Orthopedic Board Review MCQs: Trauma, Arthroplasty, Spine & Hand | Part 71

A 54-year-old man sustained a small superficial abrasion over the left acromioclavicular joint after falling from his bicycle. Examination reveals no other physical findings. Radiographs show a displaced fracture of the lateral end of the clavicle distal to a line drawn vertically to the coracoid process. Management should consist of

He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm3. Management should consist of

A patient with severe rheumatoid arthritis reports progressive hip pain. Serial hip radiographs will most likely show which of the following findings?

A 14-year-old gymnast misses her dismount off of the uneven bars, hits the mat face first, and loses consciousness for about 15 seconds. She is dazed and confused for several minutes. She does not complain of pain; numbness; or weakness, and she is moving all extremities without deficit. The athlete and coach want to go back to competition that day. How should they be advised?

A 65-year-old woman has severe pain and numbness in her hand. She notes frequent awakenings at nighttime and difficulty with fine tasks. She also has a history of cervical radiculopathy and notes intermittent pain in her upper arm and periscapular region. An examination reveals a positive Tinel sign over the midforearm and carpal tunnel. Electrodiagnostic testing shows a median nerve sensory distal latency of 3.8 ms (normal latency is 3.5 ms). Which intervention or test would best predict if carpal tunnel release would be successful in relieving this patient's symptoms?

Figure 7 shows a sagittal T 1 -weighted MRI scan. What muscle/tendon is identified by the arrow?

A 26-year-old weightlifter had increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication,

A 26-year-old man was thrown from a car and sustained the injury seen in Figures 44a and 44b. Nonsurgical management of this injury is recommended. Which of the following factors increases the risk of nonunion?

Figure 1 is the clinical photograph of a 22-year-old college pitcher who complains of posterior shoulder pain and feelings of shoulder weakness. He denies shoulder trauma. Evaluation should include

Figure 92 is the radiograph of a 45-year-old man who was thrown from his horse and now reports groin pain. Which of the following is the most common long-term sequelae of this injury?

Which of the following anatomic changes is observed as part of the normal aging process of the adult spine?

What neurovascular structure is in closest proximity to the probe in the arthroscopic view of the elbow shown in Figure 50?

When using surgery extending to the pelvis to treat long spinal deformity in adults, the addition of anterior interbody structural support at the lumbosacral junction serves what biomechanical function?

A 71-year-old woman who reports long-term use of oral steroids for asthma is referred for treatment of a distal humerus fracture. Radiographs reveal diffuse osteopenia and a severely comminuted intra-articular fracture. What is the most appropriate treatment?

A nondisplaced fracture of the proximal medial femoral neck proximal to the lesser trochanter is noted at the time of insertion of a cementless tapered wedge-type femoral component in a total hip arthroplasty. Appropriate perioperative management should include which of the following?

A mother brings in her 6-month-old infant with a knee deformity. The child had previously been treated with serial casting in flexion for 3 month at an outside facility. Examination reveals passive hyperextension to 25° and passive flexion to 15° as shown in Figures A and B respectively. A lateral radiograph of the knee is shown in Figure C. What is the most appropriate next step in treatment? Review Topic

A 23-year-old national team rower reports pain over the radial dorsum of the forearm that is made worse with flexion and extension of the wrist during competition. His primary physician initially diagnosed de Quervain’s tenosynovitis, and a subsequent corticosteroid injection into the first dorsal compartment at the wrist provided no relief. The patient continues to report pain and audible crepitus that is noted 5 cm proximal to the wrist joint, on the radial aspect. What structures are involved in the continued pathology?

Figure 38 shows the radiograph of a 40-year-old woman who reports severe groin pain and lack of motion of the right hip. History reveals that the patient underwent a femoral osteotomy for hip dysplasia approximately 30 years ago. Treatment should include

What is the mechanism of action of an intramuscular injection of botulinum type A toxin in reducing spasticitiy?

A 25-year old right-hand dominant professional baseball pitcher complains of posteromedial right elbow pain that is worsened by throwing. He also reports occasional paresthesias in his small and ring finger after lengthy bullpen sessions. On examination, he is tender along the medial olecranon and complains of pain when extending the elbow >- 20° of extension. He has negative valgus stress, moving valgus stress, and milking maneuver tests. He is stable to varus stress, chair rise, and lateral pivot shift tests. Radiographs reveal a small osteophyte along the posteromedial  border  of   the   olecranon.  What   is   the   most   likely diagnosis?

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

An 18-year-old man sustains an injury to the right brachial plexus after falling off his bicycle. Examination reveals no rhomboideus major or minor muscle function. This finding most likely indicates a preganglionic injury to which of the following nerve roots?

Decreased risk of shoulder and elbow injury in a throwing athlete has been demonstrated with which of the following? Review Topic

A 35-year-old man reports a 2-year history of right groin pain. The pain is made worse with hip flexion, prolonged sitting, and cycling. A radiograph and MRI scan are shown in Figures 16a and 16b. Nonsurgical management has failed to provide relief. What is the best surgical option?

Figures 25a and 25b show the radiograph and MRI scan of a 7 1/2-year-old boy who has been limping for 1 year. His pain has worsened over the past 2 weeks, and his parents note swelling over the dorsum of the foot for the past 4 days. Examination reveals no fever, and laboratory studies show a WBC of 6,700/mm 3 , an erythrocyte sedimentation rate of 26 mm/h, and a normal C-reactive protein level. What is the most likely diagnosis?

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Figures 191a and 191b are the radiographs of an 18-year-old man who had an ankle fracture requiring open reduction and internal fixation 2 years ago. He has a progressive symptomatic ankle deformity.Surgical intervention should consist of

making a cut toward the ball. He felt a pop and his leg gave way. During physical examination, as the knee is moved from full extension into flexion with an internal rotation and valgus force, you notice a “clunk” within the knee. What is the most likely biomechanical basis for the “clunk”?

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time? Review Topic

Figure 13 shows the clinical photograph of a 66-year-old man who has had an increasingly painful right foot deformity for the past 3 years. Examination reveals that the subtalar joint is fixed in 15° of valgus, and forefoot supination can be corrected to 10° from neutral. Nonsurgical management has failed to provide relief. Treatment should now consist of

A patient with myelopathy underwent a one-level corpectomy 1 day ago and is now home. In the middle of the night he calls to report markedly increased difficulty in swallowing, diaphoresis, a change in his voice, and difficulty lying flat. What is the best course of action?

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 35. Which of the following structures is enclosed by the circle?

A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

The incidence of osteosarcoma is highest in what age group?

Figures 44a and 44b show the radiographs of a 28-year-old woman who has had progressive hip pain for the past 3 months. What is the most likely diagnosis?

An 18-year-old boy has had pain in the right knee for the past 6 months. Examination reveals some fullness behind the knee but no significant palpable soft-tissue mass. There is no effusion, and he has full knee range of motion. The remainder of the examination is unremarkable. A radiograph and MRI scans are shown in Figures 33a through 33c, and biopsy specimens are shown in Figures 33d and 33e. What is the most likely diagnosis?

What is the plasma half-life of warfarin?

..A 75-year-old woman sustained a 4-part fracture dislocation of the proximal humerus with a comminuted humeral head. You decide to perform a reverse total shoulder replacement because of her age and activity level. This will be your first reverse total shoulder replacement. It is common practice in your hospital for an industry representative to be present when new implants are brought into the operating room. What information are you required to disclose?

A 6-year-old girl has a painless spinal deformity. Examination reveals 2+ and equal knee jerks and ankle jerks, negative clonus, and a negative Babinski. The straight leg raising test is negative. Abdominal reflexes are asymmetrical. PA and lateral radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management? Review Topic

A newborn girl with an isolated unilateral dislocatable hip is placed in a Pavlik harness with the hips flexed 100 degrees and at resting abduction. Figure 23 shows an ultrasound obtained 2 weeks later. What is the next step in management?

An year-old obese woman has left knee pain. She had surgery 5 years ago for a patellar nonunion after total knee arthroplasty that was complicated by infection, which was treated with implant removal and patellectomy. She has not been ambulatory since then. She states she is no longer on antibiotics. She has moderate pain, but her primary problem is instability of the knee. She has a 40° extensor lag. Darkening of the skin is present distal to the incision consistent with venous stasis changes. The erythrocyte sedimentation rate is 12 mm/h (reference range 0 to 20 mm/h) and her C-reactive protein level is 0 mg/L (reference range 08 to 1 mg/L). Left knee aspiration shows a white blood cell count of 800 and 20% neutrophils. What is the best next step?

A surgeon prepares a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

A 50-year-old competitive tennis player sustained a shoulder dislocation after falling on his outstretched arm 3 weeks ago. He now reports that he has regained motion but continues to have painful elevation and weakness in external rotation. A subacromial cortisone injection provided 3 weeks of relief, but the pain has returned. Which of the following studies will best aid in diagnosis?

When performing a cruciate-retaining total knee arthroplasty, trial components are inserted. The knee comes to full extension but is tight in flexion. The surgeon should consider

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

03 A 23 year old sustains an isolated right knee dislocation in an MVA. A closed reduction is performed and confirmed with radiographs. What is the next appropriate study?

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

A 55-year-old man has had a mass in his right thigh for the past 2 months. An MRI scan and biopsy specimens are shown in Figures 55a through 55c. What is the most likely diagnosis?

Which of the following clinical disorders is the result of a mutation in fibroblast growth factor recepter 3 (FGFR3)?

A patient who underwent primary total hip arthroplasty 7 years ago that resulted in excellent pain relief and a normal gait now reports pain and a limp. Postoperative and current AP radiographs are shown in Figures 2a and 2b. What is the most likely cause of the pathology seen?

A 3-year-old child has bilateral genu varum and short stature. Radiographs show physeal widening and generalized osteopenia. The femora and tibiae show anterolateral bowing. Laboratory studies show low normal serum calcium values, significantly decreased serum phosphate levels, and normal parathyroid hormone (PTH), alkaline phosphatase, and vitamin-D levels. These findings are consistent with

A 6-year-old boy presents with a mass and a lucent lesion involving the tibial shaft as seen in Figure 17a. The mass is mildly tender to palpation. The bone scan is focally hot in the tibia. Biopsy specimens are shown in Figures 17b and 17c. What is the most likely diagnosis?

Patients with patellar clunk syndrome are best managed by which of the following methods?

In patients undergoing elective hip or knee arthroplasty who are not at elevated risk (beyond the risk associated with the surgery) for venous thromboembolism or bleeding, using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism was assigned what grade of recommendation by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty?

Which of the following characteristics is seen in patients with osteochondritis dissecans of the elbow? Review Topic

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

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

A 78-year-old athletic woman has a history of severe back pain without antecedent trauma. She was in the emergency department 2 days ago with a T12 compression fracture. A dual x-ray absorptiometry (DEXA) scan performed earlier this year revealed a T-score of -2.8. Her condition may be attributable to

The photomicrograph in Figure 37 shows a repaired dural tear 4 days after surgery. The material interposed between the dural edges (D) is composed of

Which of the following is considered a contraindication to the use of a reverse total shoulder arthroplasty? Review Topic

A patient undergoes anterior spinal decompression through a left retroperitoneal approach as treatment of an L2 burst fracture. Following surgery, examination reveals the temperature of the right foot is cool when compared with the left foot. Which of the following neurologic structures has most likely been disrupted?

What factor is associated with a higher risk of dislocation after total hip arthroplasty?

The patient returns 1 year later to report curling of her toes and numbness on the plantar surface of her foot. What is the most likely cause of this condition?

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future?

Figure 109 is the radiograph of an 11-year-old boy who felt a snap in his right hip while jumping hurdles during track practice yesterday. He complains of pain to his right groin region and is walking with a limp. What physical examination test will cause the patient to experience the most discomfort?

A 37-year-old laborer falls 12 feet and sustains a comminuted tibial plafond fracture. Three years after treatment using standard techniques, what will be the most likely outcome?

A patient in the recovery room has weakness of the extensor hallucis longus and tibialis anterior muscles following a total knee replacement. Initial management should consist of

A 12-year-old girl who is Risser stage 3 has had intermittent mild midback pain for the past 4 weeks. The pain is worse after prolonged sitting and after carrying a heavy backpack at school. She occasionally takes acetaminophen, but the pain does not limit sport activities. Examination reveals a mild right rib prominence during forward bending. Neurologic examination is normal. Radiographs show a 20-degree right thoracic scoliosis with no congenital anomalies or lytic lesions. Management should consist of Review Topic

A 75-year-old man presents with worsening low back and bilateral leg pain. The pain worsens with ambulation and improves with sitting. On exam, he has strong DP and PT pulses. Straight leg raise is negative. A MRI of the lumbar spine is performed and is pictured in Figure A. On further questioning, which of the following is the patient also likely to report? Review Topic

What is the most common physical examination finding in a patient with chronic painful spondylolysis? Review Topic

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

A 70-year-old man undergoes removal of an infected total hip arthroplasty (THA) and insertion of an articulating antibiotic-loaded spacer to treat a deep periprosthetic hip infection. While in a nursing home receiving intravenous antibiotics 3 weeks after surgery, the patient trips and falls. Examination reveals swelling in the mid and distal thigh, intact skin and neurovascular structures, and severe pain with knee or  hip  movement.  Radiographs  of  the  femur  are  shown  in  Figures  1  through  4.  What  is  the  most appropriate treatment for the fracture below the implant?

-What do the bone scan findings represent?

A B Figures 82a and 82b are the clinical photograph and radiograph of a 60-year-old man with a 30-year history of diabetes complicated by borderline chronic renal failure, heart failure controlled by medication, and bilateral lower extremity neuropathy. He is currently wheelchair bound because of his cardiopulmonary limitations, but uses his legs for transfers. He has had a progressive left ankle deformity that has progressed to the point at which he cannot use his leg for pivot transfers. He is adamant that something should be done to improve his living situation. Which surgical option can best achieve his goal of using the leg for transfers?

A 15-year-old boy has a fracture of the proximal tibia extending from the apophysis of the tubercle up through the posterior part of the proximal tibial epiphysis and into the joint. What is the most likely mechanism of injury?

What are the five most common tumors that metastasize to bone?

Which of the following plain radiographic views of the shoulder best reveals a Hill-Sachs lesion of the humeral head?

Figures A through C are the radiograph and CT scans of a 42-year-old man who sustained an injury to both of his ankles and underwent surgical repair 2 weeks prior to presentation to your office. One ankle is healing well. On the contralateral side, he reports pain and restricted ankle range of motion. Management should consist of

A 66-year-old man has a high-grade angiosarcoma of the right tibia. A radiograph is shown in Figure 43. Treatment should consist of

An 8-year-old boy with severe hemophilia A (factor VIII) and no inhibitor is averaging eight transfusions per month for bleeding into the right ankle. Examination shows synovial hypertrophy; range of motion consists of 0° of dorsiflexion and 20° of plantar flexion. The patient’s knees, elbows, and left ankle have no restriction of motion. Standing radiographs of the right ankle are shown in Figure 18. Management should consist of

Figures 13a and 13b show the MRI scans of a 70-year-old patient who has a posterior calf mass. Examination reveals that the mass extends to the midcalf level. A biopsy specimen reveals a high-grade soft-tissue sarcoma. Metastatic work-up shows no lesions. Management should consist of

A surgeon prepares a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

An adult with a distal humeral fracture underwent open reduction and internal fixation. What is the most common postoperative complication?

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

83A B year-old with the injury pattern seen on the left lower extremity in CT images in Figures 83a and 83b

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

A 32-year-old recreational basketball player underwent a successful anterior cruciate ligament (ACL) reconstruction using hamstring autograft approximately 15 months ago. His chart notes that he has good functional knee outcome scores as tested by his physical therapist. However, he has not returned to play despite being cleared by his physician 3 months ago. After successful ACL reconstruction, which of the following factors has shown to contribute the greatest influence on a player's decision to return to sport? Review Topic

• Which of the following acetabular/femoral head components would be expected to show an optimal combination of linear and volumetric wear?

A 2-year-old child has been referred for management of congenital kyphosis. Neurologic examination is normal, and radiographs show a type I congenital kyphosis. Which of the following anomalies is seen in the MRI scan shown in Figure 6?

Figures 1 through 4 are the CT scans and intraoperative image of a 17-year-old boy who sustained a gunshot wound to his knee. What is the most appropriate definitive surgical management for his articular cartilage defect?

Why is tendon considered an anisotropic material?

A 15-year-old girl has left knee pain and an enlarging mass in the distal thigh. AP and lateral radiographs are shown in Figures 52a and 52b, and a biopsy specimen is shown in Figure 52c. What is the most likely diagnosis?

A 48-year-old man who is scheduled to undergo total knee replacement has an X-linked clotting disorder that leads to abnormal bleeding and recurrent, spontaneous hemarthrosis. Before undergoing surgery, he should have replacement therapy of

A 55-year-old woman has slowly increasing pain at the distal end of her little finger that is exacerbated by cold temperatures. She denies any history of trauma to her hands and is employed as a school teacher. The histology of the resected specimen is shown in Figure 71. What is the most likely diagnosis?

Decreased activity of which of the following proteins may be predictive of an aggressive soft-tissue sarcoma?

Progressive paralysis is most likely to be seen in association with what type of congenital vertebral abnormality?

Figures 28a and 28b show the sagittal and axial lumbar MRI scans of a 72-year-old man who reports dull aching back pain that spreads to his legs, calves, and buttocks. He has had the pain for several years and it is precipitated by standing and walking and relieved by sitting. His symptoms have been worsening over the past year and he notes that he is leaning forward while walking to help relieve his symptoms. He has had no treatment to date. What is his prognosis if he chooses to pursue nonsurgical management for this condition?

During a posterior approach to the right Achilles tendon, the surgeon encounters a nerve running with the small saphenous vein as shown in Figure 22. This nerve innervates what part of the foot?

9 degress Celsius, serum WBC is 14,000, and his C-reactive protein is elevated. He reports that he uses IV heroin. A coronal 3D CT scan of the left clavicle is shown in Figure B. Joint aspiration shows many grams stain positive organisms. Which of the following organisms is the most likely pathogen?

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