Orthopedic Board Prep: High-Yield OITE MCQs Part 100

About This Board Review Set

This is Part 100 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 100

This module focuses heavily on: Ankle, Arthroplasty, Fracture, Hip.

Sample Questions from This Set

Sample Question 1: A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b)....

Sample Question 2: The anterior approach to the hip (iliofemoral or Smith-Peterson) puts which of the following anatomic structures at greatest risk?...

Sample Question 3: A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?...

Sample Question 4: What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?...

Sample Question 5: Figure 12 shows the radiograph of a 55-year-old man who has severe, painful osteoarthritis of the left hip and is scheduled to undergo a left total hip arthroplasty. History reveals that he underwent a right total hip arthroplasty 5 years a...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

00:00

Start Quiz

Question 1

A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b).

Explanation

DISCUSSION
Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.
One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.
Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.
RECOMMENDED READINGS
Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012 Jul;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a. PubMed PMID: 22357084. View Abstract at PubMed
Smith NC, Beaman D, Rozbruch SR, Glazebrook MA. Evidence-based indications for distraction ankle arthroplasty. Foot Ankle Int. 2012 Aug;33(8):632-6. Review. View Abstract at PubMed
Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7. doi: 10.1302/0301-620X.92B11.24452. PubMed PMID: 21037349. View Abstract at PubMed
Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597. View Abstract at PubMed

Question 2

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 3

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?

Explanation

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 4

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Explanation

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,

pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 5

Figure 12 shows the radiograph of a 55-year-old man who has severe, painful osteoarthritis of the left hip and is scheduled to undergo a left total hip arthroplasty. History reveals that he underwent a right total hip arthroplasty 5 years ago that remains pain-free. Based on the preoperative radiograph, the patient is at greatest risk for what complication?

Explanation

DISCUSSION: The patient is at increased risk for limb-length discrepancy because the radiograph shows that the left leg is already longer than the right leg. To restore the proper biomechanics of the left hip, the left leg may have to be lengthened, further increasing the limb-length discrepancy. Intraoperative fracture, deep vein thrombosis, sciatic nerve palsy, and thigh pain are commonly associated with total hip arthroplasty, but the patient is not at increased risk for these complications.
REFERENCE: Ranawat CS, Rodriguez JA: Functional leg-length inequality following total hip arthroplasty. J Arthroplasty 1997;12:359-364.

Question 6

An 81-year-old man with severe low back pain reports right extensor hallucis longus and anterior tibialis weakness and difficulty urinating over the past 24 hours. He has a temperature of 101 degrees F (38.3 degrees C). MRI scans are shown in Figures 31a and 31b. Management should consist of

Explanation

DISCUSSION: An epidural abscess with neurologic deficit represents a medical and surgical emergency. The prognosis is related to the timeliness of diagnosis and treatment. Once identified, the primary treatment is surgical decompression of the abscess, followed by organism-specific antibiotics. In the absence of a significant anterior process such as diskitis or vertebral osteomyelitis, lumbar epidural abscesses generally can be drained through a posterior approach. Delayed stabilization usually is not required unless, in the course of decompression, removal of too much of the facets creates an instability; this is an uncommon occurrence.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Reihsaus E, Waldbaur H, Seeling W: Spinal epidural abscess: A meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204.

Question 7

The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Explanation

One of the suggested causes of Perthes disease is a hypercoaguable state in a child. This would lead to thrombotic venous occlusion in the proximal femur resulting in venous hypertension and osteonecrosis of the femoral head. Therefore look for an answer that would result in a hypercoaguable state. There is no link between hypophosphatemia or high dietary cholesterol intake and a hypercoaguable state. Elevated levels of antithrombin III would result in bleeding, not coagulation. The referenced paper demonstrated a familial occurrence in protein S and protein C deficiency and elevated levels of lipoprotien A. Protein C and S are antithrombotic factors and lipoprotein A is a thrombogenic, atherogenic lipoprotein associated with osteonecrosis in adults.

Question 8

-This boy’s parents are eager to get him back on the field as soon as possible. What is the most appropriate treatment option?

Explanation

DISCUSSION FOR QUESTIONS 60 AND 61
Although a recent increase in the number of pitches may have contributed to this patient’s development of little leaguer’s shoulder, the most significant overall factor is age. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress, and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Genetic factors and gender have not been studied in association with little leaguer’s shoulder. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms.Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to baseline pitching is implemented until the patient is back to baseline. This protocol has a long-term success rate exceeding 90%.

Question 9

What is the most likely complication after surgical treatment in this scenario?

Explanation

DISCUSSION
Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, and internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through as seen in this patient.
The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The 4 muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the 4 rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation.
This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Brighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion, a posterior opening-wedge osteotomy is appropriate.
The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability and degenerative joint disease.

Question 10

A 19-year-old man has had pain and swelling in his left forearm for the past 8 months. Laboratory studies show a mildly elevated WBC count and erythrocyte sedimentation rate. Radiographs are shown in Figures 58a and 58b, a CT scan is shown in Figure 58c, and T 1 - and T 2 -weighted MRI scans are shown in Figures 58d and 58e, respectively. A biopsy specimen is shown in Figure 58f. Immunohistochemistry demonstrates that the lesion is negative for leukocyte common antigen (CD34). What is the most common cytogenetic translocation associated with this lesion?

Explanation

DISCUSSION: The imaging studies show a permeative lytic destructive lesion in the proximal radius with “hair-on-end” periosteal reaction and a large soft-tissue mass most consistent with Ewing’s sarcoma. The pathology reveals monotonous sheets of “round blue” cells. This limits the differential diagnosis to primary lymphoma of bone versus Ewing’s sarcoma. These are best differentiated by immunohistochemistry, cytogenetics, and flow cytometry. Lymphoma of bone is typically CD34 positive and CD99 negative; whereas, the reverse is true of Ewing’s sarcoma, CD34 negative and CD99 positive. The most common cytogenetic translocation with Ewing’s sarcoma is 11; 22; 21; 22 and 7; 22 translocations have also been reported in Ewing’s sarcomas. The X; 18 translocation is most commonly associated with synovial cell sarcomas; the 12; 22 translocation is most commonly associated with clear cell sarcomas; the 2; 13 translocation is most commonly associated with alveolar rhabdomyosarcomas, and the 12; 16 translocation is most commonly associated with myxoid liposarcomas. Flow cytometry is used to characterize the cell types of lymphomas.
REFERENCES: Womer R: The cellular biology of bone tumors. Clin Orthop Relat Res 1991;262:12-21.
Yamaguchi U, Hasegawa T, Morimoto Y, et al: A practical approach to the clinical diagnosis of Ewing’s sarcoma/primitive neuroectodermal tumour and other small round cell tumours sharing EWS rearrangement using new fluorescence in situ hybridisation probes for EWSR1 on formalin fixed, paraffin wax embedded tissue. J Clin Pathol 2005;58:1051-1056.
Lazar A, Abruzzo LV, Pollock RE, et al: Molecular diagnosis of sarcomas: Chromosomal translocations in sarcomas. Arch Path Lab Med 2006;130:1199-1207.

Question 11

What is the best surgical approach for the scapular fracture shown in Figure 46?

Explanation

DISCUSSION: Indications for open reduction of glenoid intra-articular fractures include those fractures with a 5-mm articular surface displacement or when the humeral head is subluxated with the fracture fragment. Kavanaugh and associates and Leung and Lam have shown that the posterior approach with plate fixation is best for most glenoid fractures, including the Ideberg type II fracture shown here. The anterior approach is best used for anterior rim and transverse fractures.
REFERENCES: Kavanagh BF, Bradway JK, Cofield RH: Open reduction and internal fixation of displaced intra-articular fractures of the glenoid fossa. J Bone Joint Surg Am 1993;75:479-484.
Leung KS, Lam TP: Open reduction and internal fixation of ipsilateral fractures of the scapular neck and clavicle. J Bone Joint Surg Am 1993;75:1015-1018.
Ideberg R: Unusual glenoid fractures: A report on 92 cases. Acta Orthop Scand 1995;66:395-397.

Question 12

A 47-year-old man ruptured his left patellar tendon and twisted his right ankle in a fall. Initial radiographs of the ankle are unremarkable. One week following repair of the left patellar tendon, he reports increased pain with weight bearing in his right ankle. A follow-up radiograph is shown in Figure 38. Management of the ankle injury should consist of

Explanation

DISCUSSION: The radiograph reveals disruption of the syndesmosis with lateral displacement of the talus and widening of the medial ankle clear space. No fibular fracture is noted, although radiographs of the entire tibia and fibula are necessary to rule out a more proximal fibula fracture. There is clear instability of the syndesmosis, and surgical stabilization is needed, either by direct repair of the ligaments or more commonly with surgical stabilization of the fibula to the tibia with screws. Functional rehabilitation and early range of motion are indicated with anterior-lateral ankle sprains but not with true instability of the syndesmosis. In anterior syndesmotic injuries in which there are no signs of instability on plain radiographs or with stressing, cast immobilization and protected weight bearing until tenderness subsides is warranted. Long leg cast immobilization is unlikely to be adequate in maintaining reduction of the syndesmosis. Repair of the talofibular ligaments or fibular osteotomy does not address the pathology at the syndesmosis. Chronic syndesmotic disruption is likely to lead to chronic ankle pain and early arthrosis.
REFERENCES: Wuest TK: Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 1997;5:172-181.
Edwards GS Jr, DeLee JC: Ankle diastasis without fracture. Foot Ankle 1984;4:305-312.

Question 13

Figures 82a through 82c show the radiograph and 3-dimensional (3-D) CT scans of a 2-year-old boy whose scoliosis has progressed 15 degrees during the past year. The child is clinically healthy. He has been walking since 11 months of age. An MRI scan of the entire spine revealed no other anomalies. What additional study is indicated? Review Topic

Explanation

Renal anomalies are found in as many as one-third of patients with congenital scoliosis, so a renal ultrasound should be obtained. There may be other anomalies, including cardiac. There are no other anomalies on MRI, so flexion-extension cervical spine radiographs are not indicated. There is no associated marrow or platelet problem with hemivertebra. There is no indication for blood cultures because this is a noninfection disorder. The radiographs and 3-D CT scans show a hemivertebra scoliosis already beyond 45 degrees. Resection of the hemivertebra with stabilization is the indicated treatment. The scoliosis will get worse with observation and bracing. Fusion posteriorly can only minimally correct and not stop progression of the scoliosis.

Question 14

A 75-year-old woman who has groin pain states that she had total hip arthroplasty 15 years ago. The radiograph shown in Figure 40 reveals that the left acetabular component is grossly loose. Revision of the acetabular component should include use of a

Explanation

The patient has an all-poly acetabular component, which is grossly loose and has migrated. Intermediate and long-term results of revision THA’s using a cemented acetabular component have had high failure and re-revision rates. One of the reasons includes sclerotic bone lacking in the trabeculae needed for cement. Threaded cups and bipolar implants have also had unacceptably high failure rates. Published results using non-cemented components have shown they performed much better in the intermediate-term, especially those supplemented with fins, screws or spikes. The cited authors (Petrera and Rubash) preferred a titanium-mesh cup and place two supplemental screws if the cup is unstable (assessed by manipulation intraoperatively).

Question 15

A surgeon contemplates performing a hemiarthroplasty (HA) or total hip arthroplasty (THA) for an active, community ambulating 70-year-old female with a displaced femoral neck fracture. Which of the following is true for these options?

Explanation

THA has a higher perioperative complication rate than HA.
There are a few differences between THA and HA performed in the setting of displaced FNF. THA has a higher dislocation rate, greater blood loss, requires a larger exposure than HA, and the operation is longer. HA often requires reoperation because of progressive acetabular erosion. Patient outcomes and function are greater following THA than HA.
Florschultz et al. reviewed current management of FNF. They concluded that CRIF / ORIF is indicated for displaced femoral neck fractures in younger individuals, select active elderly, and medically unfit patients. HA is indicated for lower demand ambulatory older patients. THA is indicated for the active elderly and those with preexisting acetabular disease.
Avery et al. reviewed 7-10 year results of an RCT comparing THA with HA. More HA patients had died during follow-up. All surviving patients had polyethylene wear (THA) and acetabular erosion (HA). They concluded that there was lower mortality and a trend towards superior function in patients with a THA in the medium term.
Hedbeck et al. performed a RCT comparing HA and THA. At 4 years, there was improved function and quality of life with THA. They recommend THA in elderly, lucid patients with a displaced FNF.
Incorrect Answers:

Question 16

A 38-year-old woman who tripped and fell on her outstretched arm reports pain with movement. Examination reveals swelling. AP and lateral radiographs are shown in Figures 43a and 43b. Management should consist of

Explanation

DISCUSSION: The patient has a type I (Hahn-Steinthal) capitellar fracture that is best seen on the lateral radiograph. If a fracture fragment is seen proximal to the radial head, a capitellar fracture is the most likely injury because radial head fractures do not migrate proximally. The fragment is large enough for fixation. Excision is the preferred treatment for small shear osteochondral type II (Kocher-Lorenz) capitellar fractures. Closed reduction usually is not successful because of rotation of the displaced fragment.
REFERENCES: Mehdian H, McKee M: Management of proximal and distal humerus fractures. Orthop Clin North Am 2000;31:115-127.
Ring D, Jupiter J, Gulotta L: Articular fractures of the distal part of the humerus. J Bone Joint Surg Am 2003;85:232-238.

Question 17

Which of the following complications may occur subsequent to resurfacing hip arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?

Explanation

DISCUSSION: Advocates of resurfacing hip arthroplasty cite preservation of the proximal femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture of the retained femoral neck has been reported following resurfacing arthroplasty. The exact etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure, may result in femoral neck fracture.
REFERENCES: Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head osteonecrosis. J Arthroplasty 2003;18:96-99.
Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am 2004;86:1874-1877.

Question 18

An 80-year-old African American woman who lives in a large city is scheduled for total hip arthroplasty to address primary osteoarthritis. Part of the presurgical protocol includes nasal swab screening to assess for methicillin-resistant Staphylococcus aureus (MRSA) colonization. Which demographic factor places this patient at highest risk for a positive result?

Explanation

DISCUSSION:
Demographic factors are associated with increased risk for MRSA colonization, so it is important to identify vulnerable patients. Female gender and advanced age reduce the risk for colonization, whereas African American race increases this risk. Urban environments do not influence MRSA colonization.

Question 19

Which of the following radiographic parameters is most predictive of a poor result following multilevel fusion surgery for adult degenerative scoliosis? Review Topic

Explanation

Sagittal imbalance appears to be the greatest predictor of a poor surgical outcome in multilevel fusions for adult scoliosis. Coronal imbalance is better tolerated as long as it is not excessive. The amount of residual scoliosis does not seem to play a role as long as overall balance is achieved. The issue of including the L5-S1 level in long fusions remains debatable, and some residual foraminal stenosis can be tolerated, particularly when included within the stabilized/fused segments.

Question 20

When performing hip arthroscopy, the hip should be placed in neutral to slight internal rotation to protect which of the following structures? Review Topic

Explanation

The sciatic nerve is at greatest risk for injury during hip arthroscopy with placement of a posterolateral (posterior paratrochanteric portal). It can be within 3 cm of this portal. Advancing the trocar with the hip in neutral to slight internal rotation helps to protect the sciatic nerve from iatrogenic injury. The two structures in closest proximity with placement of arthroscopy portals are the lateral femoral cutaneous nerve (anterior portal) and the ascending branch of the lateral femoral circumflex artery (mid-anterior portal). The femoral nerve and medial femoral circumflex arteries are located medial to these anterior portals. Rotation of the hip has not been associated with increased risk of injury to any of these additional structures.

Question 21

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty?

Explanation

DISCUSSION: The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.
REFERENCES: Visotsky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg 2000;9:169-172.

Question 22

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Explanation

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 23

When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

Explanation

HAGL lesions may initially be treated without surgery. Recurrent instability in the setting of a HAGL lesion may be treated with a soft-tissue repair. A non-engaging or non-tracking Hill-Sachs lesion may be treated with an anterior soft-tissue (Bankart) repair. A tracking or engaging lesion may be treated with a bony glenoid procedure or a soft-tissue procedure plus remplissage. An ALPSA lesion may be treated with a soft-tissue procedure unless it is associated with a glenoid bony defect >25%. A glenoid bony defect >25% is associated with substantially higher recurrence than defects <20%, and consideration for bony glenoid reconstruction is advised. Consideration of bone augmentation procedures with less severe glenoid bone loss may be considered
in collision athletes.

Question 24

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?

Explanation

DISCUSSION: A knock-out mouse to the Vitamin D receptor would cause loss of vitamin D function, resulting in rickets. Renal failure would not occur; although Vitamin D is converted from 25 (OH) D to 1,25 (OH) D in the kidney, the active hormone acts on the gut and bone. Osteopetrosis can be seen as the phenotype for the c fos knock-out mouse; the Jansen-type metaphyseal dysplasia phenotype results from overactivation of the PTH/PTHrp receptor. Although compensatory hyperparathyroidism would occur, excessive PTH would not be able to rescue the skeletal loss and instead phosphoturia and phosphotasia would result.
REFERENCES: Glowacki J, Hurwitz S, Thornhill TS, et al: Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis undergoing total hip arthroplasty. J Bone Joint Surg Am 2003;85:2371-2377.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 51.

Question 25

A 64-year-old man who was involved in a high-speed motor vehicle accident 6 weeks ago has been in the ICU with a closed head injury. Examination reveals that his range of motion for external rotation to the side is -30 degrees. Radiographs are shown in Figures 28a and 28b. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a posterior shoulder dislocation. The AP radiograph shows overlapping of the humeral head on the glenoid. The scapular Y view shows his humeral articular surface posterior to the glenoid. The posterior shoulder dislocation is frequently missed because the patient is comfortable in the "sling" position with the arm adducted and internally rotated across the abdomen. The marked restriction in external rotation on examination raises the suspicion of a posterior dislocation, adhesive capsulitis, or glenohumeral osteoarthritis. The posterior dislocation is diagnosed based on the radiographic findings. An axillary view or CT is recommended to better evaluate the dislocation.
REFERENCES: Robinson CM, Aderinto J: Posterior shoulder dislocations and

fracture-dislocations. J Bone Joint Surg Am 2005;87:639-650.
Cicak N: Posterior dislocation of the shoulder. J Bone Joint Surg Br 2004;86:324-332.

Question 26

A 47-year-old woman has had medial ankle pain and swelling for the past 3 months. She recalls no specific injury, and casting and nonsteroidal anti-inflammatory drugs have failed to provide relief. Examination reveals a pes planus with heel valgus that is passively correctable. Radiographs show no evidence of arthritis. An MRI scan is shown in Figure 16. What is the most appropriate surgical procedure to alleviate her pain?

Explanation

DISCUSSION: The patient has a stage II posterior tibial tendon tear with a supple foot; therefore, the treatment of choice is flexor digitorum longus transfer with medial displacement calcaneal osteotomy. Triple arthrodesis is not indicated, and isolated tendon transfer will stretch out in the face of persistent heel valgus. Direct repair of the posterior tibial tendon or repair of the spring ligament is not sufficient to correct the deformity.
REFERENCES: Myerson MS, Corrigan J: Treatment of posterior tibial tendon dysfunction with flexor digitorum longus tendon transfer and calcaneal osteotomy. Orthopedics 1996;19:383-388.
Mosier-LaClair S, Pomeroy G, Manoli A II: Operative treatment of the difficult stage 2 adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:95-119.

Question 27

During preparation for the NCAA wrestling championships, a participant reports the development of vesicular lesions on his right chest wall that are mildly painful; however, they have not affected his ability to wrestle. How should this athlete be managed?

Explanation

DISCUSSION: Herpes simplex virus (HSV) can cause serious outbreaks on athletic teams, especially wrestling. HSV is highly contagious; it is secreted from active blisters, saliva, and mucous membranes. For wrestlers, the NCAA states that the athlete must be free from systemic symptoms and any new blisters for 72
hours before being allowed to participate. Also, all lesions must be dry and crusted and at least 120 hours of antiviral therapy should have been instituted.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 301-309.
Johnson R: Herpes Gladiatorium and other skin diseases. Clin Sports Med 2004;23:473-484.

Question 28

..One week after closed reduction of a primary anterior shoulder dislocation, a 25-year-old athlete should be counseled that

Explanation

CLINICAL SITUATION FOR QUESTIONS 36 THROUGH 39
A 65-year-old man experienced 6 years of worsening shoulder pain. Examination demonstrates stiffness and crepitus with range of motion, but full rotator cuff strength in all planes. Radiographs show advanced shoulder osteoarthritis, and an MRI scan ordered by the patient's primary care physician shows an intact rotator cuff.

Question 29

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?

Explanation

DISCUSSION: Shufflebarger and others have reported that the placement of anterior interbody structural support at the lumbosacral junction increases the overall construct stiffness and reduces the strain on posterior instrumentation, thereby reducing the risk of screw pull-out or fracture. The stiffness of the posterior instrumentation actually increases, whereas the actual strength of the instrumentation remains the same. Actual strain measured at an adjacent intervertebral disk to a fusion construct is expected to increase.
REFERENCES: Shufflebarger HL: Moss-Miami spinal instrumentation system: Methods of fixation of the spondylopelvic junction, in Margulies JI, Floman Y, Farcy JPC, et al (eds): Lumbosacral and Spinal Pelvic Fixation. Philadelphia, PA, Lippincott-Raven, 1996, pp 381-393.
Cunningham BW: A biomechanical approach to posterior spinal instrumentation: principles and applications, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 588-600.
Kostuik JP, Valdevit A, Chang HG, et al: Biomechanical testing of the lumbosacral spine. Spine 1998;23:1721-1728.

Question 30

An otherwise healthy 33-year-old man who works in construction reports a 3-month history of knee pain. Radiographs are shown in Figures 9a and 9b. An axial T 1 -weighted MRI scan with contrast, an angiogram, and histologies are shown in Figures 9c through 9f. What is the most likely diagnosis?

Explanation

DISCUSSION: Dedifferentiated parosteal osteosarcoma designates high-grade transformation of conventional low-grade parosteal osteosarcoma. Unlike conventional parosteal osteosarcoma, where wide surgical excision alone is considered adequate treatment, patients with dedifferentiated osteosarcoma are treated with neoadjuvant chemotherapy and wide local resection. Recognition of dedifferentiated areas with angiography can localize the area that should be biopsied and thus render an accurate diagnosis. Percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome.
REFERENCES: Sheth DS, Yasko AW, Raymond AK, et al: Conventional and dedifferentiated parosteal osteosarcoma: Diagnosis, treatment, and outcome. Cancer 1996;78:2136-2145.
Lewis VO, Gebhardt MC, Springfield DS: Parosteal osteosarcoma of the posterior aspect of the distal part of the femur: Oncological and functional results following a new resection technique. J Bone Joint Surg Am 2000;82:1083-1088.

Question 31

In infantile idiopathic scoliosis, which of the following factors suggests progression? Review Topic

Explanation

Infantile idiopathic scoliosis occurs more commonly in boys, with a 3 to 1 male to female ratio. Neural axis abnormalities, hip dysplasia, and congenital heart disease are all associated with the condition; spontaneous correction frequently occurs. Curve progression can be predicted by the rib vertebral angle difference or the phase of the rib head. Rib overlap of the apical vertebral body or a rib vertebral angle difference of greater than 20 degrees indicates that the curve is likely to progress. Gender, family history, and age at presentation have not been found to be risk factors for progression.

Question 32

Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?

Explanation

DISCUSSION: The first branch of the lateral calcaneal nerve innervates the abductor digiti minimi. It is reported to be trapped at the interval between the abductor hallucis and the quadratus plantae muscles.
REFERENCE: Baxter DE, Pfeffer GB, Thigpen M: Chronic heel pain: Treatment rationale. Orthop Clin North Am 1989;20:563-569.

Question 33

A 55-year-old man has had progressive right shoulder pain for the past 2 years. Examination reveals active elevation to 120 degrees, external rotation to 20 degrees, and internal rotation to the sacrum. AP and axillary radiographs are shown in Figures 23a and 23b. Which of the following procedures would result in the most predictable long-term pain relief?

Explanation

DISCUSSION: Total shoulder arthroplasty yields excellent pain relief and function in patients with osteoarthritis. It is favored over humeral arthroplasty, especially when there is asymmetric posterior glenoid wear and posterior humeral subluxation as shown on the axillary radiograph. Arthroscopic debridement of the glenohumeral joint may be helpful in delaying the need for arthroplasty when the arthritic changes are mild to moderate but is not indicated for advanced osteoarthritis.
REFERENCES: Cofield RH, Frankle MA, Zuckerman JD: Humeral head replacement for glenohumeral arthritis. Semin Arthroplasty 1995;6:214-221.
Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU: Hemiarthroplasty for glenohumeral osteoarthritis: Results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-454.
Matsen FA III: Early effectiveness of shoulder arthroplasty for patients who have primary glenohumeral degenerative joint disease. J Bone Joint Surg Am 1996;78:260-264.

Question 34

Figure 49 shows a histologic section of the lung in a patient who died during total hip arthroplasty. What unexpected finding is seen in the pulmonary capillaries?

Explanation

DISCUSSION: Sudden death during total hip arthroplasty has been reported. In a report from the Mayo Clinic, intraoperative death occurred during cemented total hip arthroplasty in

23 patients. Fat and marrow embolization during preparation of the femur or cementing of the femoral component was believed to be responsible for the cardiopulmonary collapse that occurred during arthroplasty. Although fat and marrow emboli were found in the pulmonary capillaries of most of the patients on autopsy, this histologic section shows two particles of cement in the pulmonary capillaries.
REFERENCES: Parvizi J, Holiday AD, Ereth MH, et al: The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
Patterson BM, Healy JH, Cornell CN, et al: Cardiac arrest during hip arthroplasty with a cemented long-stem component: A report of seven cases. J Bone Joint Surg Am

1991;73:271-277.

Question 35

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Explanation

DISCUSSION: Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury.
REFERENCES: Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.
Ford KR, Meyer GD, Hewett TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exer 2003;35:1745-1750.

Question 36

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Explanation

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,

pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,

pp 2461-2564.

Question 37

Giant cell tumors of bone can occur in many different areas throughout the body. All of the following are common locations for giant cell tumors of bone EXCEPT?

Explanation

What is the most appropriate treatment for a 65-year-old female with a 100-pack-year tobacco history who presents with a new painful lytic lesion in her femoral diaphysis?
Antegrade femoral nailing with reamings sent to pathology for analysis
Antegrade femoral nailing with adjuvant radiotherapy to the lesion 3
. Minimally invasive plating of the femur for stabilization and open cementation of the lesion
Referral to medical oncology for chemo-radiotherapy
Lesion biopsy with further treatment based on the results of the biopsy
New lesions which are not diagnosed by imaging and require surgical intervention need to have an appropriate biopsy with treatment dictated by the results of the biopsy. While this patient has a significant tobacco history, incorrect treatment of this lytic bone lesion could affect both her overall morbidity and mortality. As an example, a lytic high-grade chondrosarcoma may look exactly like a metastatic lesion but requires wide surgical excision, not just stabilization of an impending pathological fracture. Intramedullary nailing of a chondrosarcoma would spread the tumor the entire length of the bone and likely require a major amputation, not a limb salvage operation.
A 14-year-old child is referred to your office for evaluation of a tibia lesion found incidentally after a minor ankle injury. A radiograph of the child's ankle is shown in Figure A. What treatment do you suggest?

Endocrine consultation secondary to associated endocrine abnormalities
Surgical consultation secondary to associated gastrointestional cancers
Short leg cast and non-weight bearing for a minimum of 6 weeks
Open biopsy and tumor staging
Routine followup of tibial lesion
The radiograph is classic for a non-ossifying fibroma given the classic eccentric position, sclerotic margin, and benign appearance. Other than routine followup for the tibial lesion, this child requires no subsequent treatment. Marks and Bauer review the diagnosis, imaging, and treatment of many different fibrous tumors of bone and review the diagnostic imaging criteria specific to each subclass of bony fibrous tumors.
The chromosomal translocation t(X;18)is found in which of the following conditions?
Myxoid liposarcoma
Synovial Sarcoma
Osteosarcoma
Ewing's Sarcoma
Clear cell sarcoma
Synovial sarcoma is a rare soft tissue sarcoma with biphasic features of both spindle cell and epithelial differentiation. Synovial sarcoma is a rare high-grade tumor that spreads along fascial planes and, thus, can be much more widespread than apparent on initial evaluation. Males are more commonly affected than females with a ratio of 1.1:1. Synovial sarcoma is characterized by a specific chromosomal translocation t(X;18)(p11;q11) that is observed in more than 90% of cases. The t(X;18)(p11;q11) translocation fuses the SYT gene from chromosome 18 to either of 2 homologous genes at Xp11, either SSX1 or SSX2. The fusion proteins SYT-SSX1 and SYT-SSX2 function as aberrant transcriptional regulators, resulting in either activation of protooncogenes or inhibition of tumor suppressor genes.
Kawai et al found that SYT-SSX fusion transcripts are a defining diagnostic marker of synovial sarcomas. These fusion transcripts may yield important independent prognostic information and provide important information for different types of treatment.
Incorrect Answers

Question 38

Which of the following best describes the resultant forces on an increased offset stem when compared with a standard offset stem?

Explanation

DISCUSSION: The increased emphasis on restoring offset in total hip arthroplasty has implications for the forces applied to the components and the fixation interfaces. Static analysis has shown that with an increased affect, joint reaction force on the articulation is decreased. When the resultant load on the hip is “out of plane” (ie, directed anterior to posterior), there is increased torsion where the stem is turned into more retroversion.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 134-180.
Hurwitz DE, Andriaacchi TP: Biomechanics of the hip, in Callaghan J, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven , 1998.
Pauwels F: Biomechanics of the Normal and Diseased Hip. New York, NY, Springer-Verlag, 1976.

Question 39

A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. He is now 3 weeks from injury and skin swelling has subsided significantly. What is the most appropriate definitive treatment?

Explanation

External fixation is a temporizing treatment that allows the soft tissues to return to normal while maintaining your overall alignment. A fibular plate can help keep the length. Final treatment involves restoration of the tibial plafond articular surface which can only be done with ORIF +/- bone grafting. There is no role for primary arthrodesis in this young patient.
OrthoCash 2020

Question 40

Which of the following medications may have a negative effect on bone healing following fracture?

Explanation

DISCUSSION: Nonsteroidal anti-inflammatory drugs that are COX-1 primary inhibitors have been shown in animal studies to delay or inhibit fracture healing. COX-2 inhibitors also delay healing but to a lesser extent than COX-1 inhibitors. The other medications listed do not alter fracture callus formation.
REFERENCES: Gerstenfeld LC, Thiede M, Seibert K, et al: Differential inhibition of fracture healing by non-selective and cyclooxygenase-2 selective non-steroidal anti-inflammatory drugs. J Orthop Res 2003;21:670-675.
Harder AT, An YH: The mechanisms of the inhibitory effects of nonsteroidal anti-inflammatory drugs on bone healing: A concise review. J Clin Pharmacol 2003;43:807-815.

Question 41

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Explanation

The main function of the EDL is extension of the MTP joints of the lesser toes, so injury results in a claw toe deformity if left unrepaired. The EDL originates on the lateral tibial condyle, the anterior crest of the fibula, and the interosseous membrane and inserts on the base of the terminal phalanges of the four lesser toes. Innervated by the deep peroneal nerve, the EDL functions to extend the toes at the DIP joint and to dorsiflex and evert the foot. The EDL divides into two separate tendons beneath the superior retinaculum and then further divides into two lateral tendons to the fourth and fifth toes and two medial tendons to the second and third toes. The individual tendon of the EDL to each toe is joined on the lateral aspect by the tendon of the EDB. They are anchored at the level of the MTP joint by a fibroaponeurotic structure.
The EDB originates on the distal lateral and superior surface of the calcaneus and inserts on the
lateral aspect of the flexor digitorum longus tendon and also on to the base of the proximal phalanx of the first through fourth toes. There is no EDB tendon to the fifth toe. If an EDB laceration is easily identified at the time of an EDL repair, than it may be repaired as well, otherwise repair of the EDL alone is sufficient.
Heckman JD: Fractures and dislocation of the foot, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds):Rockwood and Green’s Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, pp 2166-2169.
Coughlin MJ: Disorders of tendons, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 787-788.
back to this question next question

Question 42

A 21-year-old throwing athlete has persistent shoulder pain. Figures 73a and 73b are arthroscopic photographs taken from a posterior viewing portal and an anterior viewing portal. During which phase of the throwing motion did the injury most likely occur? Review Topic

Explanation

Five distinct phases of the throwing motion have been identified, each of which places the static and dynamic stabilizers of the shoulder under different stresses. In the late cocking phase, the throwing arm is abducted and maximally externally rotated.
Rotator cuff tears in throwing athletes may be the result of either tensile or compressive forces. Tensile failure is believed to be the result of repetitive eccentric contractions. Compressive failure is thought to result from direct contact of the articular side of the rotator cuff between the greater tuberosity and posterior glenoid. Compressive failure results in tearing of the posterior supraspinatus and anterior infraspinatus, in contrast to the more common partial tearing of the anterior supraspinatus seen in the general population. In addition to tearing of the articular side of the rotator cuff, compressive forces also contribute to the peel-back mechanism and resultant avulsion of the posterosuperior labrum and biceps anchor. Articular-sided posterior supraspinatus and infraspinatus tears in combination with posterosuperior labral and biceps anchor detachment has been termed internal impingement. It is believed to be the primary result of either posterior capsular contracture (GIRD) or anterior capsular laxity.

Question 43

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Explanation

DISCUSSION: Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although parathesias lasting up to 2 weeks have been reported in up to 3% of patients.
REFERENCES: Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779.
Conn RA, Colfield RH, Byer DE, Lindstromberg JW: Interscalene block anesthesia for shoulder surgery. Clin Orthop 1987;216:94-98.

Question 44

A 65-year-old woman with rheumatoid arthritis is undergoing revision total knee arthroplasty (TKA) during which the medial collateral ligament (MCL) is damaged. Suture anchors are used to attempt primary repair, and a varus-valgus constrained insert also is used. Postsurgically she experiences instability that does not respond to bracing with a 3+ opening to valgus stress (Figure 120). What is the most appropriate surgical option?

Explanation

DISCUSSION
MCL repair or reconstruction may be considered in younger, more active patients, but this intervention is technically demanding and produces variable results. Rotating-hinge TKA is associated with good results in a number of small series that include cases performed with MCL insufficiency or absence. A rotating hinge is preferable over a fixed hinge because of decreased stresses on implants imposed by fixed-hinge devices.

Question 45

When comparing arthroscopic and open rotator cuff repairs, which of the following tears shows a decreased recurrent tear rate in the open versus the arthroscopic group? Review Topic

Explanation

As a tool for rotator cuff repair, arthroscopy has afforded surgeons the ability to repair tears without causing potential morbidity to the overlying deltoid. Follow-up studies looking at functional recovery have now shown equivalent or slightly better outcomes with arthroscopic procedures versus standard open procedures. However, small tear size may serve as a better predictor of success with arthroscopic approaches. Imaging studies have shown a higher rate of tear recurrence and/or failure of healing when tears greater than 3 cm in size are repaired arthroscopically versus a standard open approach.

Question 46

A 23-year-old man has pain and a callus beneath the second metatarsal head. Initial management should consist of

Explanation

DISCUSSION: The initial treatment of metatarsalgia with or without the presence of an intractable keratosis should be conservative. Simple paring of the callus with elevation of the metatarsals may suffice. A prefabricated “off-the-shelf” orthosis or felt pad can be used before investing in a custom orthosis. The use of medicated pads can lead to greater amounts of keratosis and should be avoided.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 163-173.
Mizel MS, Yodlowski ML: Disorders of the lesser metatarsophalangeal joints. J Am Acad Orthop Surg 1995;3:166-173.

Question 47

An 8-year-old girl has asymmetry on a forward bend test of the spine. She is asymptomatic and has a normal clinical neurologic examination. Radiographs are shown in Figures 22a and 22b. What should be the next step in her work-up? Review Topic

Explanation

There are several reasons to obtain an MRI of the entire spinal cord of this patient to evaluate for abnormalities. These include her young age and the presence of a left-sided curve. For juvenile scoliosis patients with more than a 20-degree Cobb angle, there is an approximately 20% prevalence of a neurologic abnormality. Therefore, recommendations for work-up include an MRI scan of the entire spine.

Question 48

Figures 3a and 3b show the current radiographs of a 59-year-old woman who has pain and deformity after undergoing bunion surgery 1 year ago. Nonsurgical management has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: The hallux varus seen in this patient is most likely the result of a combination of causes. Based on the degenerative changes and the significant shortening of the first metatarsal relative to the second metatarsal, a metatarsophalangeal arthrodesis is the treatment of choice. The other surgical approaches are not expected to provide a satisfactory result.
REFERENCES: Coughlin MJ, Mann RA: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby-Year Book, 2000, pp 150-269.
Skalley TC, Myerson MS: The operative treatment of acquired hallux varus. Clin Orthop 1994;306:183-191.

Question 49

A 62-year-old woman reports diffuse aches and pains of the hip and pelvis. She denies any significant trauma but does have a history of chronic anemia. Figure 17a shows a radiograph of the pelvis, and Figures 17b and 17c show T 2 -weighted MRI scans. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals diffuse osteopenia and areas in the proximal femora that are moth-eaten in appearance. The extent of the marrow-replacing process is evident on the MRI scans, which reveal signal abnormality throughout the entire pelvis and both proximal femora. This represents a marrow-packing process, of which multiple myeloma is the best choice. This diagnosis is also supported by the anemia noted on the patient’s history. Metastatic carcinoma and lymphoma also may have a similar presentation.
REFERENCE: Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA,

WB Saunders, 2002, pp 2189-2216.

Question 50

A concern when choosing irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene rather than lower dose–irradiated (4 Mrad) polyethylene is related to its inferior resistance to

Explanation

DISCUSSION
The higher the dose of radiation to the polyethylene, the higher the amount of cross-linking. Adhesive and abrasive wear resistance increases with an increase in cross-linking. However, fatigue properties of the material are decreased when polyethylene is melted (to remove free radicals) during the cross-linking process. Creep (deformation without wear) is also slightly increased with cross-linking of polyethylene.

Question 51

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

Explanation

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

Question 52

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

Explanation

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

Question 53

What is the most common cause of early failure for patellofemoral arthroplasty?

Explanation

DISCUSSION: In properly selected patients who have no or minimal tibiofemoral arthritis, the most common cause of early failure is patellofemoral instability secondary to uncorrected patellar malalignment, soft-tissue imbalance, or component malposition. Progression of tibiofemoral arthritis is also a leading cause of failure, but occurs late in about 25% of patients. Loosening of components has occurred in less than 1% of knees with cemented implants. A higher rate of loosening has been reported in cementless implants.
REFERENCES: Lonner JH: Patellofemoral arthroplasty. J Am Acad Orthop Surg 2007;15:495-506. Argenson JN, Flecher X, Parratte S, et al: Patellofemoral arthroplasty: An update. Clin Orthop Relat Res 2005;440:50-53.

Question 54

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

Explanation

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

Question 55

The fracture shown in Figure 32 is strongly indicative of what diagnosis?

Explanation

DISCUSSION: Fractures that occur through the primary spongiosa at the subphyseal region of the metaphysis are highly specific for child abuse. On radiographic studies, the metaphyseal lucency in these injuries may appear as either the so-called “bucket-handle” or “metaphyseal corner” fracture. These fractures are not typical features of osteogenesis imperfecta or vitamin D-resistant rickets. The ingestion of lead may lead to thick, transverse bands of increased density at the distal metaphysis. Fractures in the subphyseal region of the metaphysis are not typically seen in children who have osteomyelitis.
REFERENCES: Kocher MS, Kasser JR: Orthopaedic aspects of child abuse. J Am Acad Orthop Surg 2000;8:10-20.
Kleinman PK, Marks SC, Blackbourne B: The metaphyseal lesion in abused infants: A radiologic-histopathologic study. Am J Roentgenol 1986;146:895-905.

Question 56

Which of the following is considered a risk factor for the development of low back pain?

Explanation

DISCUSSION: Risk factors associated with low back pain include poor physical fitness, smoking, a history of repetitive bending or stooping on the job, or whole body vibration exposure. Some radiographic factors such as stenosis, spondyloarthropathy, severe deformity, or instability are also associated with low back pain. Gender, weight, transitional anatomy, or facet trophism are not associated with low back pain.
REFERENCE: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 627-643.

Question 57

What structure (arrow) is shown in Figure 24?

Explanation

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 58

A 40-year-old man with amyloidosis injured his left knee while walking. Figure 17a shows an AP radiograph that was obtained 2 weeks after the injury. The radiograph shown in Figure 17b was obtained after the patient wore a hinged knee brace for 3 months. A clinical photograph is shown in Figure 17c. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a Charcot arthropathy of the knee, which is associated with amyloidosis. The rapid joint destruction shown in the radiographs is most consistent with that diagnosis.
REFERENCES: Drennan D, Fahey J, Maylahn D: Important factors in achieving arthrodesis of the Charcot knee. J Bone Joint Surg Am 1971;53:1180-1193.
Soudry M, Binazzi R, Johanson N, et al: Total knee arthroplasty in Charcot and Charcot like joints. Clin Orthop 1986;208:199-204.
Buxbaum JN: The systemic amyloidoses. Curr Opin Rhemutol 2004;16:67-75.

Question 59

A 19-year-old soccer player feels a pop in his knee while making a cut and notes the development of an effusion over several hours. Examination reveals medial joint line tenderness, but the knee is stable to manual stress testing of all ligaments. Examination under anesthesia confirms a stable knee. What is the most critical factor in determining healing after repair of the lesion shown in Figure 14?

Explanation

DISCUSSION: Numerous clinical and basic science investigations have evaluated meniscal tear characteristics to identify factors that either promote or mitigate against meniscal healing. Complex tears have been noted to heal poorly, while longitudinal tears heal more predictably. Tear length, time from injury to repair, medial versus lateral meniscal tears, and the use of a fibrin clot have not been shown to consistently affect meniscal healing. However, rim width, the distance of the tear site from the peripheral meniscocapsular junction (vascular supply), has been shown to have a significant role in the ability of a meniscus repair to heal.
REFERENCES: DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.
Henning CE, Lynch MA, Clark JR: Vascularity for healing of meniscus repairs. Arthroscopy 1987;3:13-18.

Question 60

A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of

Explanation

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management.
REFERENCES: Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.
Clanton TO, Coupe KJ: Hamstring strains in the athlete: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248.

Question 61

Lumbar disk replacement has been shown to offer which of the following results?

Explanation

DISCUSSION: There is no clear evidence that disk replacement results in pain relief that is superior to fusion. Pain relief appears to be equivalent with these two procedures. No study has clearly demonstrated that normal segmental motion has been consistently restored. Preexisting facet arthropathy is considered to be a contraindication to disk replacement. Comparative long-term data demonstrating a reduced incidence of adjacent segment disease compared to fusion are not yet available.
REFERENCES: Geisler FH, Blumenthal SL, Guyer RD, et al: Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature. J Neurosurg Spine 2004;1:143-154.
Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 62

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a “pop” in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

Explanation

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.

Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 63

Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Explanation

[Radiograph: Well positioned G-H joint. Mild degenerative changes.]
Late onset of pain (average 13 years) was noted following this procedure in a small number of patients. The pain is attributed to excessive G-H compressive forces due to limited external rotation. NSAIDS and PT are first line treatments. If these fail, the authors demonstrated good results with release of the anterior structures. Choices 3 & 4 would probably be reserved for patients older than 50 with more advanced signs of degenerative disease.

Question 64

Figures 9a and 9b are the radiographs of a 19-year-old woman with a painful juvenile bunion. The pathologic findings associated with this deformity include a

Explanation

DISCUSSION
The radiographs show a hallux valgus deformity with a laterally deviated distal metatarsal articular surface, a large intermetatarsal angle with medial deviation at the first metatarsocuneiform joint, an elongated medial collateral ligament, and a contracted lateral collateral ligament. There is no distal 1-2 transverse intermetatarsal ligament. The distal transverse ligament in the first interspace extends from the second metatarsal to the lateral (fibular) sesamoid, remains intact, and keeps the sesamoids in a lateral position as the first metatarsal head migrates medially.
RECOMMENDED READINGS
Coughlin MJ. Roger A. Mann Award. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int. 1995 Nov;16(11):682-97. PubMed PMID: 8589807.
View Abstract at PubMed
Coughlin MJ, Mann RA. Hallux valgus. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby Elsevier; 2007:183-226.

Question 65

Figures 18a through 18c show injuries sustained by a 22-year-old woman after falling 45 feet while mountain climbing. After being airlifted to the nearest trauma center, her arterial blood gas was 7.21, pO2 84, pCO2 48, and delta base -11 mmol/L. Her Hgb is 8.7 and her resuscitation is ongoing. Based on this data, what would be the best management of her orthopaedic injuries?

Explanation

The patient is under-resuscitated and would benefit from minimally invasive stabilization of the pelvic ring and long bone fractures in a "damage-control" approach. External fixation of the pelvis and femur can be performed quickly and with minimal blood loss which should limit the "second hit" associated with more
prolonged, invasive surgery. Upper extremity fractures are best managed acutely with splints in this clinical setting. Definitive fracture fixation should be delayed until the patient is adequately resuscitated.

Question 66

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 67

Two years ago, a 63-year-old man underwent right total hip arthroplasty (THA) with a modular femoral head-neck and neck-stem prosthesis (a photograph of the removed implant is shown in Figure 181). He now has increasing hip pain. Radiographs reveal a stable hip arthroplasty and elevated serum cobalt and chromium levels. MR imaging is obtained, and, based on these findings, the patient’s hip is revised. Which corrosion type likely is responsible for this THA failure?

Explanation

DISCUSSION
Micromotion at the femoral head-neck or stem-neck junction can lead to fretting corrosion. Fretting corrosion is among the most common causes of failure in modular components. Modularity gives surgeons additional intraoperative flexibility but has resulted in corrosion-related failure and an implant recall. Although titanium and cobalt-chrome contain a protective surface oxide layer, continued micromotion at the modular junction may disrupt the protective layer, resulting in fretting corrosion. This may eventually lead to excessive metal ion formation and painful synovitis that necessitates a revision procedure. Galvanic corrosion is attributable to a mismatch in electrochemical gradients between dissimilar metals. Crevice or pitting corrosion occurs in fatigue cracks because of differences in oxygen tension.

Question 68

A 32-year-old professional skydiver lands awkwardly during a jump. He presents to the emergency room with bilateral knee injuries. Following successful closed reduction of both extremities, both feet are warm and pulses are present. Bedside doppler assessment is performed and the results are seen in Figure A. What would be the most appropriate next step in treatment?

Explanation

The ankle-brachial index (ABI) of left and right limbs are 0.78 and 0.96 respectively. CT angiography (or conventional angiography) of the left lower extremity is indicated because of abnormal ABI <0.9. It is sufficient to observe the right lower extremity (ABI >0.9).
Injury to the popliteal artery is present in 10-40% of knee dislocations (KD). ABI
<0.9 has sensitivity of 87% and specificity of 97% for the diagnosis of arterial disruption. Delayed recognition of an occlusive injury (>8 hours) is likely to result in above knee amputation.
Stannard et al. examined the role of selective arteriography based on serial physical examination. They found arterial injury in 7% (9 out of 134 knees), and abnormal physical findings in 10 patients, with only 1 false positive. They recommend arteriography for patients with decreased pulses, color or temperature, expanding knee hematoma, or an abnormal physical examination prior to presentation in the emergency department.
Mills et al. reviewed the value of ABI for diagnosing arterial injury after knee dislocation. They found that of the 29% with ABI <0.9, all required surgery for arterial injury. Of the remaining patients with ABI >0.9, none had vascular injury. They concluded ABI >0.9 has negative predictive value of 100%.
Nicandri et al. reviewed an algorithm for selective angiography. They recommend the following: (1) Intact pulses and ABI >0.9, observation for 24 hours. (2) Asymmetric pulses or ABI <0.9, arteriogram. (3) Hard signs of vascular injury (absent distal pulses, distal ischemia, active hemorrhage, expanding pulsatile hematoma), surgical exploration.
Figure A is a table showing systolic pressure readings at different sites. To calculate the ABI, the highest measured arterial pressure in the ankle or foot is divided by the higher brachial arterial pressure from both upper extremities.
Incorrect Answers:

Question 69

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

Explanation

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

Question 70

Figures 1 and 2 are the MRI scans of a 35-year-old right-hand dominant man who has right elbow pain after trying to lift a large television at home. An examination reveals ecchymosis, an abnormal hook test, and altered biceps muscle contour. What treatment is most likely to result in a satisfactory and predictable outcome?

Explanation

Figures 1 and 2 show a full thickness distal biceps tendon rupture with proximal retraction. Edema is seen along the course of the distal biceps tendon, and the axial cut demonstrates the absence of tendon at the radial tuberosity. The sagittal cut demonstrates the stump of the proximally retracted biceps tendon. The biceps muscle contour is abnormal in appearance, demonstrating the classic “popeye” deformity. Nonsurgical treatment options result in predictable loss of supination and elbow flexion strength that is not desirable. A local corticosteroid injection would not improve strength, and there is no evidence to support the use of a PRP injection.

Question 71

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

Explanation

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

Question 72

A 22-year-old woman sustains the injury seen in Figure 12 as a result of a motor vehicle crash. What factor is most closely associated with development of osteonecrosis?

Explanation

MRI angiography of leg
Four-compartment fasciotomy
Follow-up examination the following day
Continued monitoring and serial examinations
EMG study
The patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.
A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam.
An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinical diagnosis persists despite these efforts, urgent fasciotomy would be considered.
McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.
White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.
Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.
Incorrect Answers:
30 mm Hg or persistently elevated absolute compartment pressures.. Answer 3: It would not be appropriate to leave this patient with impending compartment syndrome.
(SBQ12TR.57) A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on the available imaging, which of the following fracture characteristics best justifies this fixation choice?

Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on inter-fragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
congruity but does not dictate implant selection. Answer 3. Extension distal to the coronoid is an indication for plate fixation but there is no evidence of such extension on the radiograph shown Answer 4. This fracture is comminuted, without a distinct fracture line.

Question 73

What is the primary concern for arthrodesis of a failed infected total knee arthroplasty using internal fixation?

Explanation

DISCUSSION: Arthrodesis of the failed infected total knee arthroplasty may be accomplished by external fixation, intramedullary rod fixation, and dual plates and screws. External fixation runs the risk of pin tract infection, although after its removal, there are no metal surfaces left in place. Intramedullary rods have been used successfully in the treatment of infected total knees, although they also leave metal within the region of the infection. The dual plate technique of knee fusion is useful in patients with rheumatoid arthritis who require fusion in the absence of infection because it provides good initial stability and avoids the use of external pins. However, in the face of infection, the large surface area of the screws and plates may serve as a site for bacteria to hide within a glycocalyx and make eradication of the infection almost impossible.
REFERENCE: Windsor RE: Knee arthrodesis, in Insall JN, Windsor R, Kelly M, et al (eds): Surgery of the Knee. New York, NY, Churchill Livingstone, 1993, pp 1103-1116.

Question 74

A 20-year-old collegiate baseball pitcher has persistent deep shoulder pain. Examination reveals normal strength, 130 degrees of external rotation in abduction, 10 degrees of internal rotation in abduction, mild dynamic scapular winging, and equivocal findings on provocative tests for labral tears. Management should consist of

Explanation

DISCUSSION: Although management of shoulder pain in the throwing athlete is controversial, there are some general principles. Initial management generally includes rest from throwing, restoring normal joint function, specifically motion and strength as well as eliminating pain. In this patient, examination reveals excessive external rotation and decreased internal rotation. This pattern is common in pitchers; however, the total arc of motion should remain close to 180 degrees in abduction. In this patient, the total arc is 140 degrees. Treatment should first focus on restoring a 180-degree arc with posterior scapular stretching, as well as pain control and muscle rehabilitation. Injections and surgery are generally reserved for patients who fail to respond to rest and rehabilitation.
REFERENCE: Burkhart SS, Morgan CD, Kibler WB: Shoulder injuries in overhead athletes: The “dead arm” revisited. Clin Sports Med 2000;19:125-158.

Question 75

Pacinian corpuscles are lamellated nerve endings that are responsible for providing the perception of

Explanation

DISCUSSION: Pacinian corpuscles are nerve endings that provide the perception of pressure.
REFERENCE: Sunderland SS: Nerves and Nerve Injuries, ed 2. New York, NY, Churchill Livingstone, 1978, pp 343-347.

Question 76

A 35-year-old woman who is training for a triathlon has had a 2-month history of heel pain with weight bearing and is unable to run. History reveals that she is amenorrheic. Examination reveals that she is thin and has pain over the heel that is exacerbated with medial and lateral compression. Range of motion and motor and sensory function are normal. Radiographs are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The most likely diagnosis is a stress fracture of the calcaneus and is supported by the history of running, female gender, and amenorrhea. Reproducing pain with medial and lateral compression of the heel also supports the diagnosis. A bone scan or MRI would most likely confirm the diagnosis. Plantar fasciitis would result in pain on the bottom of the heel with point tenderness. The lack of other areas of involvement or other symptoms does not support a seronegative inflammatory arthritis. Tarsal tunnel syndrome and peripheral neuropathy are unlikely because of the normal neurologic examination.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.
Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 179-191.

Question 77

A 14-year-old boy sustained a 100% displaced distal radius Salter-Harris type II fracture. Neurologic examination demonstrates normal motor examination and two-point discrimination. He undergoes fracture reduction to the anatomic position with the application of a long arm cast. Postreduction he reports increasing hand and wrist pain with diminution of two-point discrimination to 10 mm over the index and middle fingers over the next several hours after surgery. The cast is bivalved and the padding released relieving all external pressure over the arm. Reevaluation reveals increasing sensory deficit over the affected area. What is the next most appropriate management intervention?

Explanation

DISCUSSION: The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression.
REFERENCES: Waters PM, Mih AD: Fractures of the distal radius and ulna, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, p 361.
Paley D, McMurtry RY: Median nerve compression by volarly displaced fragments of the distal radius. Clin Orthop Relat Res 1987;215:139-147.

Question 78

A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?

Explanation

The most common reason for revision surgery following unconstrained shoulder arthroplasty for glenohumeral OA is loosening of an implant. In most studies that distinguish glenoid from humeral loosening, it appears the glenoid is the problem. Comprehensive systematic reviews have found that radiographic glenoid loosening can comprise nearly 30% to 40% of all complications following shoulder arthroplasty for non-
inflammatory arthritis. Infections, periprosthetic fractures, and rotator cuff tears are uncommon. In the population-based study by Matsen and associates, 10% of the revisions were performed for loosening versus
7% for infection and 7% for rotator cuff tearing.

Question 79

At the first postoperative visit after mini-open carpal tunnel release, a patient reports hand weakness. Poor index finger interphalangeal joint extension and metacarpophalangeal joint flexion are present. This finding is most consistent with

Explanation

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If it were injured, the result would not be weakness of interphalangeal joint extension.

Question 80

Figures 49a and 49b show MRI scans of the shoulder. What is the most likely diagnosis?

Explanation

DISCUSSION: The supraspinatus tendon shows clear detachment and retraction from its greater tuberosity attachment by the absence of the normal dark subacromial signal extending to the attachment on the greater tuberosity. There is no anterior inferior glenoid labral detachment that usually is seen in a Bankart lesion. The acromioclavicular joint shows no evidence of separation. The humeral head is migrated cranially, indicating a chronic rotator cuff tear.
REFERENCES: Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.
Seeger LL, Gold RH, Bassett LW, Ellman H: Shoulder impingement syndrome: MR findings in 53 shoulders. Am J Roentgenol 1988;150:343-347.
Williams MM, Snyder SJ, Buford D Jr: The Buford complex: The “cord-like” middle glenohumeral ligament and absent anterosuperior labrum complex. A normal anatomic capsulolabral variant. Arthroscopy 1994;10:241-247.

Question 81

Titanium and its alloys are unsuitable candidates for which of the following implant applications?

Explanation

DISCUSSION: Titanium alloy is highly biocompatible, has higher strength than stainless steel, and is highly resistant to corrosion. It is particularly suited for use in fracture plates, bone screws, and intramedullary nails because of its low modulus of elasticity (low stiffness), which can reduce stress shielding. It is also widely used for porous-ingrowth coatings. However, clinical experience has shown that titanium alloy bearing surfaces such as a femoral ball are highly susceptible to severe metallic wear, particularly in the presence of third-body abrasive particles (PMMA fragments, bone chips, metal debris, etc).
REFERENCES: McKellop HA, Sarmiento A, Schwinn CP, et al: In vivo wear of titanium-alloy hip prostheses. J Bone Joint Surg Am 1990;72:512-517.
Salvati EA, Betts F, Doty SB: Particulate metallic debris in cemented total hip arthroplasty. Clin Orthop 1993;293:160-173.
Evans BG, Salvati EA, Huo MH, et al: The rationale for cemented total hip arthroplasty. Orthop Clin North Am 1993;24:599-610.

Question 82

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

Explanation

DISCUSSION: Multiple attempts at closed reduction, delayed surgery for proximal humeral fractures, and associated closed head injury all have been associated with a higher incidence of heterotopic ossification.
REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, p 291.
Neer CS: Displaced proximal humerus fractures: Part II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.

Question 83

A 52-year-old woman underwent open reduction and internal fixation for radial and ulnar shaft fractures 2 months ago. In a second fall she refractured her forearm and required revision surgery with bone grafting. One month after the second operation she notes erythema, swelling, and drainage from the volar radial incision. In addition to antibiotic treatment, management should consist of

Explanation

DISCUSSION: Deep infections after plating of closed fractures of the forearm are unusual. However, the risk increases with repeat surgeries. Debridement of all infected, nonviable tissue is the initial step in management. The fixation may be retained if it is stable, but if the plate and screws are loose, they should be removed and revision performed after removal of nonviable bone. Either external fixation or repeat plating may be performed. Late infections after fracture union may be treated with plate and screw removal, debridement, and IV antibiotics.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 53-63.
Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.

Question 84

Figure 19 shows the radiograph of a 6-month-old infant who has limited hip motion. History reveals no complications during pregnancy or delivery. Examination reveals that hip abduction is 45 degrees in flexion bilaterally. The neurologic examination is normal. What is the best course of action?

Explanation

DISCUSSION: Diminished hip abduction can occur in normal children and is not always associated with hip pathology; therefore, initial management should consist of observation.
REFERENCE: Castelein RM, Korte J: Limited hip abduction in the infant. J Pediatr Orthop 2001;21:668-670.

Question 85

A 45-year-old man has a draining sinus and recurrent infection of his right total knee arthroplasty. He has had two prior revision surgeries after the primary procedure and three other surgeries before his initial replacement, including a proximal tibial osteotomy and subsequent hardware removal. On clinical examination, he has a draining sinus in the mid portion of his surgical scar and a range of motion of 5° to 85°. AP and lateral radiographs of the right knee are shown in Figures below. During surgery, the femoral component is found to be grossly loose, but the tibial component is well fixed. What is the most appropriate extensile approach that would provide adequate exposure and aid in tibial component extraction?

Explanation

DISCUSSION:
Extended tibial tubercle osteotomy is an extensile approach to revision total knee arthroplasty that affords excellent exposure and can facilitate removal of tibial sleeves and cones. This patient has had multiple surgeries, including a proximal tibial osteotomy, as well as poor range of motion, patella baja, and a well-fixed metaphyseal sleeve component. Classically, an extended tibial tubercle osteotomy provides outstanding exposure for component removal in the setting of prior high tibial osteotomy and patella baja. For this patient, it is important to recognize the patella baja on the radiographs, as well as the tibial sleeve. In many of these cases the osteotomy provides access to the sleeve to help with extraction, because the stem will not pull through the sleeve or detach from the tray to allow visualization of the sleeve. The extended medial parapatellar approach is just a long medial approach that typically yields good exposure
but would not help with the patella baja or extraction of the tibial sleeve. The quadriceps snip would give good exposure to the knee but would not aid in tibial component removal. Lastly, the medial epicondyle osteotomy could help with exposure and tensioning of the medial complex of the knee but would not help with tibial component extraction.

Question 86

A patient with refractory long head biceps pain in the shoulder undergoes biceps tenotomy. The patient is concerned about possible postoperative deformity and loss of supination strength. Which of the following techniques provides the strongest initial fixation to prevent distal migration?

Explanation

DISCUSSION: Recent articles have looked at the cyclic load failure and ultimate load failure of biceps tenodesis techniques. The interference screw has proved superior to bone tunnel, suture anchor, and soft-tissue tenodesis techniques in laboratory cadaveric testing. Whether this is clinically relevant or not is still unknown.
REFERENCES: Ozalay M, Akpinar S, Karaeminogullari O, et al: Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21:992-998.
Richards DP, Burkhart SS: A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy 2005;21:861-866.

Question 87

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Explanation

The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.

Question 88

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Explanation

DISCUSSION: There is a negative change of calcium balance with a decrease

in intestinal absorption and an increase in urinary calcium loss. The reduction of

intestinal absorption is accompanied by reduced circulating concentrations of total, but

not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 89

Figure 17 shows the radiograph of a 2-year-old girl who sustained a fracture of the femur in a fall while walking with her parents. History reveals that this is her third long bone fracture, having sustained a humerus fracture 1 year ago and a fracture of the opposite femur 9 months ago. There is no family history of any similar problem. Examination reveals distinctly blue sclerae, normal appearing teeth, and no skin lesions. What is the most likely cause of this patient’s disorder?

Explanation

DISCUSSION: Osteogenesis imperfecta (OI) is a genetically determined disorder of type I collagen synthesis that is characterized by bone fragility. This patient has had three fractures of the long bones by age 2 years, with the last one occurring after relatively minor trauma. The patient’s history and clinical features are consistent with a diagnosis of Sillence type IA OI. Type I OI is the mildest and most common form. Inheritance is autosomal-dominant; however, as in this patient, new mutations are frequent. Type I is subclassified into the A type (absence of dentinogenesis imperfecta) and B type (presence of dentinogenesis imperfecta). The sclerae are blue, and the first fractures usually occur in the preschool years after walking has begun. Cells from individuals with type I OI largely demonstrate a quantitative defect of type I collagen; they synthesize and secrete about half the normal amount of type I procollagen. Qualitative mutations that lead to an abnormal type I procollagen molecule result in more severe types of the disorder. There are no indications that this child has been abused. Radiographs of the femur show no evidence of rickets, pyknodysostosis, or osteopetrosis. Morquio syndrome, characterized by excess excretion of keratin sulfate in the urine, is not associated with bone fragility.
REFERENCES: Kocher MS, Shapiro F: Osteogenesis imperfecta. J Am Acad Orthop Surg 1998;6:225-236.
Sillence DO, Senn A, Danks DM: Osteogenesis imperfecta: An expanding panorama of variants. Clin Orthop 1981;159:11-25.
Cole WG: Etiology and pathogenesis of heritable connective tissue diseases. J Pediatr Orthop 1993;13:392-403.

Question 90

A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports. Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally. What is the most likely diagnosis?

Explanation

DISCUSSION: Calcaneal apophysitis (Sever’s disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus.
REFERENCES: Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38. 500.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 91

Figures below show the radiographs obtained from a 75-year-old woman who underwent right total hip arthroplasty in 2009. She did well until last month, when a right posterior hip dislocation occurred after she fell from her bed to the floor. Successful closed reduction was performed. She sustained two more posterior dislocations requiring closed reduction under anesthesia. The surgical report from the index arthroplasty notes a 54-mm monoblock acetabular component with a 28-mm inner diameter compression molded polyethylene and a high offset neck cementless stem with a +8-mm length, 28-mm head. What is the best next step?

Explanation

DISCUSSION:
This patient has demonstrated recurrent instability, and her current implants lack the modularity to upsize and improve the head-neck ratio and range to impingement. Given the monoblock acetabular component and a +7-mm neck length, the best option is revision to a large-diameter femoral head or dual-mobility component. Placement of a hip spica cast and resection arthroplasty are unreasonable. Revision to a longer ball length likely would not solve this recurrent instability pattern.

Question 92

A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of

Explanation

DISCUSSION: The patient has a stable bony fracture that will heal with immobilization in a rigid collar. Flexion-extension radiographs may be obtained at 6 weeks to verify that there is no instability; mobilization may then be begun.
REFERENCE: Clarke CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.

Question 93

A quarterback sustains a rough tackle after which he appears confused, has a dazed look on his face and an unsteady gait on standing. He denies loss of consciousness. Reexamination within 10 minutes is normal, the patient is lucid, and he wants to return to play. The coach and the player should be advised that he may

Explanation

DISCUSSION: The patient has a grade I (mild) concussion that can result in confusion and disorientation, without loss of consciousness. This concussion syndrome is completely reversible, with no long-term sequelae. Athletes who sustain a grade I concussion may return to play after 15 minutes if there are no lingering symptoms, such as headache or vertigo. A grade II concussion is characterized by loss of consciousness of less than 5 minutes. With this type of injury, the athlete can return to play in 1 week, if asymptomatic. If a grade III (severe) concussion is sustained, the athlete should avoid contact for a minimum of 1 month before considering a return to competition. A grade III concussion is characterized by a loss of consciousness of greater than 5 minutes or posttraumatic amnesia of greater than 24 hours. A CT scan is not indicated in a grade I injury. An athlete who sustains three grade I or grade II concussions, or two grade III concussions may not return to play for the season.
REFERENCES: Torg JS, Gennarelli TA: Head and cervical spine injuries, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine Principles & Practice. Philadelphia, PA, WB Saunders, 1994, vol 1, pp 417-462.
Cantu RC: Criteria for return to competition after closed head injury, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby, 1991.

Question 94

Figures 1 and 2 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.The patient undergoes successful primary THA with a metal-on-metal bearing. At 1-year follow-up, she reports no pain and is highly satisfied with the procedure. However, 3 years after the index procedure, she reports atraumatic right hip pain that worsens with activities. Radiographs reveal the implants in good position with no sign of loosening or lysis. An initial laboratory evaluation reveals a normal sedimentation rate and C-reactive protein (CRP) level. The most appropriate next diagnostic step is

Explanation

DISCUSSION:
THA has proven to be durable and reliable for pain relief and improvement of function in 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. Because it offers 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 after the possible 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 work-up of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including the erythrocyte sedimentation rate, C-reactive protein (CRP) level, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging, including MRI with MARS, should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cell counts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following a revision of failed metal-on-metal hip replacements.

Question 95

A 33-year-old male patient presents with a comminuted open tibia fracture after involvement in a motor vehicle crash. He has a history of smoking but is otherwise healthy. He is given antibiotics, and taken immediately for irrigation and debridement, followed by an un-reamed stainless steel intramedullary nail. Due to bone loss there is a non-circumferential cortical defect measuring 12 mm at the fracture site. All of the following factors in this patient's history and presentation increase his risk for adverse outcome EXCEPT:

Explanation

Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation.
The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail,
residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found.
Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intrameduallry nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship.
Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.
Incorrect answers:

Question 96

What cell type causes the bone destruction in metastatic lesions?

Explanation

DISCUSSION: The main consequence of tumor invading the bone is activation of both osteoblasts and osteoclasts. However, the osteoclastic effect predominates in the majority of tumors early after the invasion of bone by tumor cells, causing resorption of bone.
REFERENCES: Cramer SF, Fried L, Carter KJ: The cellular basis of metastatic bone disease in patients with lung cancer. Cancer 1981;48:2649-2660.
Clohisy DR, Palkert D, Ramnaraine ML, Pekurovsky I, Oursler MJ: Human breast cancer induces osteoclast activation and increases the number of osteoclasts at sites of tumor osteolysis. J Orthop Res 1996;14:396-402.

Question 97

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

Explanation

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

Question 98

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

Explanation

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

Question 99

What is the most common site of nerve compression in radial tunnel syndrome?

Explanation

A 25-year-old man has an isolated flexor digitorum profundus laceration just proximal to the distal interphalangeal (DIP) flexion crease of his ring finger. The tendon ends are trimmed, removing 10 mm from each end (secondary to fraying) and the tendon repaired. Four months later, he reports limited finger motion of the long, ring, and small fingers. He cannot fully extend his wrist and all joints of the 3 fingers simultaneously. He has full passive flexion but cannot actively completely close his fingers into a fist. What is the most likely cause?
A. Quadrigia
B. Intrinsic tightness
C. Lumbrical plus deformity
D. Disruption of the tendon repai

Question 100

A 22-year-old man reports that he initially dislocated his shoulder while playing basketball 2 years ago and was subsequently treated with an arthroscopic Bankart repair. Despite appropriate rehabilitation, the patient continues to report recurrent instability. An axillary view radiograph and CT scan are shown in Figures 57a and 57b. What is the most appropriate management at this time? Review Topic

Explanation

Although the changes are subtle on the radiograph, an anterior inferior glenoid bone defect is clearly evident on the CT scan. With loss of greater than 20% to 25% of the glenoid width, patients may experience persistent instability despite appropriate labral repair and capsulorrhaphy. Therefore, nonsurgical management with supervised therapy or surgical treatments that do not address the bony defect, such as arthroscopic or open labral repair and capsulorrhaphy, are not likely to stabilize the joint. An open shoulder stabilization procedure with a bone block should address the defect and stabilize the joint. Shoulder arthrodesis is not warranted in this patient at this time because the shoulder is likely salvageable.

Full Question & Answer Text (for Search Engines)

Question 1:

A 46-year-old woman had an ankle fracture and ORIF 6 years ago. She had subsequent removal of some of the hardware, but her pain has persisted (Figures 44a and 44b).

Options:

Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)
Ankle distraction arthroplasty
Ankle fusion
Total ankle arthroplasty (TAA)

Correct Answer: Tibial and/or fibular osteotomy with open reduction and internal fixation (ORIF)

Explanation:

DISCUSSION
Patients younger than 40 years of age who have ankle arthritis pose an ongoing clinical challenge. Nonsurgical treatment should be maximized, although distraction arthroplasty can be used in an effort to delay the need for fusion.
One of the strongest indications for ankle arthroplasty is a preexisting hindfoot fusion with a goal to retain some ankle/hindfoot motion. Ankle fusion is perhaps the most predictable surgical treatment for a relatively young, active patient with ankle arthritis. Moreover, there are concerns regarding implant loosening when performing TAA in active patients.
Outcome after syndesmosis ORIF has been linked to the quality of the reduction at the index procedure. Syndesmotic malreduction that is severe necessitates osteotomy and revision ORIF.
RECOMMENDED READINGS
Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012 Jul;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a. PubMed PMID: 22357084.
View Abstract at PubMed
Smith NC, Beaman D, Rozbruch SR, Glazebrook MA. Evidence-based indications for distraction ankle arthroplasty. Foot Ankle Int. 2012 Aug;33(8):632-6. Review.
View Abstract at PubMed
Kim BS, Knupp M, Zwicky L, Lee JW, Hintermann B. Total ankle replacement in association with hindfoot fusion: Outcome and complications. J Bone Joint Surg Br. 2010 Nov;92(11):1540-7. doi: 10.1302/0301-620X.92B11.24452. PubMed PMID: 21037349.
View Abstract at PubMed
Daniels TR, Younger AS, Penner M, Wing K, Dryden PJ, Wong H, Glazebrook M. Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study. J Bone Joint Surg Am. 2014 Jan 15;96(2):135-42. doi: 10.2106/JBJS.L.01597.
View Abstract at PubMed

Question 2:

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 3:

Options:

Chronic deep infection
Heterotopic bone
Femoral loosening
Parkinsonism
Acetabular loosening

Correct Answer: Femoral loosening

Explanation:

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 4:

What is one of the principle concerns when a fracture such as the one seen in Figure 18 is encountered?

Options:

Fractures of the lower extremities
Paroxysmal hypertension
Infection
Epidural hematoma
Gastrointestinal bleeding

Correct Answer: Epidural hematoma

Explanation:

DISCUSSION: The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following knee fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.
REFERENCES: Ludwig S, Zarro CM: Complications encountered in the management of patients with ankylosing spondylitis, in Vaccaro AR, Regan JJ, Crawford AH, et al (eds): Complications of Pediatric and Adult Spine Surgery. New York, NY, Marcel Dekker, 2004,
pp 279-290.
Wu CT, Lee ST: Spinal epidural hematoma and ankylosing spondylitis: Case report and review of the literature. J Trauma 1998;44:558-561.

Question 5:

Options:

Intraoperative fracture
Deep vein thrombosis
Limb-length discrepancy
Sciatic nerve palsy
Thigh pain

Correct Answer: Limb-length discrepancy

Explanation:

Question 6:

Options:

hospital admission for IV antibiotics and observation.
an epidural steroid.
anterior diskectomy and fusion with autologous bone graft.
laminectomy for decompression and debridement.
laminectomy for decompression with an instrumented posterolateral fusion.

Correct Answer: laminectomy for decompression and debridement.

Explanation:

Question 7:

- The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Options:

hypophosphatemia
high dietary cholesterol intake
deficiency of lipoprotein A
deficiency of protein S and protein C
elevated levels of antithrombin III

Correct Answer: deficiency of protein S and protein C

Explanation:

Question 8:

-This boy’s parents are eager to get him back on the field as soon as possible. What is the most appropriate treatment option?

Options:

Screw fixation of the epiphysis
Arthroscopic debridement
A shut-down period until the boy is asymptomatic, and gradual return to pitching via a throwing program
An intra-articular cortisone injection

Correct Answer: A shut-down period until the boy is asymptomatic, and gradual return to pitching via a throwing program

Explanation:

DISCUSSION FOR QUESTIONS 60 AND 61
Although a recent increase in the number of pitches may have contributed to this patient’s development of little leaguer’s shoulder, the most significant overall factor is age. Little leaguer’s shoulder is caused by rotational stress placed on the proximal humeral epiphysis during overhead throwing. The growth plate is weakest to torsion stress, and is most susceptible to injury during periods of rapid growth commonly seen during puberty. Most chronic shoulder injuries occur in throwing athletes between 13 and 16 years of age. Genetic factors and gender have not been studied in association with little leaguer’s shoulder. An initial 3-month period of rest and activity modification will typically result in resolution of symptoms.Nonsteroidal anti-inflammatory drugs may be used as needed. After the rest period, a gradual return to baseline pitching is implemented until the patient is back to baseline. This protocol has a long-term success rate exceeding 90%.

Question 9:

What is the most likely complication after surgical treatment in this scenario?

Options:

Recurrent instability
Degenerative joint disease
Shoulder stiffness
Axillary nerve injury

Correct Answer: Shoulder stiffness

Explanation:

Question 10:

Options:

(11; 22) (q24; q12)
(X; 18) (p11; q11)
(12; 22) (q13; q12)
(2; 13) (q35; q14)
(12; 16) (q13; p11)

Correct Answer: (11; 22) (q24; q12)

Explanation:

DISCUSSION: The imaging studies show a permeative lytic destructive lesion in the proximal radius with “hair-on-end” periosteal reaction and a large soft-tissue mass most consistent with Ewing’s sarcoma. The pathology reveals monotonous sheets of “round blue” cells. This limits the differential diagnosis to primary lymphoma of bone versus Ewing’s sarcoma. These are best differentiated by immunohistochemistry, cytogenetics, and flow cytometry. Lymphoma of bone is typically CD34 positive and CD99 negative; whereas, the reverse is true of Ewing’s sarcoma, CD34 negative and CD99 positive. The most common cytogenetic translocation with Ewing’s sarcoma is 11; 22; 21; 22 and 7; 22 translocations have also been reported in Ewing’s sarcomas. The X; 18 translocation is most commonly associated with synovial cell sarcomas; the 12; 22 translocation is most commonly associated with clear cell sarcomas; the 2; 13 translocation is most commonly associated with alveolar rhabdomyosarcomas, and the 12; 16 translocation is most commonly associated with myxoid liposarcomas. Flow cytometry is used to characterize the cell types of lymphomas.
REFERENCES: Womer R: The cellular biology of bone tumors. Clin Orthop Relat Res 1991;262:12-21.
Yamaguchi U, Hasegawa T, Morimoto Y, et al: A practical approach to the clinical diagnosis of Ewing’s sarcoma/primitive neuroectodermal tumour and other small round cell tumours sharing EWS rearrangement using new fluorescence in situ hybridisation probes for EWSR1 on formalin fixed, paraffin wax embedded tissue. J Clin Pathol 2005;58:1051-1056.
Lazar A, Abruzzo LV, Pollock RE, et al: Molecular diagnosis of sarcomas: Chromosomal translocations in sarcomas. Arch Path Lab Med 2006;130:1199-1207.

Question 11:

What is the best surgical approach for the scapular fracture shown in Figure 46?

Options:

Anterior
Anterior and superior
Posterior
Percutaneous pinning
Closed reduction

Correct Answer: Posterior

Explanation:

Question 12:

Options:

functional rehabilitation with range of motion and strengthening.
reduction and screw fixation of the syndesmosis.
closed reduction and a long leg cast.
repair of the talofibular ligaments.
fibular osteotomy and plate fixation.

Correct Answer: reduction and screw fixation of the syndesmosis.

Explanation:

Question 13:

Options:

Renal ultrasound
Blood cultures
Flexion-extension cervical spine radiographs
Platelet count

Correct Answer: Renal ultrasound

Explanation:

Question 14:

- A 75-year-old woman who has groin pain states that she had total hip arthroplasty 15 years ago. The radiograph shown in Figure 40 reveals that the left acetabular component is grossly loose. Revision of the acetabular component should include use of a

Options:

constrained acetabular component
protrusion ring with morselized graft
cemented metal backed acetabular component
cemented all-polyethylene acetabular component
cementless hemispherical component with screw fixation

Correct Answer: cementless hemispherical component with screw fixation

Explanation:

Question 15:

Options:

There is no significant difference in operative time when using cemented stems compared with uncemented stems
Comparing HA to THA, there is no difference in blood loss
Longer term outcomes are better with HA
Bipolar HA performed through a direct anterior or lateral approach leads to equivalent patient outcomes as THA
Perioperative complication rate is greater after THA than bipolar HA

Correct Answer: Comparing HA to THA, there is no difference in blood loss

Explanation:

Question 16:

Options:

excision of the fracture fragment.
radial head replacement.
closed reduction and cast immobilization.
open reduction and internal fixation of the radial head.
open reduction and internal fixation of the capitellum.

Correct Answer: open reduction and internal fixation of the capitellum.

Explanation:

Question 17:

Which of the following complications may occur subsequent to resurfacing hip arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?

Options:

Aseptic loosening of the acetabular component
Fracture of the femoral neck
Fracture of the acetabulum
Infection
Groin pain

Correct Answer: Fracture of the femoral neck

Explanation:

DISCUSSION: Advocates of resurfacing hip arthroplasty cite preservation of the proximal femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture of the retained femoral neck has been reported following resurfacing arthroplasty. The exact etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure, may result in femoral neck fracture.
REFERENCES: Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head osteonecrosis. J Arthroplasty 2003;18:96-99.
Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am 2004;86:1874-1877.

Question 18:

Options:

Gender
Age
Race
Environment

Correct Answer: Race

Explanation:

Question 19:

Which of the following radiographic parameters is most predictive of a poor result following multilevel fusion surgery for adult degenerative scoliosis? Review Topic

Options:

An L5-S1 degenerative disk left out of the fusion
Coronal imbalance
Residual scoliosis of greater than 25 degrees
Residual foraminal stenosis
Sagittal imbalance

Correct Answer: Sagittal imbalance

Explanation:

Question 20:

When performing hip arthroscopy, the hip should be placed in neutral to slight internal rotation to protect which of the following structures? Review Topic

Options:

Femoral nerve
Lateral femoral cutaneous nerve
Ascending lateral femoral circumflex artery
Ascending medial femoral circumflex artery
Sciatic nerve

Correct Answer: Sciatic nerve

Explanation:

Question 21:

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty?

Options:

Improved superior stability
Fixed fulcrum kinematics
Creates a metal-to-bone articulation with the acromion
Increased deltoid moment arm
Increased glenohumeral offset

Correct Answer: Creates a metal-to-bone articulation with the acromion

Explanation:

DISCUSSION: The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.
REFERENCES: Visotsky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg 2000;9:169-172.

Question 22:

Haversian canals are found in the center of an osteon in compact bone. They contain blood vessels and nerves.

Options:

A prosthetic foot which incorporates a multi-axis articulated foot assembly is recommended for which of the following amputees?
Low functioning diabetic who needs to transfer bed to chair
Long distance runner with below knee amputation
Elderly male with above knee amputation
Below knee amputee who needs to regularly walk on uneven ground
year-old male with above knee amputation from osteosarcoma

Correct Answer: Long distance runner with below knee amputation

Explanation:

The multi-axis articulated foot assembly is the best prosthetic for ambulation over uneven ground, and functions best for below knee amputations. Low functioning patients who need a prosthesis for transfers would probably benefit from a solid ankle, cushioned heel prosthesis. Runners and athletes often require high end carbon fiber prostheses. Patients with above knee
amputations have several options to optimize ambulation including solid, energy storing, and multi-axial prothesis.
Aaron et al. reviews the important considerations for patient specific prostheses and new developments on the horizon to maximize ambulation in prosthesis users.
Mesenchymal stem cells have the capacity to differentiate into all the following cell types EXCEPT?
Osteoclasts
Chondrocytes
Adipocytes
Osteoblasts
Fibroblasts
Mesenchymal stem cells are multipotent stem cells which retain the ability to self-renew and to form cells of the mesenchymal lineage. They can therefore form muscle, fat, tendon (made from fibroblasts), bone, cartilage, and the marrow stromal cells. Mesenchymal stem cells do not however form osteoclasts, which are formed from the monocyte lineage - from hematopoietic stem cells.
Caterson et al review the use of mesenchymal stem cells in tissue engineering and regeneration of musculoskeletal tissue.
A 60 year-old male was brought into the operating room for total hip replacement. Before making the incision, what precautionary procedure must be performed by the entire staff to minimize surgical error?
Mark the word "No" on the nonoperative extremities
Use intraoperative fluoroscopic imaging
Perform "timeout"
Have blood products ready in the operating room
Use the newest prosthesis
Surgical "timeout" is now part of the standard procedure which must be performed before starting surgery to minimize surgical error such as wrong site surgery.
Which of the following statements regarding articular cartilage is TRUE?
Cartilage is an isotropic material
Most of the water in articular cartilage exists in the deep layer next to the calcified cartilage
Cartilage only heals if the injury does not pass through the tidemark
Calcified cartilage is the only place that type IV collagen is found
Cartilage exhibits stress shielding of the solid matrix components
Cartilage exhibits significant stress shielding of the solid matrix components due to its high water content, the non-compressibility of water, and the structural organization of collagen and proteoglycans. Cartilage is composed of a permeable porous matrix and 65 to 80% of the total weight of articular cartilage is made up of water. A pressure gradient causes the water to flow through the porous-permeable solid matrix. Significant flow of fluid through the solid matrix requires high hydrodynamic pressures because of the low
permeability of the solid matrix.
The other answers are incorrect because cartilage is anisotropic, most of the water is located in the superficial layers, it only heals if the injury does pass through the tidemark, type X collagen is found in calcified cartilage and is thought to be involved in mineralization. Type IV collagen is found in the basal lamina.
A 38-year-old patient presents 6 months after intramedullary nailing of a distal third tibia fracture with symptoms consistent with complex regional pain syndrome. During the early stage of the disease he was treated with intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Despite these modalities, he continues to have severe and debilitating symptoms. Which of the following treatment options is indicated as a second line of treatment?
Long leg cast immobilization for 3 months
Walking boot with non weight bearing for three months
Exchange nailing to stimulate healing response to the limb
Epidural spinal cord stimulator
Surgical sympathectomy of the affected limb
Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.
The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated.
Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.
Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy
- which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.
Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.
You are planning an intramedullary nail to treat a geriatric patient with a peritrochanteric femur fracture. Which of the following preoperative considerations is correct regarding your implant?
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur
Closed section nails have less stiffness than slotted nails
The medial/lateral nail starting point relative to the greater trochanter does not affect varus/valgus position in the fracture
The bending stiffness of your nail is proportional to the second power of the radius
Intramedullary nails allow for mostly direct intramembranous bone healing
The radius of curvature of an intramedullary nail is generally greater than the radius of curvature of the femur, which is why anterior distal femur
penetration is a known complication of intramedullary nailing procedures.
Egol et al. evaluated the radius of curvature of 948 femurs (474 matched pairs) and compared those data with current intramedullary nails. He found the average femoral anterior radius of curvature was 120 cm (± 36 cm)
whereas the radius of curvature of the intramedullary nails ranged from 186 to 300 cm.
The other answers are incorrect because closed section nails have more stiffness than slotted nails. The starting position on the greater trochanter greatly affects the post- operative varus/valgus of the fracture. Intramedullary nails allow for mostly indirect enchondral bone healing due to relative motion at the fracture site.
All of the following antibiotics function by interfering with protein synthesis by inhibiting ribosomes EXCEPT
gentamicin
tobramycin
vancomycin
erythromycin
linezolid
Gentamicin and tobramycin are aminoglycosides that function by inhibition of bacterial protein synthesis via irreversible binding to ribosomal subunits. Erythromycin functions by binding to the 50s subunit of the bacterial 70s rRNA complex and thereby inhibits protein synthesis. Linezolid binds to the 23s portion of the ribosomal subunit and inhibits protein synthesis. In contrast, Vancomycin acts by inhibiting proper cell wall synthesis and does not inhibit the ribosome.
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant?

Question 23:

When a patient has recurrent anterior shoulder instability, a bony glenoid reconstructive procedure should be considered in which clinical setting?

Options:

Associated humeral avulsion of the glenohumeral ligament (HAGL) lesion
Non-engaging Hill-Sachs lesion
Glenoid bone loss of at least 25%
Anterior labral periosteal sleeve avulsion (ALPSA)

Correct Answer: Glenoid bone loss of at least 25%

Explanation:

Question 24:

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?

Options:

Osteopetrosis
Renal failure
Rickets
Jansen-type metaphyseal dysplasia
Compensatory hyperparathyroidism and no skeletal phenotype

Correct Answer: Rickets

Explanation:

Question 25:

Options:

Adhesive capsulitis
Calcific tendinitis
Anterior shoulder dislocation
Posterior shoulder dislocation
Glenohumeral osteoarthritis

Correct Answer: Posterior shoulder dislocation

Explanation:

DISCUSSION: The patient has a posterior shoulder dislocation. The AP radiograph shows overlapping of the humeral head on the glenoid. The scapular Y view shows his humeral articular surface posterior to the glenoid. The posterior shoulder dislocation is frequently missed because the patient is comfortable in the "sling" position with the arm adducted and internally rotated across the abdomen. The marked restriction in external rotation on examination raises the suspicion of a posterior dislocation, adhesive capsulitis, or glenohumeral osteoarthritis. The posterior dislocation is diagnosed based on the radiographic findings. An axillary view or CT is recommended to better evaluate the dislocation.
REFERENCES: Robinson CM, Aderinto J: Posterior shoulder dislocations and
fracture-dislocations. J Bone Joint Surg Am 2005;87:639-650.
Cicak N: Posterior dislocation of the shoulder. J Bone Joint Surg Br 2004;86:324-332.

Question 26:

Options:

Triple arthrodesis
Isolated flexor digitorum longus transfer
Flexor digitorum longus transfer with medial displacement calcaneal osteotomy
Debridement and direct repair of the posterior tibial tendon
Repair of the spring ligament

Correct Answer: Flexor digitorum longus transfer with medial displacement calcaneal osteotomy

Explanation:

Question 27:

Options:

He may wrestle if his lesions are covered.
He may wrestle if he is on oral antiviral agents for 48 hours.
He may wrestle immediately with no other treatment.
He cannot wrestle until the lesions are scabbed over and there are no new lesions for at least 72 hours.
He cannot wrestle for 2 weeks.

Correct Answer: He cannot wrestle until the lesions are scabbed over and there are no new lesions for at least 72 hours.

Explanation:

Question 28:

..One week after closed reduction of a primary anterior shoulder dislocation, a 25-year-old athlete should be counseled that

Options:

recurrence rate is reduced with 4 weeks of immobilization instead of 2 weeks of immobilization.
age at the time of injury is the most consistent risk factor for recurrent instability.
a majority of patients in this age group will elect to have surgery for recurrent instability.
after an in-season return to sports, his likelihood of choosing surgery after the season is 25%. DISCUSSION.. In a study by Sachs and associates, age younger than 25 years at the time of presentation was found to be the strongest predictor of recurrent instability. In this age group (20-to 29-year-olds), only 14% elected to proceed with surgery. After an in-season return to sports, about 50% of patients in this same study chose to proceed with surgery after completing the season. Immobilization in a sling for longer than 2 weeks has no effect on future instability.

Correct Answer: age at the time of injury is the most consistent risk factor for recurrent instability.

Explanation:

Question 29:

Options:

Improves the bone mineral density of the vertebral bodies
Reduces the strain at the adjacent intervertebral disk
Reduces the stiffness of the posterior instrumentation
Reduces the strain on posterior instrumentation
Increases the strength of the posterior instrumentation

Correct Answer: Reduces the strain on posterior instrumentation

Explanation:

Question 30:

Options:

Conventional osteosarcoma
Myositis ossificans
Osteochondroma
Parosteal osteosarcoma
Dedifferentiated parosteal osteosarcoma

Correct Answer: Dedifferentiated parosteal osteosarcoma

Explanation:

DISCUSSION: Dedifferentiated parosteal osteosarcoma designates high-grade transformation of conventional low-grade parosteal osteosarcoma. Unlike conventional parosteal osteosarcoma, where wide surgical excision alone is considered adequate treatment, patients with dedifferentiated osteosarcoma are treated with neoadjuvant chemotherapy and wide local resection. Recognition of dedifferentiated areas with angiography can localize the area that should be biopsied and thus render an accurate diagnosis. Percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome.
REFERENCES: Sheth DS, Yasko AW, Raymond AK, et al: Conventional and dedifferentiated parosteal osteosarcoma: Diagnosis, treatment, and outcome. Cancer 1996;78:2136-2145.
Lewis VO, Gebhardt MC, Springfield DS: Parosteal osteosarcoma of the posterior aspect of the distal part of the femur: Oncological and functional results following a new resection technique. J Bone Joint Surg Am 2000;82:1083-1088.

Question 31:

In infantile idiopathic scoliosis, which of the following factors suggests progression? Review Topic

Options:

Age at presentation
Rib overlap of the apical vertebra
Rib vertebral angle difference of greater then 10 degrees
Male gender
Family history

Correct Answer: Rib overlap of the apical vertebra

Explanation:

Question 32:

Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?

Options:

Medial plantar
Medial calcaneal
First branch of lateral plantar
Lateral plantar
Lateral calcaneal

Correct Answer: Lateral calcaneal

Explanation:

Question 33:

Options:

Arthroscopic debridement of the glenohumeral joint
Open subscapularis lengthening and cheilectomy
Humeral hemiarthroplasty
Bipolar humeral hemiarthroplasty
Total shoulder arthroplasty

Correct Answer: Total shoulder arthroplasty

Explanation:

Question 34:

Figure 49 shows a histologic section of the lung in a patient who died during total hip arthroplasty. What unexpected finding is seen in the pulmonary capillaries?

Options:

Pulmonary embolism
Methylmethacrylate cement
Hemorrhagic infarct
Granuloma formation
Amyloid

Correct Answer: Methylmethacrylate cement

Explanation:

DISCUSSION: Sudden death during total hip arthroplasty has been reported. In a report from the Mayo Clinic, intraoperative death occurred during cemented total hip arthroplasty in
23 patients. Fat and marrow embolization during preparation of the femur or cementing of the femoral component was believed to be responsible for the cardiopulmonary collapse that occurred during arthroplasty. Although fat and marrow emboli were found in the pulmonary capillaries of most of the patients on autopsy, this histologic section shows two particles of cement in the pulmonary capillaries.
REFERENCES: Parvizi J, Holiday AD, Ereth MH, et al: The Frank Stinchfield Award. Sudden death during primary hip arthroplasty. Clin Orthop 1999;369:39-48.
Patterson BM, Healy JH, Cornell CN, et al: Cardiac arrest during hip arthroplasty with a cemented long-stem component: A report of seven cases. J Bone Joint Surg Am
1991;73:271-277.

Question 35:

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Options:

Males have greater total valgus knee loading.
Females have greater total valgus knee loading.
Males have greater total varus knee loading.
Females have greater total varus knee loading.
There is no gender difference in total varus or valgus knee loading.

Correct Answer: Females have greater total valgus knee loading.

Explanation:

Question 36:

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Options:

surgical correction.
continued casting.
botulinum toxin injection into the gastrocnemius-soleus complex.
an ankle-foot orthosis.
observation with no further treatment.

Correct Answer: surgical correction.

Explanation:

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,
pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,
pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,
pp 2461-2564.

Question 37:

Giant cell tumors of bone can occur in many different areas throughout the body. All of the following are common locations for giant cell tumors of bone EXCEPT?

Options:

Sacrum
Distal radius
Tibial diaphysis
Distal femur
Phalanges of the hand

Correct Answer: Phalanges of the hand

Explanation:

Giant cell tumors are common around the knee, distal radius, sacrum and hands. They are not typically found in the diaphysis of bone.
Giant cell tumors are one of the more common tumors in young adults 22-40 years of age. There is much argument as to whether giant cell tumors arise in the metaphysis or the epiphysis, but most authors agree that giant cell tumors are very uncommon in the diaphysis. The most common sites of giant cell tumors in bone, which are the distal radius, sacrum, distal femur, proximal tibia and proximal humerus. Treatment typically involves intralesional curettage with adjuvant treatment (e.g., phenol, hydrogen peroxide, argon beam, etc).
Williams et al undertook a prospective study to evaulate the recurrence rate of giant cell tumors of the hand and they found that soft tissue extension of the tumor significantly increased the rate of local recurrence. This finding is significant because multiple previous studies have demonstrated similar higher recurrence rates for giant cell tumors with soft tissue extension in other areas like around the knee and the distal radius.
Illustration A are radiographs classic for a giant cell tumor showing a large lytic metaphseal-epiphyseal lesion in the distal femur. Illustration B is an axial CT of the distal femur showing the lytic giant cell tumor, abutting and fracturing the subchondral bone. Illustration C is histology classic for a giant cell tumor where the nuclei of the multi-nucleated giant cells look identical to the nuclei of the stromal cells.
Incorrect Answers:
What is the most appropriate treatment for a 65-year-old female with a 100-pack-year tobacco history who presents with a new painful lytic lesion in her femoral diaphysis?
Antegrade femoral nailing with reamings sent to pathology for analysis
Antegrade femoral nailing with adjuvant radiotherapy to the lesion 3
. Minimally invasive plating of the femur for stabilization and open cementation of the lesion
Referral to medical oncology for chemo-radiotherapy
Lesion biopsy with further treatment based on the results of the biopsy
New lesions which are not diagnosed by imaging and require surgical intervention need to have an appropriate biopsy with treatment dictated by the results of the biopsy. While this patient has a significant tobacco history, incorrect treatment of this lytic bone lesion could affect both her overall morbidity and mortality. As an example, a lytic high-grade chondrosarcoma may look exactly like a metastatic lesion but requires wide surgical excision, not just stabilization of an impending pathological fracture. Intramedullary nailing of a chondrosarcoma would spread the tumor the entire length of the bone and likely require a major amputation, not a limb salvage operation.
A 14-year-old child is referred to your office for evaluation of a tibia lesion found incidentally after a minor ankle injury. A radiograph of the child's ankle is shown in Figure A. What treatment do you suggest?
Endocrine consultation secondary to associated endocrine abnormalities
Surgical consultation secondary to associated gastrointestional cancers
Short leg cast and non-weight bearing for a minimum of 6 weeks
Open biopsy and tumor staging
Routine followup of tibial lesion
The radiograph is classic for a non-ossifying fibroma given the classic eccentric position, sclerotic margin, and benign appearance. Other than routine followup for the tibial lesion, this child requires no subsequent treatment. Marks and Bauer review the diagnosis, imaging, and treatment of many different fibrous tumors of bone and review the diagnostic imaging criteria specific to each subclass of bony fibrous tumors.
The chromosomal translocation t(X;18)is found in which of the following conditions?
Myxoid liposarcoma
Synovial Sarcoma
Osteosarcoma
Ewing's Sarcoma
Clear cell sarcoma
Synovial sarcoma is a rare soft tissue sarcoma with biphasic features of both spindle cell and epithelial differentiation. Synovial sarcoma is a rare high-grade tumor that spreads along fascial planes and, thus, can be much more widespread than apparent on initial evaluation. Males are more commonly affected than females with a ratio of 1.1:1. Synovial sarcoma is characterized by a specific chromosomal translocation t(X;18)(p11;q11) that is observed in more than 90% of cases. The t(X;18)(p11;q11) translocation fuses the SYT gene from chromosome 18 to either of 2 homologous genes at Xp11, either SSX1 or SSX2. The fusion proteins SYT-SSX1 and SYT-SSX2 function as aberrant transcriptional regulators, resulting in either activation of protooncogenes or inhibition of tumor suppressor genes.
Kawai et al found that SYT-SSX fusion transcripts are a defining diagnostic marker of synovial sarcomas. These fusion transcripts may yield important independent prognostic information and provide important information for different types of treatment.
Incorrect Answers

Question 38:

Which of the following best describes the resultant forces on an increased offset stem when compared with a standard offset stem?

Options:

Increased joint reaction force, increased torsional load
Increased joint reaction force, decreased torsional load
Decreased joint reaction force, increased torsional load
Decreased joint reaction force, decreased torsional load
No change in joint reaction force or torsional load

Correct Answer: Decreased joint reaction force, increased torsional load

Explanation:

Question 39:

Options:

open reduction internal fixation of the fibula only
open reduction internal fixation of the tibia and fibula
removal of external fixator and conversion to a walking cast
dynamization of the external fixator
tibio-talar arthrodesis

Correct Answer: open reduction internal fixation of the tibia and fibula

Explanation:

Question 40:

Which of the following medications may have a negative effect on bone healing following fracture?

Options:

COX-1 nonsteroidal anti-inflammatory drugs
Phenytoin
Temazepam
Serotonin reuptake blockers (SSRIs)
Amitriptyline

Correct Answer: COX-1 nonsteroidal anti-inflammatory drugs

Explanation:

Question 41:

03 A 26-year-old woman has chronic toe pain after hitting a bedpost 3 months ago. A radiograph is shown in Figure 27. Her injury represents an avulsion of the

Options:

lumbrical insertion.
extensor digitorum brevis.
extensor digitorum longus.
extensor hallucis longus.
flexor digitorum longus.
back answer Question 105.03

Correct Answer: extensor digitorum longus.

Explanation:

Question 42:

Options:

Wind-up
Early cocking
Late cocking
Acceleration
Deceleration

Correct Answer: Late cocking

Explanation:

Question 43:

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Options:

Cardiovascular collapse
Block failure
Seizure secondary to intravascular injection
Phrenic nerve injury
Laryngeal nerve injury

Correct Answer: Block failure

Explanation:

Question 44:

Options:

Femoral revision with distal augment
MCL allograft reconstruction
Ultracongruent insert
Rotating-hinge TKA

Correct Answer: Rotating-hinge TKA

Explanation:

Question 45:

When comparing arthroscopic and open rotator cuff repairs, which of the following tears shows a decreased recurrent tear rate in the open versus the arthroscopic group? Review Topic

Options:

Partial-thickness tears
Tears less than 1 cm in width
Tears between 1 and 2 cm in width
Tears greater than 3 cm in width
Tears showing retraction medial to the glenoid

Correct Answer: Tears greater than 3 cm in width

Explanation:

Question 46:

A 23-year-old man has pain and a callus beneath the second metatarsal head. Initial management should consist of

Options:

corn pads impregnated with salicylic acid.
paring of the callus and an offloading orthosis.
metatarsal dorsiflexion osteotomy.
metatarsal head excision.
plantar condylectomy.

Correct Answer: paring of the callus and an offloading orthosis.

Explanation:

Question 47:

Options:

MRI of the cervical thoracic lumbar spine
Supine side bending radiographs of the spine
Return to the clinic in 12 months with repeat radiographs
Anterior and posterior spinal fusion with instrumentation
Echocardiogram and renal ultrasound

Correct Answer: MRI of the cervical thoracic lumbar spine

Explanation:

Question 48:

Options:

revision first metatarsal osteotomy.
medial soft-tissue release and lateral plication.
metatarsophalangeal arthrodesis.
transfer of the extensor hallucis longus tendon.
reverse Akin osteotomy of the proximal phalanx.

Correct Answer: metatarsophalangeal arthrodesis.

Explanation:

Question 49:

Options:

Chondrosarcoma
Diffuse fibrous dysplasia
Multiple myeloma
Osteoporosis
Bone infarcts

Correct Answer: Multiple myeloma

Explanation:

Question 50:

Options:

adhesive wear.
abrasive wear.
fatigue wear.
creep.

Correct Answer: fatigue wear.

Explanation:

Question 51:

Options:

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

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

Explanation:

Question 52:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 53:

What is the most common cause of early failure for patellofemoral arthroplasty?

Options:

Progression of tibiofemoral arthritis
Loosening of the femoral trochlear component
Loosening of the patellar component
Patellar instability/maltracking
Rupture of the quadriceps tendon from trochlear component impingement secondary to excessive anterior placement and flexion of the implant

Correct Answer: Patellar instability/maltracking

Explanation:

Question 54:

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

Options:

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

Correct Answer: the surgical margin.

Explanation:

Question 55:

The fracture shown in Figure 32 is strongly indicative of what diagnosis?

Options:

Osteogenesis imperfecta
Vitamin D-resistant rickets
Lead toxicity
Child abuse
Osteomyelitis

Correct Answer: Child abuse

Explanation:

Question 56:

Which of the following is considered a risk factor for the development of low back pain?

Options:

Gender
Facet trophism
Vibration exposure
Weight
Transitional vertebrae

Correct Answer: Vibration exposure

Explanation:

Question 57:

What structure (arrow) is shown in Figure 24?

Options:

Ilioinguinal nerve
Sympathetic chain
Ureter
Iliac vein
L5 nerve

Correct Answer: Sympathetic chain

Explanation:

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 58:

Options:

Pyarthrosis
Pigmented villonodular synovitis
Synovial osteochondromatosis
Charcot arthropathy
Spontaneous osteonecrosis

Correct Answer: Charcot arthropathy

Explanation:

Question 59:

Options:

Rim width
Rim length
Time from injury to repair
Use of a fibrin clot
Whether the tear occurred in the medial versus lateral meniscus

Correct Answer: Rim width

Explanation:

Question 60:

Options:

ultrasound, iontophoresis, and stretching, with an early return to sports.
a local corticosteroid injection and strengthening, with a delayed return to sports.
immobilization and rehabilitation, with a delayed return to sports.
early surgical repair, prolonged rehabilitation, and a return to sports.
rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

Correct Answer: early surgical repair, prolonged rehabilitation, and a return to sports.

Explanation:

Question 61:

Lumbar disk replacement has been shown to offer which of the following results?

Options:

Provides long-term pain relief superior to that achieved with lumbar fusion
Provides long-term pain relief equivalent to that achieved with lumbar fusion
Provides long-term pain relief in patients with symptomatic degenerative disk disease and facet arthropathy
Consistently prevents the development of adjacent segment disease
Consistently restores normal segmental motion

Correct Answer: Provides long-term pain relief equivalent to that achieved with lumbar fusion

Explanation:

Question 62:

Options:

Type 2 tear of the superior labrum anterior and posterior
Tear of the anterior labrum
Tear of the subscapularis tendon
Tear of the latissimus dorsi tendon
Tear of the supraspinatus tendon

Correct Answer: Tear of the latissimus dorsi tendon

Explanation:

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.
Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 63:

- Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Options:

Manipulation Under Anesthesia
Arthroscopic acromioplasty
Arthroscopic debridement of G-H joint
Replacement of the humeral head
Lengthening of the subscapularis and release of the anterior capsule

Correct Answer: Lengthening of the subscapularis and release of the anterior capsule

Explanation:

Question 64:

Figures 9a and 9b are the radiographs of a 19-year-old woman with a painful juvenile bunion. The pathologic findings associated with this deformity include a

Options:

Laterally deviated distal metatarsal articular surface, a
lax or disrupted distal 1-2 transverse intermetatarsal 12
ligament, and a contracted lateral collateral (lateral first
metatarsophalangeal) ligament.
Laterally deviated distal metatarsal articular surface, a contracted lateral collateral (lateral first metatarsophalangeal) ligament, and a medially deviated or hypermobile first metatarsocuneiform joint.
Medially deviated or hypermobile first metatarsocuneiform joint, a lax or disrupted distal 1-2 transverse intermetatarsal ligament, and a contracted lateral collateral (lateral first metatarsophalangeal) ligament.
Lax or disrupted distal 1-2 transverse intermetatarsal ligament, laterally deviated distal metatarsal articular surface, and a medially deviated or hypermobile first metatarsocuneiform joint.

Correct Answer: lax or disrupted distal 1-2 transverse intermetatarsal 12

Explanation:

Question 65:

Options:

External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus
External fixation of the pelvis, external fixation of the distal femur, and intramedullary nailing of the humerus
External fixation of the pelvis, open reduction and internal fixation of the distal femur, and splinting of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and intramedullary nailing of the humerus
Open reduction and internal fixation of the pelvis, open reduction and internal fixation of the distal femur, and open reduction and internal fixation of the humerus

Correct Answer: External fixation of the pelvis, external fixation of the distal femur, and splinting of the humerus

Explanation:

Question 66:

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 67:

Options:

Galvanic
Pitting
Fretting
Crevice

Correct Answer: Fretting

Explanation:

Question 68:

Options:

Long-leg splinting of bilateral lower extremities, monitoring of bilateral pedal pulses for 48 hours
Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals
Perform CT angiography for bilateral lower extremities
Perform CT angiography for the left lower extremity, monitor right pedal pulses for 48 hours
Surgical exploration of bilateral lower extremities

Correct Answer: Intravenous dextran administration, repeat doppler evaluation at 6 hourly intervals

Explanation:

Question 69:

Options:

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

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

Explanation:

Question 70:

Options:

Period of immobilization followed by physical therapy
Local corticosteroid injection
Surgical repair
Platelet-rich plasma (PRP)

Correct Answer: Surgical repair

Explanation:

Question 71:

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

Options:

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

Correct Answer: notification of child protection services

Explanation:

Question 72:

A 22-year-old woman sustains the injury seen in Figure 12 as a result of a motor vehicle crash. What factor is most closely associated with development of osteonecrosis?

Options:

Reduction quality
Time from injury to surgery
Presence or absence of a capsulotomy
Type of implant used for internal fixation
Location of the fracture within the femoral neck

Correct Answer: Reduction quality

Explanation:

A displaced femoral neck fracture in a young patient is considered a surgical urgency and prompt anatomic reduction and internal fixation is recommended. There are a few studies that have specifically looked at the rate of osteonecrosis in this patient population. A review of femoral neck fractures in patients ages 15 to 50 years revealed that the incidence of osteonecrosis in displaced fractures was 27% compared with 14% in nondisplaced fractures. The quality of the reduction also influenced the rate of osteonecrosis. Time to reduction, type of implant, presence or absence of capsulotomy, and location of the fracture are not associated with osteonecrosis risk.
(SBQ12TR.90) A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?
Review
Topic
MRI angiography of leg
Four-compartment fasciotomy
Follow-up examination the following day
Continued monitoring and serial examinations
EMG study
The patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.
A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam.
An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinical diagnosis persists despite these efforts, urgent fasciotomy would be considered.
McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.
White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.
Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.
Incorrect Answers:
30 mm Hg or persistently elevated absolute compartment pressures.. Answer 3: It would not be appropriate to leave this patient with impending compartment syndrome.
(SBQ12TR.57) A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on the available imaging, which of the following fracture characteristics best justifies this fixation choice?
Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on inter-fragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
congruity but does not dictate implant selection. Answer 3. Extension distal to the coronoid is an indication for plate fixation but there is no evidence of such extension on the radiograph shown Answer 4. This fracture is comminuted, without a distinct fracture line.

Question 73:

What is the primary concern for arthrodesis of a failed infected total knee arthroplasty using internal fixation?

Options:

Recurrent infection
Lack of stability
Lack of soft-tissue coverage
Stress shielding
Stress risers

Correct Answer: Recurrent infection

Explanation:

Question 74:

Options:

shoulder arthroscopy and repair of a possible labral tear.
anterior capsulorrhaphy for subtle anterior instability.
diagnostic arthroscopy of the glenohumeral joint and arthroscopic subacromial decompression.
rest from pitching, initiation of a rehabilitation program to restore internal rotation, and scapular stabilization.
rest from pitching and a corticosteroid injection into the subacromial space.

Correct Answer: rest from pitching, initiation of a rehabilitation program to restore internal rotation, and scapular stabilization.

Explanation:

Question 75:

Pacinian corpuscles are lamellated nerve endings that are responsible for providing the perception of

Options:

pain.
light touch.
pressure.
temperature.
vibration.

Correct Answer: pressure.

Explanation:

Question 76:

Options:

Plantar fasciitis
Seronegative inflammatory arthritis
Stress fracture of the calcaneus
Tarsal tunnel syndrome
Peripheral neuropathy

Correct Answer: Stress fracture of the calcaneus

Explanation:

Question 77:

Options:

Cast removal and measurement of carpal canal pressure
Immediate carpal tunnel release and pinning of the fracture
Continued observation
Surgical reduction and pinning of the fracture
Electromyography/nerve conduction velocity studies

Correct Answer: Immediate carpal tunnel release and pinning of the fracture

Explanation:

DISCUSSION: The patient has an evolving acute carpal tunnel syndrome. Initial management for this injury is to relieve all external pressure that may elevate the neural compression. Surgical decompression of the median nerve at the carpal tunnel is the optimal intervention. Further nonsurgical interventions (cast removal or further bivalving) are insufficient to alleviate the neural compression.
REFERENCES: Waters PM, Mih AD: Fractures of the distal radius and ulna, in Beaty JH, Kasser JR (eds): Fractures in Children, ed 6. Philadelphia, PA, Lippincott, 2006, p 361.
Paley D, McMurtry RY: Median nerve compression by volarly displaced fragments of the distal radius. Clin Orthop Relat Res 1987;215:139-147.

Question 78:

A healthy 65-year-old woman undergoes anatomic total shoulder arthroplasty to address osteoarthritis (OA). The surgery is uncomplicated. What is the most common indication for future revision?

Options:

Deep infection
Periprosthetic fracture
Glenoid component loosening
Rotator cuff tear

Correct Answer: Glenoid component loosening

Explanation:

Question 79:

Options:

unrecognized injury to the recurrent motor branch.
neuropraxia of the proper palmar digital nerve.
new-onset stenosing flexor tenosynovitis.
injury to the flexor digitorum profundus to the index finger.

Correct Answer: neuropraxia of the proper palmar digital nerve.

Explanation:

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If
it were injured, the result would not be weakness of interphalangeal joint extension.

Question 80:

Figures 49a and 49b show MRI scans of the shoulder. What is the most likely diagnosis?

Options:

Rotator cuff tear
Normal anatomic variant
Stage II impingement
Bankart lesion
Acromioclavicular grade II sprain

Correct Answer: Rotator cuff tear

Explanation:

Question 81:

Titanium and its alloys are unsuitable candidates for which of the following implant applications?

Options:

Fracture plates
Femoral heads in a hip prosthesis
Bone screws
Intramedullary nails
Porous coatings for bone ingrowth

Correct Answer: Femoral heads in a hip prosthesis

Explanation:

Question 82:

Which of the following is most frequently associated with heterotopic ossification about the shoulder?

Options:

Acute anterior dislocation
Acute posterior dislocation
Multiple attempts at closed reduction of chronic unreduced fracture-dislocations
Immediate open reduction and internal fixation of greater tuberosity fractures
Open reduction of midshaft clavicular fractures

Correct Answer: Multiple attempts at closed reduction of chronic unreduced fracture-dislocations

Explanation:

Question 83:

Options:

observation and splinting.
local wound drainage under local anesthesia.
incision and drainage, deep wound cultures, removal of the plates and screws, and cast application.
incision and drainage, deep wound cultures, and removal of the fixation only if it is loose.
incision and drainage, deep wound cultures, and bone grafting.

Correct Answer: incision and drainage, deep wound cultures, and removal of the fixation only if it is loose.

Explanation:

Question 84:

Options:

Adductor tenotomy
Physical therapy
Observation
Abduction orthosis
Neurologic consultation

Correct Answer: Observation

Explanation:

Question 85:

Options:

Extended medial parapatellar approach
Quadriceps snip
Extended tibial tubercle osteotomy
Medial epicondyle osteotomy

Correct Answer: Extended tibial tubercle osteotomy

Explanation:

Question 86:

Options:

Tenotomy with medial transfer
Tenotomy with soft-tissue tenodesis
Tenotomy with tenodesis using suture anchors
Tenotomy with tenodesis using bone tunnels
Tenotomy with tenodesis using an interference screw

Correct Answer: Tenotomy with tenodesis using an interference screw

Explanation:

DISCUSSION: Recent articles have looked at the cyclic load failure and ultimate load failure of biceps tenodesis techniques. The interference screw has proved superior to bone tunnel, suture anchor, and soft-tissue tenodesis techniques in laboratory cadaveric testing. Whether this is clinically relevant or not is still unknown.
REFERENCES: Ozalay M, Akpinar S, Karaeminogullari O, et al: Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21:992-998.
Richards DP, Burkhart SS: A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy 2005;21:861-866.

Question 87:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

Question 88:

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Options:

Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss
A net negative change in calcium balance because of a decrease in intestinal absorption and a lesser decrease in urinary calcium loss
An increase of intestinal resorption with an increase of free 1,25-dihydroxyvitamin D
Loss of estrogen stimulating loss of calcium via increased PTH levels and subsequent decreased renal tubular absorption of calcium
No true change in calcium metabolism, but rather a net increased turnover of bone because of a decrease in circulating estrogen

Correct Answer: Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss

Explanation:

DISCUSSION: There is a negative change of calcium balance with a decrease
in intestinal absorption and an increase in urinary calcium loss. The reduction of
intestinal absorption is accompanied by reduced circulating concentrations of total, but
not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 89:

Options:

A quantitative defect of type I collagen synthesis
A deficiency of vitamin D
Parental abuse
Abnormal osteoclast function
Excess excretion of keratin sulfate in the urine

Correct Answer: A quantitative defect of type I collagen synthesis

Explanation:

Question 90:

Options:

Plantar fasciitis
Calcaneal apophysitis
Achilles tendinitis
Calcaneal bursitis
Stress fractures of the calcanei

Correct Answer: Calcaneal apophysitis

Explanation:

Question 91:

Options:

Hip spica cast placement
Acetabular revision arthroplasty
Resection arthroplasty
Femoral head revision to a 28-mm diameter, +10-mm length head

Correct Answer: Acetabular revision arthroplasty

Explanation:

Question 92:

A 30-year-old woman sustained a nondisplaced unilateral facet fracture of C5 in a motor vehicle accident. She is neurologically intact and has no other injuries. Management should consist of

Options:

skeletal tong traction for 6 weeks.
halo application.
immobilization in a rigid collar for 6 weeks.
open reduction posteriorly with interspinous wiring and bone grafting.
open reduction anteriorly with diskectomy, interbody grafting, and plating.

Correct Answer: immobilization in a rigid collar for 6 weeks.

Explanation:

Question 93:

Options:

return to play immediately.
return to play in 1 week, if asymptomatic.
return to play in 1 month, if asymptomatic.
return only after a screening CT scan.
not return to play for the season.

Correct Answer: return to play immediately.

Explanation:

Question 94:

Options:

MRI with metal artifact reduction sequence (MARS) only. B. serum cobalt only.
serum cobalt and chromium levels.
serum cobalt and chromium levels and MRI with MARS.

Correct Answer: MRI with metal artifact reduction sequence (MARS) only. B. serum cobalt only.

Explanation:

Question 95:

Options:

High-energy mechanism of injury
Use of un-reamed nail
Implant material
Fracture gap
History of smoking

Correct Answer: High-energy mechanism of injury

Explanation:

Question 96:

What cell type causes the bone destruction in metastatic lesions?

Options:

Osteoblast
Osteoclast
Macrophage
T lymphocyte
Null killer cells

Correct Answer: Osteoclast

Explanation:

Question 97:

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

Options:

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

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

Explanation:

Question 98:

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

Options:

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

Correct Answer: a reduced risk for revision surgery.

Explanation:

Question 99:

What is the most common site of nerve compression in radial tunnel syndrome?

Options:

Fibrous bands anterior to the radiocapitellar joint
Recurrent radial vessels
Medial edge of the extensor carpi radialis brevis (ECRB)
Proximal aponeurotic edge of the supinator (arcade of Frohse) Radial tunnel syndrome occurs as the result of radial nerve compression at 5 potential sites. These are the fibrous bands anterior to the radiocapitellar joint, the radial recurrent vessels (known as the leash of Henry), the medial edge of the ECRB, the proximal aponeurotic edge of the supinator (arcade of Frohse), and the distal edge of the supinator. The arcade of Frohse is the most common site of compression. The chief discomfort is deep, aching pain in the dorsoradial proximal forearm. Motor and sensory symptoms usually are absent. This condition often is seen when pain persists after surgery for lateral epicondylitis. Lateral epicondylitis and radial tunnel syndrome coexist 5% of the time. Examination findings are tenderness 4 cm distal to the lateral epicondyle, pain with resisted supination, and pain with resisted long finger extension. Electromyogram/nerve conduction study and MRI results usually are normal. A steroid injection can be diagnostic and also may provide temporary relief of symptoms. Surgery involves decompression of all potential areas of compression and allows good to excellent results in only 50% to 90% of cases. Symptoms may take 9 to 18 months to resolve after surgery.

Correct Answer: Proximal aponeurotic edge of the supinator (arcade of Frohse) Radial tunnel syndrome occurs as the result of radial nerve compression at 5 potential sites. These are the fibrous bands anterior to the radiocapitellar joint, the radial recurrent vessels (known as the leash of Henry), the medial edge of the ECRB, the proximal aponeurotic edge of the supinator (arcade of Frohse), and the distal edge of the supinator. The arcade of Frohse is the most common site of compression. The chief discomfort is deep, aching pain in the dorsoradial proximal forearm. Motor and sensory symptoms usually are absent. This condition often is seen when pain persists after surgery for lateral epicondylitis. Lateral epicondylitis and radial tunnel syndrome coexist 5% of the time. Examination findings are tenderness 4 cm distal to the lateral epicondyle, pain with resisted supination, and pain with resisted long finger extension. Electromyogram/nerve conduction study and MRI results usually are normal. A steroid injection can be diagnostic and also may provide temporary relief of symptoms. Surgery involves decompression of all potential areas of compression and allows good to excellent results in only 50% to 90% of cases. Symptoms may take 9 to 18 months to resolve after surgery.

Explanation:

Question 100:

Options:

Supervised physical therapy
Arthroscopic capsulorrhaphy and labral repair
Open shoulder capsulorrhaphy and labral repair
Open shoulder capsulorrhaphy and bone block
Shoulder arthrodesis

Correct Answer: Open shoulder capsulorrhaphy and bone block

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

OITE & ABOS Orthopedic Board Prep: Hip, Ankle, Fracture & Arthroplasty MCQs Part 100

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 100

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index