:

Treatment consisting of complete surgical resection with clean margins offers the best survival.
They occur in the clivus and sacrum and occur only 15% of the time in the rest of the spine.
They are locally aggressive and invasive tumors.
They are highly radiosensitive.
They have the ability to become malignant.

Correct Answer: They are highly radiosensitive.

Explanation:

DISCUSSION: Casali and associates provided a recent review of the treatment options for chordomas. These tumors are not radiosensitive; however, modern intensity modulated radiosurgery techniques may be of value. The combination of surgery and radiotherapy compared to surgery alone results in the same disease-free survival time. Complete surgical resection of the chondroma with clean margins offers the best survival; however, its location may make total removal impossible. Thus subtotal resection followed by radiotherapy results in better survival despite the tumor’s lack of radiosensitivity.
REFERENCE: Casali PG, Stacchiotti S, Sangalli C, et al: Chordoma. Curr Opin Oncol 2007;19:367-370.

Question 60:

Options:

intramedullary fixation.
arterial embolization.
curettage and cementation.
radiation therapy.
segmental resection and reconstruction using a diaphyseal metal spacer.

Correct Answer: radiation therapy.

Explanation:

Question 61:

The superior glenohumeral ligament primarily restrains

Options:

posterior translation of the humeral head with the arm in 90 degrees of abduction.
inferior translation of the humeral head with the arm in adduction.
anterior translation of the humeral head in 90 degrees of abduction.
anterior translation of the humeral head with the arm in 45 degrees of abduction.
anterior translation of the humeral head with the arm in 90 degrees of abduction and external rotation.

Correct Answer: inferior translation of the humeral head with the arm in adduction.

Explanation:

Question 62:

Options:

casting in flexion.
observation.
arthroscopic drilling and pinning of the lesion.
removal and reattachment of the osteochondral lesion.
allograft transplantation for the lesion.

Correct Answer: casting in flexion.

Explanation:

Question 63:

Options:

resumption of full activity as soon as tolerated.
a brace.
anterior stabilization and fusion.
posterior stabilization and fusion.

Correct Answer: a brace.

Explanation:

DISCUSSION
Disruption of the posterior ligamentous complex is an important determinant of the stability of a burst fracture. This patient is neurologically intact and his MR images do not reveal posterior ligamentous complex (PLC) disruption. The standing radiograph confirms that overall alignment is acceptably and relatively preserved. Nonsurgical treatment with or without a brace is acceptable in this scenario; however, the patient should not be cleared to resume full activity until fracture healing, which may be as long as 3 months after the date of injury. Anterior or posterior surgery should be reserved for patients with PLC disruption, neurological injury, or, in some cases, multiple trauma.
RECOMMENDED READINGS
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024.
View
Abstract at PubMed
Vaccaro AR, Lehman RA Jr, Hurlbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Zeiller SC, Anderson DG, Bono CM, Stock GH, Brown AK, Kuklo T, Oner FC. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976). 2005 Oct 15;30(20):2325-33. PubMed PMID: 16227897.
View Abstract at
PubMed
Vaccaro AR, Zeiller SC, Hulbert RJ, Anderson PA, Harris M, Hedlund R, Harrop J, Dvorak M, Wood K, Fehlings MG, Fisher C, Lehman RA Jr, Anderson DG, Bono CM, Kuklo T, Oner FC. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech. 2005 Jun;18(3):209-15. PubMed PMID: 15905761.
View
Abstract at PubMed
RESPONSES FOR QUESTIONS 86 THROUGH 89
Proximal junctional kyphosis (PJK)
Adjacent segment degeneration
Intraoperative neurological injury
Postsurgical wound infection
Please select the complication listed above that most commonly is associated with a clinical scenario described below.

Question 64:

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Options:

Both CT and MRI have equivalent cost for the patient.
Both CT and MRI have equivalent safety for the patient.
Associated soft-tissue damage can be more reliably shown on CT scans.
Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Correct Answer: Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Explanation:

Question 65:

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

Options:

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

Correct Answer: Tenotomy of the flexor tendons

Explanation:

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

Question 66:

-Use of the shorter, anterior screw may result in

Options:

deformity of the acetabular labrum when the hip is flexed.
injury to the femoral artery.
chondrolysis.
lack of stabilization of the epiphysis.

Correct Answer: deformity of the acetabular labrum when the hip is flexed.

Question 67:

What is the most appropriate management at this time? Review Topic

Options:

Repeat epidural steroid injections
Wide lumbar laminectomy
Microdiskectomy from either a midline approach or far lateral approach
Referral to pain management
Minimally invasive posterior lumbar interbody fusion

Correct Answer: Microdiskectomy from either a midline approach or far lateral approach

Explanation:

Question 68:

Options:

Immediate MRI of the brain
Physical therapy and observation
Subacromial injection
Decompression of the suprascapular nerve at the suprascapular notch
Decompression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch

Correct Answer: Physical therapy and observation

Explanation:

Question 69:

Options:

PMMA is stronger in tension than compression.
Porosity reduction increases the fatigue strength of PMMA.
Hypotension that occasionally results after PMMA is placed in the femoral canal is independent of a patient’s intraoperative blood volume.
Inclusion of antibiotics does not alter the strength of PMMA.
PMMA bonds chemically to bone and the implant surface.

Correct Answer: Porosity reduction increases the fatigue strength of PMMA.

Explanation:

Question 70:

Options:

Flexor-pronator avulsion
Ulnar nerve subluxation
Medial collateral ligament injury
Lateral ulnar collateral ligament rupture
Triceps tendon subluxation

Correct Answer: Medial collateral ligament injury

Explanation:

Question 71:

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Options:

Upper third
Junction of upper third and middle third
Middle third
Junction of middle third and lower third
Lower third

Correct Answer: Lower third

Explanation:

Question 72:

At the time of revision knee arthroplasty, a surgeon performs a rectus snip to gain exposure to the knee. When compared with a standard parapatellar approach, what is the expected outcome?

Options:

Improvement in range of motion
Reduction in range of motion
Increase in extensor mechanism lag
No differences in motion and strength

Correct Answer: No differences in motion and strength

Explanation:

DISCUSSION:
Rectus snip during total knee arthroplasty has no effect on motion or strength at long-term follow-up. It has not been associated with extensor mechanism lag.

Question 73:

03 Which of the following findings is the best indication for the use of temporary external fixation of a femoral shaft fracture?

Options:

Type IIIA open fracture
back to this question next question
Hemodynamic instability
Segmental fracture
Distal one third fracture
Ipsilateral tibial shaft fracture 33.03

Correct Answer: back to this question next question

Explanation:

These days, femoral shaft fractures at Tulane / Charity are commonly encountered by orthopaedic residents on the night-float team.
Despite the presence of a well-rested 4th year surgeon, definitive orthopaedic fixation is not always the correct answer for each trauma patient.
Tulane defines “Orthopaedic Tunnel Vision” as a condition commonly associated with a young MD at the Bulldog without a proper
wing-man, trying to make advances on the wrong patron due to his relatively easy 80-hour work week schedule and a few too many refined hops.
Skeletal Trauma (p. 1967) describes “Orthopaedic Tunnel Vision” as looking at the orthopaedic injury without considering the
patient’s injury in general. Femoral shaft fractures are typically high energy injuries which often do not occur in isolation. In these fractures, it is particularly important to not have tunnel vision.
Indications for temporary bridging external fixation includes hemodynamic instability
(ans. 2), acidosis, hypothermjia, hypoxemia, coagulopathy, sepsis or severely contaminated soft tissues that cannot be adequately debrided. Definitive fixation is performed after the general surgical and medical issues have resolved.
The other answer choices, including the type IIIA open fracture are not contraindications to definitive fixation in themselves (typically IM nailing—antegrade or retrograde).

Question 74:

A 59-year-old man underwent interposition arthroplasty for osteoarthritis of the elbow 9 years ago. Over the past year the patient has had

Options:

Bracing
Physiotherapy
Cortisone injection
Conversion to total elbow arthroplasty
Revision interposition arthroplasty

Correct Answer: Conversion to total elbow arthroplasty

Explanation:

In a series reported by Blaine and associates, 12 patients were converted from interposition to total elbow arthroplasty. This procedure was successful in 10 out of 12 patients.

Question 75:

Figures 46a through 46e show the radiographs of a 22-year-old man who injured his wrist in a motorcycle accident. He has no other injuries. What is the best course of action?

Options:

Radiolunate fusion
Open repair of the volar extrinsic wrist ligaments
Open reduction and internal fixation
Thumb spica cast immobilization for 6 weeks
External fixator

Correct Answer: Open reduction and internal fixation

Explanation:

Question 76:

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 77:

Options:

Application of a compressive dressing and boot brace and monitoring of compartment pressures
Administration of IV antibiotics and strict elevation
Oral antibiotics, elevation, and close follow-up
Debridement of the bullae and application of a new cast
Urgent surgical debridement and IV antibiotics

Correct Answer: Urgent surgical debridement and IV antibiotics

Explanation:

Question 78:

The structure that runs just beneath the peroneal tubercle of the calcaneus is the

Options:

flexor hallucis longus tendon.
peroneus brevis tendon.
peroneus longus tendon.
calcaneal fibular ligament.

Correct Answer: peroneus longus tendon.

Explanation:

DISCUSSION
The peroneal tubercle is often a good landmark at which to identify the peroneus longus tendon surgically, and a hypertrophic tubercle has been associated with peroneus longus tendinopathy. Both peroneal tendons curve anteriorly around the tip of the fibula, with the peroneal tubercle separating the 2 tendons at the level of the calcaneus. The peroneus brevis runs in front of the tubercle and the longus behind. The flexor hallucis longus runs through a fibro-osseus tunnel posterior to the hindfoot formed by the posterolateral (os trigonum) and posteromedial tubercle of the talus. The calcaneal fibular ligament attaches to the calcaneus below the posterior facet of the subtalar joint and deep to the peroneal tendons.
RECOMMENDED READINGS
Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005 Nov;26(11):947-50. Pub PMID: 16309609.
View Abstract at PubMed
Bruce WD, Christofersen MR, Phillips DL. Stenosing tenosynovitis and impingement
of the peroneal tendons associated with hypertrophy of the peroneal tubercle. Foot Ankle Int. 1999 Jul;20(7):464-7. PubMed PMID: 10437932.
View Abstract at PubMed

Question 79:

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Options:

Differential forces generated from the vastus lateralis and vastus medialis
Differential tension within the bundles of the posterior cruciate ligament
Differential radius of curvature between the medial and lateral femoral condyles
Asymmetry of the tibial tubercle on the anterior surface of the tibia
Asymmetric forces generated from the uneven patellar facets

Correct Answer: Differential radius of curvature between the medial and lateral femoral condyles

Explanation:

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 80:

Which structure is shown in Video 27? 27

Options:

Superficial medial collateral ligament
Semimembranosus tendon
Posterior oblique ligament
Medial patellofemoral ligament

Correct Answer: Medial patellofemoral ligament

Explanation:

Question 81:

When examining a patient with marked hyperreflexia, which of the following findings best suggests that the condition is not caused by a cerivcal spine pathology?

Options:

Positive finger adduction test and finger escape sign
Positive grip and release test and rapid opening and closing of the hand
Positive jaw jerk reflex
Extensor Babinski response
Loss of proprioception in the great toes

Correct Answer: Positive jaw jerk reflex

Explanation:

Question 82:

.The least gliding resistance for a flexor tendon laceration at the thumb palmar-digital crease as shown inFigure 75 can be achieved with

Options:

a 6-strand repair.
a division and repair.
debridement of the partial laceration.
no debridement, motion therapy only.
multiple-strand core repair with epitendinous repair.

Correct Answer: multiple-strand core repair with epitendinous repair.

Explanation:

Question.9 . A 42-year-old woman has the injury shown in Figures 78a and 78b. The decision to treat the ulnar styloid surgically is based upon which finding?
Patient age
Displacement of the radius fracture
Displacement of the ulnar styloid fracture
Position of the ulnar styloid after open reduction and internal fixation of the radius
Stability of the distal radioulnar joint after open reduction and internal fixation of the radius

Question 83:

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

Options:

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

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

Explanation:

Question 84:

Options:

neoadjuvant chemotherapy followed by surgical resection and reconstruction.
chemotherapy followed by radiation therapy.
IV antibiotics for 4 weeks, followed by oral antibiotics for 4 weeks.
surgical resection and reconstruction followed by chemotherapy.
radiation therapy alone.

Correct Answer: neoadjuvant chemotherapy followed by surgical resection and reconstruction.

Explanation:

DISCUSSION: The imaging studies and histology are consistent with high-grade osteosarcoma. The standard treatment for osteosarcoma is neoadjuvant chemotherapy combined with wide surgical resection that can be performed with amputation or limb salvage depending on characteristics unique to each tumor and each patient. In most patients, limb salvage surgery can be performed with reconstruction using allografts and/or megaprostheses. Osteosarcoma is poorly responsive to radiation therapy. Chemotherapy alone, in the absence of appropriate surgery, has not proven effective.
REFERENCES: Simon MA, Springfield DS: Surgery for Bone and Soft-Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 265-274.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 85:

Options:

stretching of the forearm in pronation, wrist flexion, and splinting.
primary tendon repair of the flexor pollicis longus and flexor digitorum profundus to the index finger, followed by immobilization.
electrodiagnostic examination, followed by decompression of the anterior interosseous nerve within the next 2 to 3 weeks.
splinting followed by observation; surgical decompression of the median nerve may be required if no improvement in seen in 3 months.
splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.

Correct Answer: splinting followed by observation; surgical decompression of the anterior interosseous nerve may be required if no improvement is seen in 6 months.

Explanation:

Question 86:

What muscle is most often encountered during surgical approaches to C5-6?

Options:

Omohyoid
Cricohyoid
Splenius capitus
Thyrohyoid
Posterior digastric

Correct Answer: Omohyoid

Explanation:

DISCUSSION: The omohyoid muscle crosses the surgical field from inferior lateral to anterior superior traveling from the scapula to the hyoid bone and may need to be transected. The posterior digastric crosses the field as well but higher near C3-4. The other muscles run longitudinally.
REFERENCES: Chang U, Lee MC, Kim DH: Anterior approach to the midcervical spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 45-56.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 87:

A 75-year-old female with a longstanding history of brachial plexus palsy 2 . A 63-year-old male with a 6 month history of shoulder pain and inability to abduct past 30 degrees

Options:

A 67-year-old female with chronic shoulder pain and evidence of significant proximal migration of the humerus on x-ray
A 70-year-old female with severe shoulder pain and radiographic evidence of glenoid erosion to the coracoid process
A 72-year-old male who is 9 months status post right TKA for OA with debilitating shoulder pain and an MRI demonstrating an intact rotator cuff

Correct Answer: A 67-year-old female with chronic shoulder pain and evidence of significant proximal migration of the humerus on x-ray

Explanation:

A total shoulder arthroplasty (TSA) is indicated in the 72 year old male with debilitating shoulder pain and an intact rotator cuff on MRI. The other patient scenarios are examples of contraindications for TSA.
A TSA involves replacement of the humeral head with a metal head and resurfacing of the glenoid to a cemented all-polyethylene surface. In order to achieve optimal results, patients must be selected carefully. Patients with an irreparable rotator cuff tear, non-functioning deltoid, inadequate glenoid bone stock and brachial plexopathy are poor candidates for TSA.
Edwards et al. conducted a multicenter randomized controlled trial to compare TSA versus hemiarthroplasty in patients with primary osteoarthritis of the shoulder. They found that TSA provided better scores for pain, mobility, and activity than hemiarthroplasty at 2 year follow-up. Boileau et al. followed 45 consecutive patients who underwent reverse TSA ( rTSA) for cuff tear arthropathy (CTA), post-traumatic arthritis, and failure of revision arthroplasty. After a mean follow-up of 40 months, they found that the reverse prosthesis improved function and was able to restore active elevation in patients with incongruent cuff-deficient shoulders. They also found that
the results were less predictable and complication and revision rates were higher in patients undergoing revision surgery as compared to those patients undergoing rTSA for CTA.
Illustrations A and B show the preoperative and postoperative x-rays of a patient with characteristic OA of the glenohumeral joint that was treated with TSA.
Incorrect Answers:
Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?
Immobilization in external rotation for 6 weeks Arthroscopic bony Bankart repair
Arthroscopic Remplissage procedure
Glenoid augmentation using coracoid transfer Glenoid augmentation using tricortical iliac crest graft
This patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.
Older (>20 years old), recreational athletes with minor glenoid bone loss (<20 % of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid.
Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.
Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.
Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.
Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.
Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss. Incorrect Answers:
A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?
Nonsynergistic action of the transferred muscle Fatty atrophy of the supraspinatus and infraspinatus Deficiency of the subscapularis
Absence of the coracoacromial ligament Deltoid weakness
A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer.
The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.
An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure?
Anchor fatigue and breakage Anchor pull out from bone
Suture rupture secondary to anchor eyelet abrasion Suture pull out from the repaired tissue
Infection
Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).
George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.
Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include highstrength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.
Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, singlerow configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 1215 mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing. Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.
Incorrect Responses
Biocomposite anchors exhibit high load-to-failure and result in fatigue failure less commonly than metal anchors.
A 32-year-old cross-training athlete awakens with severe left neck and shoulder pain after a day of intense upper body training. Aside from a recent viral illness, he is otherwise healthy. His pain improves, but two weeks later he notes significant left shoulder weakness. Examination reveals weakness of shoulder abduction, forward elevation and external rotation with the arm at his side. Radiographs are normal. Electromyography demonstrates 2+ positive sharp waves and fibrillations. Sensory nerve conduction studies show reduced amplitudes. MRI of the brain, cervical spine and shoulder are shown in Figures A-D, respectively. Which of the following is true of his prognosis?
Decompression will result in improved muscle strength and function.
The patient can expect a gradual return of muscle strength without long term functional deficits. Immunomodulators may decrease the number and severity of his relapses. 4 . Arthroscopic repair will result in the best functional outcomes given the patient's high activity level.

Question 88:

Options:

application of a femoral traction pin.
intramedullary nailing of the femur and tibia.
surgical irrigation and debridement.
external fixation of the femoral fracture.
reduction of the femoral head.

Correct Answer: reduction of the femoral head.

Explanation:

Question 89:

Options:

Semitendinosis figure-of-eight graft
Subclavius tendon transfer
Medial clavicular osteotomy
Medial clavicular resection
Sternoclavicular arthrodesis

Correct Answer: Semitendinosis figure-of-eight graft

Explanation:

DISCUSSION: Improved peak-to-load failure data have been demonstrated by reconstruction of the sternoclavicular joint using a semitendinosis graft in a figure-of-eight pattern through the clavicle and manubrium. Resection of the medial clavicle, which compromises the integrity of the costoclavicular ligament, results in medial clavicular instability.
REFERENCES: Rockwood CA, Wirth MA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Spencer EE, Kuhn JE, Huston LJ, et al: Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. J Shoulder Elbow Surg 2002;11:43-47.

Question 90:

Options:

rotator cuff repair.
revision acromioplasty.
fragment excision.
open reduction and internal fixation.
continued rehabilitation.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 91:

Options:

Since p > 0.05, the activity levels of women and men are statistically equal.
If, in the general population, there is no difference between the average activity levels of women and men, the difference observed between the women and men in this study would occur by chance selection in nine out of 100 times that the study was performed.
The sample size was too small for this study, so the p-value has no meaning.
Though a difference was measured between the two groups, the findings are not clinically significant, since p > 0.05.
There is a 9% difference between the two groups because p = 0.09.

Correct Answer: If, in the general population, there is no difference between the average activity levels of women and men, the difference observed between the women and men in this study would occur by chance selection in nine out of 100 times that the study was performed.

Explanation:

Question 92:

Figures 47a and 47b show the CT scans of a patient who reports persistent pain in the sinus tarsi following a fall. The avulsion fracture fragment remains attached to what ligament?

Options:

Bifurcate
Spring
Plantar fascia
Lisfranc
Interosseous

Correct Answer: Bifurcate

Explanation:

Question 93:

Which of the following best describes the relationship of the median nerve to the flexor carpi radialis tendon just proximal to the carpal canal?

Options:

Median nerve is volar and ulnar
Median nerve is radial and volar
Median nerve is dorsal and ulnar
Median nerve is dorsal and radial
Median nerve is volar and radial

Correct Answer: Median nerve is dorsal and ulnar

Explanation:

DISCUSSION: The median nerve has an intimate association with the palmaris longus and the flexor carpi radialis at the proximal aspect of the carpal canal. The median nerve lies just ulnar and dorsal to the flexor carpi radialis tendon.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.
Henry A: Extensile Exposure, ed 3. Edinburgh, UK, Churchill Livingstone, 1995, pp 100-107.

Question 94:

Options:

Nerve conduction velocity studies and electromyography
Extension splinting of the fingers
Exploration and repair of the extensor tendon laceration
Exploration and repair of the posterior interosseous nerve
Observation

Correct Answer: Exploration and repair of the posterior interosseous nerve

Explanation:

Question 95:

Arthritic change in cartilage is characterized by which of the following findings?

Options:

Proteoglycan loss in the cartilage matrix
Increased compressive modulus compared to normal cartilage
Increased tensile modulus
Decreased water content
Increase in the shear modulus

Correct Answer: Proteoglycan loss in the cartilage matrix

Explanation:

Question 96:

Options:

intense physical therapy.
an intramuscular injection of botulinum toxin A.
radical posterior soft-tissue release.
supracondylar femoral extension osteotomy.
gradual correction with a circular ring external fixator.

Correct Answer: radical posterior soft-tissue release.

Explanation:

Question 97:

Options:

Posterior capsular tightness
Tightness of the rotator cuff interval
Anterior inferior glenohumeral ligament laxity
Excessive retroversion of the proximal humerus
Subacromial impingement

Correct Answer: Posterior capsular tightness

Explanation:

Question 98:

Options:

A positive Lhermitte sign
A positive Spurling sign
A positive Jackson sign
A positive Lasegue sign
A positive Hoffmann sign

Correct Answer: A positive Lhermitte sign

Explanation:

Question 99:

Options:

Skeletal traction
Temporizing external fixation
Reamed intramedullary nailing
Unreamed intramedullary nailing
Open reduction and internal fixation

Correct Answer: Reamed intramedullary nailing

Explanation:

Question 100:

Options:

What is the next most appropriate step in treatment?
Exchange nailing
Manipulation under anesthesia
Nail removal and plate fixation
Percutaneous locked plating
Nail dynamization

Correct Answer: Manipulation under anesthesia

OITE & ABOS Orthopedic Exam MCQs: Trauma, Foot & Knee Board Review Part 132

Orthopedic Board Review MCQs: Foot & Ankle, Spine, & Trauma | Part 63

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 63

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index