OITE & ABOS Orthopedic MCQs: Foot & Trauma | Part 110

About This Board Review Set

This is Part 110 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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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 110

This module focuses heavily on: Ankle, Foot, Fracture, Nerve, Shoulder.

Sample Questions from This Set

Sample Question 1: The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?...

Sample Question 2: A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsifl...

Sample Question 3: Which of the following findings is more suggestive of neurogenic rather than vascular claudication in the differential diagnosis of leg pain?...

Sample Question 4: A 29-year-old woman reports dysesthesias and burning after undergoing bunion surgery that consisted of a proximal crescentic first metatarsal osteotomy 6 months ago. Examination reveals a positive Tinel’s sign at the proximal aspect of the ...

Sample Question 5: A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

The management of a complex multifragmentary diaphyseal fracture of either the tibia or femur has changed during the last decade. Which of the following principles of treatment is now considered less important?

Explanation

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,

pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 2

A patient with diabetic peripheral neuropathy undergoes a partial first ray amputation for a chronic ulcer beneath the first metatarsal head. The insertion of the anterior tibialis is preserved. The patient has 10 degrees of passive dorsiflexion at the ankle and no other foot deformities or ulcers. Which of the following is considered appropriate shoe wear for this patient?

Explanation

DISCUSSION: The steel shank is a flat 1-inch steel strip placed between layers of the shoe to extend the foot lever and prevent deformity at the toe break seen following a partial first ray amputation. A rocker sole may be added as well to facilitate transition from foot flat to the toe-off phase of gait. Proper shoe fit is important, but “snug” fitting shoes in a patient with peripheral neuropathy and likely fluctuations in volume from intermittent swelling are to be avoided. A custom shoe is an unnecessary expense. The patient has at least 10 degrees of dorsiflexion at the ankle with an intact anterior tibialis muscle; therefore, catching the sole on carpeting should not be a problem.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, et al: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Pinzur MS, Dart HC: Pedorthic management of the diabetic foot. Foot Ankle Clin 2001;6:205-214.

Question 3

Which of the following findings is more suggestive of neurogenic rather than vascular claudication in the differential diagnosis of leg pain?

Explanation

All of the answers except answer 3 are suggestive of vascular claudication. Additional signs and symptoms of vascular claudication include diffuse aching/cramping/tired pain that is worse with exertion, is usually in the calves (also may be in feet, thighs, hips, and buttocks). Neurogenic claudication, on the other hand, usually is sharply painful, occurs in the back, buttocks, thighs, calves; is worse with spine extension and walking; is better/less with spine flexion and lying recumbent; pulses and skin are unaffected.

Question 4

A 29-year-old woman reports dysesthesias and burning after undergoing bunion surgery that consisted of a proximal crescentic first metatarsal osteotomy 6 months ago. Examination reveals a positive Tinel’s sign at the proximal aspect of the healed incision. What injured nerve is responsible for her continued symptoms?

Explanation

DISCUSSION: Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.
REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 5

A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder

Explanation

The axial MRI scan shows rupture of the subscapularis tendon with dislocation of the biceps tendon. Treatment should include a biceps tenotomy or tenodesis in conjunction with a subscapularis repair. A pectoralis major transfer may be necessary in chronic cases where the subscapularis is irreparable, but in this patient the tendon is repairable. As a single operation, biceps tenolysis will not correct the instability, and would likely result in a cosmetic deformity. Physical therapy will not restore subscapularis function.

Question 6

In the anterior cruciate ligament (ACL)-deficient knee, which of the following variables has the highest correlation with the development of arthritis?

Explanation

DISCUSSION: Ample evidence supports an increased rate of degenerative arthritis in the ACL-deficient knee. Several variables play a role in the development of the arthritis, but the integrity of the meniscus has been shown to be the single most important factor.
REFERENCES: O’Brien WR: Degenerative arthritis of the knee following anterior cruciate ligament injury: Role of the meniscus. Sports Med Arthroscopy Rev 1993;1:114-118.
Fetto JF, Marshall JL: The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 1980;147:29-38.
McDaniel WJ Jr, Dameron TB Jr: The untreated anterior cruciate ligament rupture. Clin Orthop 1983;172:158-163.

Question 7

Figures 11a and 11b show the clinical photograph and radiograph of a newborn. Based on these findings, what is the best course of action?

Explanation

DISCUSSION: The newborn has posteromedial bowing of the tibia and calcaneal valgus deformity of the foot. Both are thought to be caused by abnormal intrauterine positioning. The foot deformity typically responds to stretching. The tibial bowing straightens with growth. The long-term problem is limb-length discrepancy.
REFERENCES: Heyman CH, Herndon CH, Heiple KG: Congenital posterior angulation of the tibia with talipes calcaneus. J Bone Joint Surg Am 1959;41:476-488.
Hofmann A, Wenger DR: Posteromedial bowing of the tibia: Progression of discrepancy in leg lengths. J Bone Joint Surg Am 1981;63:384-388.

Question 8

Bioabsorbable polymers are used in a wide range of orthopaedic devices, including anchors, staples, pins, plates, and screws. What is the primary drawback for bioabsorbable implants?

Explanation

DISCUSSION: A number of bioabsorbable polymers are used in orthopaedic applications, and all have in common reports of foreign body reactions, which occur in more than 50% of patients in some series. In general, the high cost of these polymers is offset by the elimination of a second surgery to remove the implant. Bioabsorbable polymers are low strength in comparison to metallic alloys but of sufficient strength for many orthopaedic applications. The elastic modulus is not as high as many other orthopaedic biomaterials, making them suitable for applications where lower stiffness is an asset.
REFERENCES: Ambrose CG, Clanton TO: Bioabsorbable implants: Review of clinical experience in orthopedic surgery. Ann Biomed Eng 2004;32:171-177.
Bergsma JE, de Bruijn WC, Rozema FR, et al: Late degradation tissue response to poly

(L-lactide) bone plates and screws. Biomaterials 1995;16:25-31.

Question 9

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. Radiographs of the player’s right ankle confirm there are no fractures. With a lateral talar tilt test result of 19°, which additional structure is most likely damaged?

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 10

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

Explanation

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

Question 11

An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?

Explanation

DISCUSSION: A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other
radiographic findings consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique).

Question 12

-The patient has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they “want to get the therapy over with as fast as possible” to expedite his return to sports,and the surgeon and rehabilitation team consider their request. Compared to nonaccelerated rehabilitation,patients who follow an early accelerated rehabilitation protocol experience

Explanation

DISCUSSION FOR QUESTIONS 44 AND 45
The Lachman test is the most sensitive examination for acute ACL injuries. ACL injury rates are higher in women than in men. This likely is attributable to anatomic differences (smaller notches, smaller ligaments, and different landing biomechanics). Lateral meniscal tears are more common than medial tears. The anterior drawer test is accentuated with 30 degrees of external rotation of the tibia. The MRI scan shows bone bruises consistent with an ACL tear. It is also always necessary to examine other structures of the knee in patients with ACL tears. All ligaments of the affected knee should be assessed.Lateral meniscal tears are frequently associated with ACL tears. Medial meniscal tears and posterolateral corner deficiency are also possible. Randomized clinical trials comparing an early accelerated vs nonaccelerated rehabilitation have demonstrated no significant differences in long-term results. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 13

What is the most common causative bacteria in septic arthritis in children?

Explanation

DISCUSSION: The spectrum of causative bacteria and frequency of occurrence of specific pathogens in septic arthritis are similar to those seen in osteomyelitis, with Staphylococcus aureus being the most common. Other common causative organisms include Kingella Kingae, Streptococcus pneumonia, Klebsiella species, Salmonella, Brucella melitensis, and Haemophilus influenzae.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, p 2109.
Jackson MA, Nelson JD: Etiology and medical management of acute suppurative bone and joint infections in pediatric patients. J Pediatr Orthop 1982;2:313-323.

Question 14

Figures 1 through 3 are the radiographs of a 27-year-old man who has had wrist pain since falling 1 day ago. Which treatment offers the best prognosis for prevention of carpal collapse and progressive arthritis?

Explanation

EXPLANATION:
Although this patient’s history includes a recent fall, the radiographs show evidence of a scaphoid nonunion with carpal collapse but no arthritis. Obtaining union of the scaphoid is important to prevent progressive carpal collapse and arthritic changes. ORIF with bone graft is most appropriate to obtain union and correct the collapse deformity. Screw fixation with volar wedge graft often is performed to realign a scaphoid humpback deformity, although cancellous bone graft also is a reasonable option. Vascularized bone graft is considered for a nonunion of long duration, avascular necrosis of the proximal pole, and failed prior surgery. Cast immobilization will not lead to union of the scaphoid. Percutaneous screw fixation is not indicated for the treatment of a displaced nonunion. A proximal
row carpectomy is a salvage procedure and is not indicated for this patient because there are no arthritic changes.

Question 15

CLINICAL SITUATION Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. Based on the radiographs shown in Figures 1 and 2, her tibia is a

Explanation

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone nonunions, especially in the femur.

Question 16

A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Explanation

Subscapularis repair-Traumatic rupture of the tendon of the subscapularis muscle is caused by forceful hyperextension or external rotation of the adducted arm. A simple clinical maneuver called the "lift-off test", reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon.

Question 17

A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Explanation

Neurogenic shock is defined as vascular hypotension with bradycardia as a result of spinal injury. The first few minutes after spinal cord injury are associated with hypertension and tachycardia, with a subsequent drop in pressure and pulse rate.

Question 18

A 65-year-old man has a painful right hip mass that has been growing for several years. A radiograph, CT scan, and photomicrograph are shown in Figures 56a through 56c. What is the most appropriate treatment?

Explanation

DISCUSSION: This is a conventional chondrosarcoma. The radiograph and the CT scan show a lesion arising from the inferior pubic ramus with a large soft-tissue mass. Abundant punctate, stippled, or “popcorn-like” calcification is present. The photomicrograph demonstrates hypercellular cartilage. Surgical resection is the only effective treatment. Whereas chemotherapy might play a role in the treatment of a dedifferentiated chondrosarcoma, it has no role in the treatment of a conventional chondrosarcoma. Chondrosarcomas are relatively radioresistant.
REFERENCES: Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530.
Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome.

J Bone Joint Surg Am 1999;81:326-338.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.

Question 19

A 7-year-old boy sustained an acute puncture wound of the foot after stepping barefoot on a piece of glass 1 day ago. His mother states that she is not sure if she got the piece of glass out; however, she reports that his immunizations are up-to-date. Examination reveals that the wound is slightly erythematous, less than 1 mm in length on the heel, and is not currently draining. What is the next most appropriate step im management?

Explanation

DISCUSSION: The child has an up-to-date tetanus; therefore, a booster is not recommended. Pseudomonas coverage is most likely not needed because the child was barefoot. It is too early to evaluate for abscess or osteomyelitis with MRI, and a formal debridement is rarely indicated without signs of an abscess or a retained foreign body. Radiographs with soft-tissue penetration should be obtained to check for a retained foreign body.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 199-205.
DeCoster TA, Miller RA: Management of traumatic foot wounds. J Am Acad Orthop Surg 1994;2:226-230.

Question 20

Which of the following variables has been shown to have the greatest influence on the higher rate of anterior cruciate ligament (ACL) tears in women when compared to men for similar sports?

Explanation

DISCUSSION: All of the variables have been proposed as possible causes for the increased incidence of ACL tears in women versus men. The general differences in the level of neuromuscular training however, specifically conditioning and muscle strength, have been shown to play the greatest role.
REFERENCES: Harmon KJ, Ireland ML: Gender differences in noncontact anterior cruciate ligament injuries. Clin Sports Med 2000;19:287-302.
Arendt EA: Knee injury patterns among men and women in collegiate basketball and soccer. Am J Sports Med 1995;23:694-701.
Rozzi SL, Lephart SM, Gear WS, Fu FH: Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players. Am J Sports Med 1999;27:312-319.

Question 21

Figure 45 shows the radiograph of a 2-year-old patient who has progressive lumbar scoliosis as the result of hemivertebra. Examination reveals no associated cutaneous lesions, and an MRI scan shows no associated intraspinal anomalies. Treatment should consist of

Explanation

DISCUSSION: In a retrospective review of 10 patients treated with hemivertebra excision for hemivertebra in the levels of T12 to L3, the procedure was found to be safe and effective. The procedure provided an average curve correction of 67° and was greatest in patients who were younger than age 4 years at the time of surgery. Long anterior and posterior fusion with instrumentation is not the treatment of choice at this age. Either anterior hemiepiphyseodesis or posterior hemiarthrodesis in this isolated hemivertebra setting would be inadequate. Brace treatment is ineffective in management of the primary curvature.
REFERENCE: Callahan BC, Georgopoulos G, Eilert RE: Hemivertebral excision for congenital scoliosis. J Pediatr Orthop 1997;17:96-99.

Question 22

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Explanation

DISCUSSION: The decreased mobility of the polymer chains from cross-linking leads to decreased volumetric wear but also to decreases in ductility and fatigue resistance. Stresses at the knee are higher and varied in the point of application, leading to the concern for fatigue resistance and fracture.
REFERENCE: Koval KJ (ed): Orthopaedic Knowlegde Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 193-199.

Question 23

Hamstring lengthening and posterior transfer of the rectus femoris will be most successful in a patient with cerebral palsy who has which of the following gait abnormalities?

Explanation

DISCUSSION: Children with cerebral palsy typically ambulate with a crouched gait characterized by excessive flexion of the hips and knees during stance. Many patients exhibit co-contracture of the quadriceps and hamstrings, causing a stiff-knee gait. Normally, the rectus femoris fires at the initiation of swing and in terminal swing through initial contact. Prolonged activity of the rectus femoris throughout the swing phase interferes with normal knee flexion. This contributes to a stiff knee during swing phase and prevents clearance of the foot. Lengthening of the hamstrings alone will not improve foot clearance. Hamstring lengthening is contraindicated when there is hyperextension during stance. Transfer of the rectus femoris to one of the knee flexors has been shown to improve knee flexion during swing by an average of 15°. This allows improved foot clearance.
REFERENCES: Gage JR, Perry J, Hicks RR, Koop S, Werntz JR: Rectus femoris transfer to improve knee function of children with cerebral palsy. Dev Med Child Neurol 1987;29:159-166.
Sutherland DH, Santi M, Abel MF: Treatment of stiff-knee gait in cerebral palsy: A comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release. J Pediatr Orthop 1990;10:433-441.

Question 24

A 63-year-old woman is seen 10 weeks after sustaining a closed minimally displaced distal radius fracture. She has been in a short-arm cast and reports minimal pain but notes that she is having difficulty using her thumb. An extensor pollicis longus (EPL) tendon rupture is suspected. Which examination finding would confirm lack of EPL function?

Explanation

EXPLANATION:
As many as to 5% of patients with a nondisplaced distal radius fracture experience EPL rupture. The extensor pollicis brevis (EPB) tendon often attaches to the extensor hood and sometimes continues more distally, providing weak metacarpophalangeal extension even in the setting of EPL disruption. However, because of the vector of its pull, the EPB cannot extend the thumb dorsal to the plane of the palm. A positive Froment sign is noted when flexion of the thumb interphalangeal joint with an attempted key pinch is caused by adductor pollicis weakness from ulnar nerve dysfunction. Compression of the median nerve in the carpal tunnel affects the recurrent motor branch of the abductor pollicis brevis, leading to thenar atrophy. The flexor pollicis longus tendon (FPL) is intact so the patient would not have difficulty flexing the thumb with the palm flat.

Question 25

A 25-year-old man sustained a head injury after being ejected from his car. Examination reveals a Glasgow Coma Scale score of 7 and a swollen right knee. Clinical examination shows that the knee is very unstable, suggesting tears of the medial collateral and anterior and posterior cruciate ligaments, as well as the posterior lateral corner. What is the most appropriate first step to rule out a vascular injury?

Explanation

DISCUSSION: A knee dislocation carries the potential for an arterial injury and has always brought up the question of need for arteriography to rule out this limb-threatening injury. However, arteriography has an inherent complication rate that may compromise the general care of the patient. In over 240 published cases with documented knee dislocations that were evaluated for vascular injury by physical examination (without imaging studies), not a single missed injury was reported, for a 100% negative predictive value (0% false-negative rate). This degree of accuracy at excluding major vascular injury is unsurpassed by the results obtained with arteriography but with no risk involved and a marked savings in time, equipment, and costs. Therefore, the most appropriate first step to rule out vascular injury is examination of the pedal pulses. If there is any doubt about an arterial injury, another option is the ankle-brachial index (ABI). If the ABI is greater than 0.9, the chance of arterial injury is again nonexistent. However, a positive physical examination or an ABI of less than 0.9 is not 100% predictive of an arterial injury; therefore, arteriography is recommended.
REFERENCES: Miranda FE, Dennis JW, Veldenz HC, et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: A prospective study. J Trauma 2002;52:247-252.
Mills WJ, Barei DP, McNair P: The value of the ankle-brachial index for diagnosing arterial injury afterknee dislocation: A prospective study. J Trauma 2004;56:1261-1265.

Question 26

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Explanation

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 27

Figure 11 shows the anatomic dissection of the medial side of the knee joint after removal of the superficial fascia. The arrow is pointing to what structure?

Explanation

DISCUSSION: The semitendinosus and gracilis tendons lie beneath the superficial fascia and superficial to the medial collateral ligament. The semitendinosus is located more inferior to the gracilis tendon. The sartorius is more posterior and distal as is the medial collateral ligament. The semimembranosus is posterior.
REFERENCES: Pagnani MJ, Warner JJ, O’Brien SJ, Warren RF: Anatomic considerations in harvesting the semitendinosus and gracilis tendons and a technique of harvest. Am J Sports Med 1993;21:565-571.
Warren LF, Marshall JL: The supporting structures and layers on the medial side of the knee: An anatomical analysis. J Bone Joint Surg Am 1979;61:56-62.

Question 28

Figure 13a shows the radiograph of a 9-year-old girl who sustained complete transverse fractures of the radial and ulnar shafts while in-line skating. A manipulative closed reduction is performed, and the result is seen in Figure 13b. What is the next most appropriate step in management?

Explanation

DISCUSSION: Bayonet apposition of the radius and ulnar shafts is quite acceptable, as long as the angulation is less than 10 degrees. The rotation must be acceptable as well. This patient went on to full healing, with full supination and pronation of the forearm and no cosmetic deformity.
REFERENCES: Price CT, Scott DS, Kurzner ME, Flynn JC: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-712.
Vittas D, Larsen E, Torp-Pedersen S: Angular remodeling of midshaft forearm fractures in children. Clin Orthop 1991;265:261-264.

Question 29

Figures 122a and 122b are the radiographs of a 79-year-old woman with a 2-year history of progressively worsening right hip pain. She had a right total hip arthroplasty 7 years prior. An infection workup is negative. She opts for revision surgery; the most appropriate surgical plan to address her femoral component is

Explanation

DISCUSSION
The patient’s radiographs show loosening of the cemented femoral stem and varus remodeling of the femur. An extended trochanteric osteotomy is necessary because attempting to extract the existing prosthesis and implant another prosthesis without an osteotomy is likely to cause a proximal femoral fracture. Also, an osteotomy would facilitate atraumatic removal of the stem and cement. Cementless fixation is likely to produce a more predictable long-term outcome than cemented fixation for the revision implant.

Question 30

Reconstruction of the injured structure is performed. After surgery, the patient initially notes limitation in motion, and later develops recurrent instability of the knee. Which factor most likely contributed to the development of instability?

Explanation

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to 63 the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056. View Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068. View Abstract at PubMed

Question 31

A 35-year-old rock climber sustains an L1 burst fracture from a 30-foot fall while climbing. He sustained no other fractures or serious injuries. He is neurologically intact and has minimal posterior tenderness without increased spinous process separation on examination. Radiographs reveal kyphosis of 20 degrees between T12 and L2 with 30% vertebral height loss. A CT scan shows 55% canal compromise. What is the most appropriate management? Review Topic

Explanation

Wood and associates have shown that the use of a TLSO or a body jacket was equally effective as surgery for the treatment of thoracolumbar burst fractures without neurologic deficit. The only difference in any of the measured parameters (including pain, functional outcome, residual canal compromise, and kyphosis) was a decreased complication rate in the nonsurgical group compared with the surgical group. The maximum time to mobilization in the nonsurgical group was 5 days.

Question 32

An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Explanation

Treatment of an early infection demands thorough debridement of the wound and appropriate parenteral antibiotics. Systemic treatment with appropriate antimicrobial agents should continue for a minimum of 4 weeks following debridement for an early infection. An infection diagnosed later than 4 weeks following surgery is less likely to have a successful result without removal of the components. OKU V pg. 490.
Arthroscopic debridement not recommended secondary to missing cutaneous tracks and soft tissue/muscle involvement.

Question 33

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

DISCUSSION: The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated.
REFERENCES: Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.
Angermann P, Hougaard D: Chronic Achilles tendinopathy in athletic individuals: Results of nonsurgical treatment. Foot Ankle Int 1999;20:304-306.

Question 34

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Explanation

Closed treatment of humeral shaft fractures with functional bracing is indicated in the vast majority of isolated injuries. An ipsilateral brachial plexus injury, however, is a contraindication to nonoperative management in a functional brace.
Indications for operative management of humeral shaft fractures are limited given the high rates of union and ability of adjacent joints to compensate for deformity. Intact muscular tone is necessary to effect bony apposition in closed treatment with a functional brace. The absence of neurologic and muscle function in patients with a flail extremity leads to increased rates of nonunion and malunion.
Rutgers and Ring conducted a retrospective review of patients managed with functional bracing of humeral shaft fractures at a single institution. The authors found a 90% overall union rate, with maintenance of shoulder and elbow motion. They caution though, that 29% of their proximal third fractures went on to nonunion.
Figure A demonstrates an AP radiograph of a comminuted humeral shaft fracture with varus alignment.
Incorrect Answers:

Question 35

A 14-year-old boy has failed physical therapy management for Scheuermann kyphosis, and an extension thoracolumbosacral orthosis brace is recommended. The boy and his parents are told that the brace will force his thoracic spine into normal sagittal alignment and put the anterior vertebral bodies of the thoracic segment into tension, which will induce bone growth and normalization of wedge-shaped vertebrae. What name is associated with this process?

Explanation

The Heuter-Volkmann principle shows that bone placed in longitudinal tension will tend to stimulate longitudinal growth, and that compressive longitudinal forces inhibit longitudinal growth, making this response the best choice. Hooke's law relates to stress being proportional to strain and is not directly related to bone growth. Kirchhoff's laws apply to electrical circuit design. Wolff's law states that bone
remodels in response to mechanical stress, with the correlate that increased stress causes increased growth, and decreased stress leads to bone loss.

Question 36

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

Explanation

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

Question 37

What is the goal of surgical treatment in this scenario?

Explanation

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 38

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

Explanation

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

Question 39

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

Explanation

DISCUSSION: The sural nerve crosses near the midline at the level of the musculotendinous junction before descending to its more lateral location distally. The saphenous nerve and vein are further medial and at less risk. The posterior tibial nerve is at risk only during deep dissection, such as harvesting flexor hallucis longus tendon graft. The plantaris muscle lies in this area but is of little clinical significance.
REFERENCES: Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon. Foot Ankle Int 2000;21:475-477.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 40

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

Explanation

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 41

Suprapatellar intramedullary nailing for tibia fractures when compared to infrapatellar nailing is associated with

Explanation

Discussion: Suprapatellar nailing has been very useful in the management of proximal tibia fractures, allowing a better reduction. Both arthroscopy and MRI have been utilized after suprapatellar nailing to evaluate for changes in the patellofemoral joints, and no significant changes can be attributed to this technique. In a comparative study between suprapatellar nailing and standard (infrapatellar) nailing, both techniques showed excellent range of motion and no significant differences between the methods. In a separate study, it was noted that patients who underwent suprapatellar nailing did not complain of anterior knee pain that is often seen with standard nailing.

Question 42

Figures 23a and 23b show the MRI scans of a 50-year-old woman who has increasing gait disturbance. She reports three falls in the past week. Examination reveals hyperreflexia, motor weakness in the biceps and triceps, and a positive Hoffman’s sign. What is the most appropriate treatment plan?

Explanation

DISCUSSION: The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option.
REFERENCES: Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951.
Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.
Herkowitz HN: A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774-780.

Question 43

A 45-year-old man feels a pop in the anterior aspect of his elbow while lifting furniture. He denies any antecedent pain or injury. Which examination method is best for diagnosing a distal biceps rupture?

Explanation

EXPLANATION:

Question 44

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Explanation

Open chain exercises of the lower extremity are defined as "The foot is mobile, and motion at the knee joint occurs independent of motion at the hip and ankle joints, as opposed to closed chain exercises in which the foot is fixed and motion at the knee joint is accompanied by motion at the hip and ankle joints in a predictable manner.

Question 45

A patient has a tibial shaft fracture and is suspected of having a compartment syndrome involving the deep posterior compartment. Associated signs and symptoms would include paresthesias over the

Explanation

A compartment syndrome of the deep posterior compartment causes symptoms related to structures running through that compartment. The deep posterior compartment includes the tibialis posterior, flexor hallucis longus, flexor digitorum longus, popliteus muscle, as well as the posterior tibial artery and the tibial nerve. Elevated pressures in this compartment would cause paresthesias in the distribution of the tibial nerve (plantar aspect of the foot) and would cause associated pain with passive stretch of the muscles in the compartment (great toe extension).

Question 46

What is the primary mechanism of wear of polyethylene acetabular components?

Explanation

Although previous theories on acetabuIar wear implicated fatigue cracking and delamination which is a major mode of polywear in knees, the primary mechanism of wear of polyethylene acetabular components has been shown to be adhesion and abrasion. In an analysis of 128 componenets retrieved at autopsy or revision surgery, wear appeared to occur mostly at the surface of the components and to be due to large strain plastic deformation and orientation of the surface layers into fibrils that subsequently ruptured during multidirectional motion. It was also shown conclusively that 32 mm displayed significantly more wear (volumetric wear) than with either 22 or 26/28 mm heads ( 1 mm increase in size increased volumetric wear by 10%). The wear at the articulating surface was characterized by highly worn polished areas superiorly and less worn areas inferiorly separated by a ridge. Abrasion was very common, occurring after adhesion and plastic deformation of poly fibrils, and abrasion secondary to third body wear. As well, wear rates decreased with longer survival of components, indicating a "wearing in" phenomenon, arguing against oxidative and fatigue wear. Crevice corrossion = occurs in fatigue cracks with low 02 tension (under screw heads,etc.) Oscillatorry fretting = cyclical outer surface abrading from small movements. Fatigue and delamination = predominant in total knees, where stresses are maximum just below the surface of the poly, causing fatigue over time with susequent delamination. In contrast, hip wear occurs primarily at the surface of the poly.

Question 47

Figure A is an AP radiograph of a 68-year-old man who presents to clinic with shoulder pain and dysfunction. On examination of his shoulder, he has pseudoparalysis with attempt at forward elevation and a positive hornblower's sign while demonstrating normal belly press test. Treatment should consist of: Review Topic

Explanation

The clinical presentation and radiograph is consistent with a diagnosis of a massive posterosuperior rotator cuff tear and arthropathy. Of the options listed, a reverse total shoulder arthroplasty (RTSA) with latissmus dorsi transfer (LDT) is most appropriate.
RTSA can improve pain and function in shoulders with forward elevation pseudoparalysis secondary to rotator cuff tear arthropathy. Following arthroplasty, the deltoid alone can restore overhead elevation but it does not address active external rotation deficit. LDT is a well described procedure for treatment of irreparable posterosuperior rotator cuff tear. Combining RTSA and LDT can address both deficits and in select patients yields significant pain relief and restoration of function.
Walch et al found that hornblower's sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor.
Puskas et al present clinical outcomes of RTSA combined with LDT for treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder in 40 patients. At a mean follow-up of 53 months, the author report excellent clinical outcomes.
Figure A demonstrates a proximal migration of the humerus resulting in femoralization of the humeral head and acetabularization of the acromion from a massive rotator cuff tear.
Incorrect answers:

Question 48

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

Explanation

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

Question 49

What is the main mechanism for nutrition of the adult disk?

Explanation

DISCUSSION: Disk nutrition occurs via diffusion through pores in the end plates. The disk has no direct blood supply, and the anulus is not porous to allow diffusion. The dorsal root ganglion does not provide blood supply to the disc.
REFERENCES: Biyani A, Andersson GB: Low back pain: Pathophysiology and management. J Am Acad Orthop Surg 2004;12:106-115.
Urban JG, Holm S, Maroudas A, et al: Nutrition of the intervertebral disc: Effect of fluid flow on solute transport. Clin Orthop 1982;170:296-302.
Park AE, Boden SD: Intervertebral disk: Form and function, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 50

During primary total knee arthroplasty, the trial components are in place. The extensor space is tight, but the flexion space is normal. What is the best gap balancing solution?

Explanation

DISCUSSION: The first rule of total knee arthroplasty is to restore the joint line to its original location. This will ensure optimal patellofemoral biomechanics and will facilitate ligament balancing. Changes on the tibial side affect both the flexion and extension gaps equally. Changes in femoral component sizing or position affect the flexion gap only. Tibial changes affect both the flexion and extension gaps. To convert a tight extension gap to a normal flexion gap, more distal femur needs to be resected.
REFERENCES: Vince KG: Revision knee arthroplasty technique. Instr Course Lect 1993;42:325-339.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 513-536.

Question 51

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Explanation

DISCUSSION: The blood supply to the adult capitellum and lateral trochlea comes from posterior vessels arising from the radial recurrent, radial collateral, and interosseous recurrent arteries. These arteries penetrate the distal humerus posterior and superior to the capitellum.
REFERENCE: Yamaguchi K, Sweet FA, Bindra R, et al: The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am 1997;79:1653-1662.

Question 52

A prospective randomized trial is conducted to test the efficacy of Vitamin C versus placebo in treating patients who develop chronic regional pain syndrome (CRPS) after distal radius fractures. At first follow-up, the rates of CRPS are 1% and 9% in the study and placebo group, respectively. Which statistical test is most appropriate to determine significance?

Explanation

In the study provided, we need to determine whether distributions of categorical variables differ from one another. The appropriate study is the chi-square test.
Data can be classified as numerical (continuous) or categorical (proportional). Responses to such questions as "What is your major?" or Do you own a car?" are categorical because they yield data such as "biology" or "no." In contrast, responses to such questions as "How tall are you?" or "What is your G.P.A.?" are numerical. When comparing two independent means from numeric data, a t-test is performed. However, if categorical data is being compared, the chi-square test will determine if the proportions are really different.
Kocher et al. review basic clinical epidemiology and biostatistics relevant to orthopaedic surgery. Amongst other things, they describe that data can be summarized in terms of measures of central tendency, such as mean, median, and mode, and in
terms of measures of dispersion, such as range, standard deviation, and percentiles. Illustration A shows an algorithm for determining which test to use for varying data.
Incorrect Answers:

Question 53

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

Explanation

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

Question 54

A 14-year-old patient has sustained a complete ACL tear of his right knee. Which of the following options has shown to be the most limiting factor for access to pediatric orthopaedic management in the United States?

Explanation

The type of health insurance in the pediatric population has shown to be a significant factor for access to specialized healthcare in the United States.
Access to pediatric orthopaedic management has been well investigated. Numerous Level 4 studies have shown that orthopaedic offices in urban and rural areas prefer treating patients with private insurance over patients with Medicaid.
Iobst et al. telephoned 100 urban and rural orthopaedic outpatient offices to schedule an appointment for a 10-year-old patient with a forearm fracture. They showed that 8/100 offices would schedule an appointment within 1 week to the child with Medicaid insurance, as compared to 36/100 that gave an appointment to a child with private insurance.
Pierce et al. contacted 42 orthopaedic practices to schedule an appointment for a 14-year-old patient with an ACL injury. They showed that 38/42 offices scheduled an appointment for the child within 2 weeks with private insurance. This compared to 6/42 that scheduled an appointment for a similar child with Medicaid.
Incorrect Answers:

Question 55

Use of prophylactic knee bracing in contact sports participants results in which of the following?

Explanation

DISCUSSION: Several studies have looked at the effects of knee bracing, and it appears to be effective in prophylactically decreasing the incidence of medial collateral ligament sprains. Najibi and Albright reported that although evidence is not conclusive, bracing appears to help decrease the incidence of medial collateral ligament injuries. Albright and associates showed similar findings. Prophylactic knee braces have been associated with an increased incidence of ankle injuries.
REFERENCES: Albright JP, Powell JW, Smith W, et al: Medial collateral ligament knee sprains in college football: Effectiveness of preventive braces. Am J Sports Med 1994;22:12-18.
Najibi S, Albright JP: The use of knee braces: Part 1. Prophylactic knee braces in contact sports. Am J Sports Med 2005;33:602-611.

Question 56

Figure 23 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain? Review Topic

Explanation

This patient has a mechanism of injury and MRI consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 57

A 12-year-old boy with an ankle fracture undergoes closed reduction under sedation in the emergency department. Figure 27 shows a lateral radiograph of the ankle after two attempts at closed reduction. Based on these findings, treatment should now consist of

Explanation

DISCUSSION: The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.
REFERENCES: Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibial physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.
Gruber HE, Phieffer LS, Wattenbarger JM: Physeal fractures: Part II. Fate of interposed periosteum in a physeal fracture. J Pediatr Orthop 2002;22:710-716.

Question 58

Figure 37 shows the clinical photograph of a 1-day-old infant who weighed 10.25 lb at birth. Examination reveals an absent right Moro reflex and limited active motion of the right shoulder, elbow, and wrist, but flexion of the fingers. Passive range of motion of the shoulder and elbow is normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s right upper extremity is held in the “head waiter’s” posture with the shoulder internally rotated, the elbow extended, and the wrist in flexion. The Erb type of obstetrical brachial plexus palsy involves the C5 and C6 nerve root, and occasionally, as in this child, the C7 nerve root. Obstetrical palsy is a traction injury, and is associated with a high birth weight, shoulder dystocia, cephalopelvic disproportion, or the use of forceps. Erb palsy is four times more common than injury to the entire plexus or injury to the C8 and T1 nerve roots. It results from the shoulder being depressed while the head and neck are laterally rotated, extended, and tilted in the opposite direction. Most patients recover wrist extension and elbow flexion. Patients with residual weakness of shoulder external rotation and abduction will benefit from release of the pectoralis major, latissimus dorsi, and teres major, with transfer of the latissimus dorsi and the teres major to the posterosuperior aspect of the rotator cuff. Recent studies using arthrograms and CT scans have shown a higher incidence of posterior glenoid deficiency and posterior subluxation than that observed with plain radiographs. The posterior subluxation or dislocation can be effectively reduced by tendon release and transfer procedures.
REFERENCES: Hoffer MM, Phipps GJ: Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:997-1001.
Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667.
Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:668-677.

Question 59

Figures below show the radiographs, MRI, and MR arthrogram obtained from a 25-year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of 10. He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 60

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Explanation

A patient with an injury at the level of: C4 injury needs puffer control; C5 can use hand controls; C6 can use a manual wheelchair and sliding board transfers; C7 allows independent transfers; and no cervical injury routinely allows ambulation with crutches and leg braces.

Question 61

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Explanation

DISCUSSION: Unlike malignant bone tumors, malignant soft-tissue tumors usually are asymptomatic and present with the presence of a mass. Malignant soft-tissue tumors enlarge by centrifugal growth, creating a mass while compressing surrounding tissue. Symptoms may develop as the result of direct compression on neurovascular structures as the tumor enlarges. This is especially true in the pelvis where the tumor can enlarge appreciably without being noticed. However, in the extremities, the tumor is most often apparent before neurologic symptoms develop. An asymptomatic mass is not necessarily benign; therefore, biopsy should not be delayed. It is uncommon for a malignant soft-tissue mass to be discovered incidentally. Soft-tissue tumors are not typically apparent on radiographs; they are best identified with MRI.
REFERENCES: Brouns F, Stas M, De Wever I: Delay in diagnosis of soft tissue sarcomas. Eur J Surg Oncol 2003;29:440-445.
Rougraff B: The diagnosis and management of soft tissue sarcomas of the extremities in the adult. Curr Probl Cancer 1999;23:1-50.
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 62

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

Explanation

DISCUSSION: Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42 point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
REFERENCES: Lyons MK, Atkinson JL, Wharen RE, et al: Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic Experience. J Neurosurg

2000;93:53-57.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.
Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study. Spine 2004;29:1049-1055.

Question 63

Figures 33a and 33b show the radiographs of a 10-year-old girl who reports a 4-month history of medial foot pain after she was kicked while playing soccer. The pain is worse with activity and partially relieved by rest. Examination reveals tenderness directly over a prominent navicular tuberosity. Management should consist of

Explanation

DISCUSSION: An accessory tarsal navicular is located at the medial tuberosity of the navicular bone. Nearly all children and adolescents who have a symptomatic accessory tarsal navicular bone become asymptomatic when they reach skeletal maturity. Initial management should include activity restrictions, shoe modification to avoid pressure over the prominent navicular, and non-narcotic analgesics. Although anecdotal, the use of arch supports may be helpful. When pain is refractory to these methods, a short period of cast immobilization may be useful. Surgery should be reserved for patients who have disabling symptoms despite a prolonged period of nonsurgical management. When surgery is indicated, simple excision of the accessory navicular is recommended.
REFERENCES: Sella EJ, Lawson JP, Ogden JA: The accessory navicular synchondrosis. Clin Orthop 1986;209:280-285.
Bennett GL, Weiner DS, Leighley B: Surgical treatment of symptomatic accessory tarsal navicular. J Pediatr Orthop 1990;10:445-449.

Question 64

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month followup appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 21. What is the most likely diagnosis? Review Topic

Explanation

Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

Question 65

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

Explanation

DISCUSSION: The radiographs show the characteristic features of osteopetrosis. The condition results from defective resorption of immature bone by osteoclasts. There are three distinct clinical forms: (1) infantile-malignant, which is autosomal recessive and fatal in the first few years of life if untreated; (2) intermediate autosomal recessive; and (3) autosomal dominant. These conditions do not follow a malignant course, and patients have normal life expectancy with orthopaedic problems and anemia. In the malignant form, the clinical features include frequent fractures, macrocephaly, progressive deafness and blindness, hepatosplenomegaly, and severe anemia beginning in early infancy or in utero. Deafness and blindness are generally thought to represent effects of pressure on nerves and usually occur later in life. The anemia is caused by encroachment of bone on marrow, resulting in obliteration, and the hepatosplenomegaly is caused by compensatory extramedullary hematopoiesis. Dental caries and abscesses, as well as osteomyelitis of the mandible, are also seen. Most patients have normal intelligence. Treatment of the malignant form includes high dose 1,25 dihydroxy vitamin D with a low-calcium diet to stimulate bone resorption, not because there are vitamin deficiencies. Bone marrow transplant has also been successful.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, p 1550.
Zaleske DJ: Metabolic and endocrine abnormalities, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 212-214.
Kaplan FS, August CS, Fallon MD, et al: Successful treatment of infantile malignant osteopetrosis by bone-marrow transplantation: A case report. J Bone Joint Surg Am 1988;70:617-623.

Question 66

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

Explanation

The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.

Question 67

A 15-year-old girl who plays high school basketball has had worsening forefoot pain and swelling that is aggravated by activity for the past 5 weeks. She denies any history of an injury. Examination reveals no deformities. A radiograph is shown in Figure 38. Initial management should consist of

Explanation

DISCUSSION: Freiberg’s infraction is believed to be an osteochondrosis of the second metatarsal head. It is the only osteochondrosis that has a predilection for females. The typical patient is an athletically active adolescent female. The radiograph shows stage II disease wherein reossification is occurring; it is at this time that the second metatarsal head is most susceptible to deformation. Therefore, initial management should consist of a short leg

walking cast.
REFERENCE: Mann RA, Coughlin MJ: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 413-415.

Question 68

Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation? Review Topic

Explanation

The apprehension sign and Jobe relocation test are helpful for the diagnosis of anterior shoulder instability. The sulcus sign provides information on the status of the rotator interval. The jerk test is helpful for the diagnosis of posterior instability, but a fixed posterior shoulder dislocation is associated with loss of external rotation. Since an AP radiograph may miss this diagnosis, an axillary view should be obtained on patients with a shoulder injury.

Question 69

A 51-year-old woman has had progressively increasing right knee pain for the past 6 months. She has a history of metastatic renal cell carcinoma to the lung and the skeletal system. Radiographs are seen in Figures 18a and 18b. The next step in management of the right distal femur lesion should consist of

Explanation

DISCUSSION: In a patient with known metastatic disease, the surgeon must rule out additional lesions throughout the femur prior to surgical management. Lesions located in the diaphysis or in the peritrochanteric region may influence the surgical procedure.
REFERENCES: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.
Sim FH: Metastatic bone disease of the pelvis and femur. Instr Course Lect 1992;41:317-327.

Question 70

At the time of revision total knee arthroplasty, the surgeon is trialing the knee and finds that it extends fully and is stable in flexion with a 23-mm trial spacer; however, the patella is impinging on the polyethylene spacer. No augments were used on the femur or the tibia because the components fit well without them. What is the most appropriate action at this time?

Explanation

DISCUSSION: The surgeon in this case is faced with a common scenario at the time of revision total knee arthroplasty and the tendency is to elevate the joint line. Elevation of the joint line is associated with deleterious effects including anterior knee pain, restricted knee flexion, and instability. The error that has been made is resting the femoral component on the bone that is left behind after removal of the prior component; this typically leads to a femoral component that is too small (leading to an enlarged flexion gap) and proximal to where it should be (enlarging the extension gap). Although the flexion and extension gaps are equivalent, joint line elevation has occurred. To correct this problem, the femoral component size should be increased or offset posteriorly (to decrease the size of the flexion gap) and distal femoral augments should be used to decrease the size of the extension gap and restore the joint line to the appropriate level.
REFERENCES: Laskin RS: Joint line position restoration during revision total knee replacement. Clin Orthop Relat Res 2002;404:169-171.
Yoshii I, Whiteside LA, White SE, et al: Influence of prosthetic joint line position on knee kinematics and patellar position. J Arthroplasty 1991;6:169-177.
Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction
Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 123-145. Question 100
A 68-year-old woman is undergoing a cementless medial/lateral tapered femoral placement during a total hip arthroplasty and the surgeon notices a small crack forming in the anteromedial femoral neck with final implant insertion. The most appropriate management should include which of the following?
Placement of a cerclage cable around the femoral neck above the lesser trochanter
Removal of the implant, placement of a cable around the femoral neck above the lesser trochanter, and reinsertion of the implant
Removal of the press-fit implant and cementing of the same femoral stem
Final seating of the cementless femoral component without additional measures
Removal of the cementless femoral component and placement of a revision modular taper- fluted femoral stem
DISCUSSION: The recognized treatment of the proximal periprosthetic fracture is first to identify its extent and then to optimize the correction. Removing the implant seems logical to accomplish the identification. Several studies indicate that proximal cerclage wiring is adequate to create a “barrel hoop” stability of the proxima l femur. The postoperative management may also include protected weight bearing and periodic radiographs.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Warren PJ, Thompson P, Fletcher MD: Transfemoral implantation of the Wagner SL stem: The abolition of
subsidence and enhancement of osteotomy union rate using Dall-Miles cables. Arch Orthop Trauma Surg 2002;122:557-560.
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Question 71

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

Explanation

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

Question 72

Prescribing touch (10 to 15 kg) weight-bearing would be most appropriate in the following scenario?

Explanation

Touch weight bearing (10 to 15 kg) regimens have shown to minimize joint reaction forces across the hip. This weight bearing restriction should be considered in patients who have undergone open reduction internal fixation of transtectal transverse posterior wall fractures.
The definition of touch weight bearing (also known as touch-down weight bearing) is ill-defined in the literature. Published data suggest touch weight bearing to be 10 to 15 kg of load applied to ground by the affected limb or less than 20% of body weight. In contrast, partial weight bearing is reported as 20 to 25 kg or 30% to 50% of body weight. Joint reaction forces across the hip have been shown to be lowest with touch weight-bearing. In this scenario, the foot should be flat against the ground so the flexor and extensor musculature that cross the hip are relaxed. With non-weight bearing restrictions, the musculature across the hip will be contracted, which increases contact pressures and joint reaction forces.
Rubin et al. looked at the validity of touch weight-bearing and partial weight bearing regimens. They found that most patients overload the limb up to 50% more than the target weight prescribed.
Lewis et al. showed that maintaining non-weight-bearing position of the involved leg produces increased compressive forces across the hip joint due to activation of the hip flexors compared to restricted weight-bearing.
Incorrect Answers:

Question 73

A 27-year-old man has recurrent right shoulder instability. He first dislocated his shoulder in college while playing rugby and was treated nonsurgically. Since then, he has sustained nearly 1 dozen dislocations and says that his shoulder always feels “loose.” The shoulder recently dislocated in his sleep and while he was putting on clothes. Which factor is a contraindication to an arthroscopic soft-tissue repair?

Explanation

CLINICAL SITUATION FOR QUESTIONS 90 THROUGH 92
Figure 90 is the radiograph of a 14-year-old pitcher who plays in a year-round baseball program and has vague pain in his dominant shoulder. The pain occurs with throwing, and it has been worsening for 2 months. Pain typically occurs during the late cocking phase of throwing. He has no tenderness of the rotator cuff and 5/5 rotator cuff strength. His arc of motion is symmetric between his dominant and nondominant arms. The sulcus sign is negative.

Question 74

A 68-year-old male presents with gait instability, clumsiness of the hands, and the MRI images shown in Figure A. You decide to proceed with surgical decompression. When planning your surgical treatment, it is important to note that compared to a posterior approach, the anterior procedure has: Review Topic

Explanation

Surgical decompression of cervical myelopathy via an anterior procedure has lower reported blood loss compared to a posterior procedure.
Cervical myelopathy has a progressive course and therefore if there is evidence of functional impairment surgical decompression is indicated. Either an anterior decompression or posterior decompression can be used depending on a variety of factors including number of levels involved and sagittal alignment of the cervical spine. In general, a posterior approach is used when three or more levels are involved and the spine is in neutral or lordotic alignment.
Fehlings et al. did a prospective study on the risks of complications associated with surgical treatment of cervical myelopathy. They found that combined anterior and posterior procedures had a significantly higher rate of complication than either anterior-only or posterior-only procedures. Posterior procedures had a higher rate of wound infections compared to anterior. They found no statistical difference in the over-all complication rate, incidence of C5 radiculopathy, or dysphagia between an anterior-only or posterior-only procedure.
Fehlings et al. did a prospective study on outcomes following surgical treatment of cervical myelopathy. At one year follow-up they found a significant improvement in mJOA score, Nurick grade, NDI score, and all SF-36v2 dimensions. With the exception of mJOA scores, these improvements were not statistically related to severity of disease.
Liu et al. performed a meta-analysis of outcomes following surgical decompression of cervical myelopathy. They found outcomes following anterior procedures were better than those for posterior procedures when there were less than 3 affected levels. With 3 or greater levels, no statistical difference in outcomes could be found between the two approaches. They note none of their reviewed publications represent high-quality prospective randomized trials.
Figure A is a sagittal MR image of the cervical spine showing multi-level degenerative disease with cord compression consistent with cervical myelopathy.
Incorrect Answers:

Question 75

Results of a study demonstrating no difference between treatments when a difference truly exists is an example of which of the following?

Explanation

A type II error (also known as a beta error) occurs when results demonstrate that two groups are similar when, in reality, they are different (with regard to the statistic being measured). Type I errors show that a difference exists when, in reality, no difference exists. A statistically insignificant result may lead an investigator to conclude that no difference exists between two groups; this may be correct (and therefore not a type II error). The concept of fragile p-values is that small sample sizes may result in wide variability of p-values with only one change in a data point for a given group. This singular change could be a chance occurrence, but it still can affect the statistical
significance of the outcomes analysis. Fragility of p-values is limited by increasing sample sizes. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

Question 76

The natural history of cervical spondylolytic myelopathy is best described as

Explanation

DISCUSSION: The natural history of cervical myelopathy has been described by Lees and Turner as exacerbations of symptoms followed by often long periods of static or deteriorating function (or very rarely improvement). This stepwise pattern of decreasing function has been corroborated by Clarke and Robinson. These authors described long periods of stable neurologic function, sometimes lasting for years, in about 75% of their patients. In the majority of the patients, however, the condition deteriorated between quiescent streaks. About 20% of their patients showed a slow, steady progression of symptoms and signs without a stable period, and 5% had rapid deterioration of neurologic function.
REFERENCES: Emery SF: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Lees F, Turner JA: The natural history and prognosis of cervical spondylosis. Brit Med J 1963;2:1607-1610.
Clarke E, Robinson PK: Cervical myelopathy: A complication of cervical spondylosis. Brain 1956;79:486-510.

Question 77

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Explanation

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 78

A 20-year-old man sustained an isolated displaced type II odontoid fracture in a motor vehicle accident. He is neurologically intact. Treatment consists of placement in halo traction, and the fracture is reduced. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined.
REFERENCES: Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193.
Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.
Fiore AJ, Haid RW, Rodts GE, et al: Atlantal lateral mass screws for posterior spinal reconstruction: Technical note and case series. Neurosurg Focus 2002;12:E5.

Question 79

A construction worker sustained a comminuted calcaneus fracture 2 years ago. He now reports progressive hindfoot pain with the recent onset of anterior ankle pain. A lateral hindfoot radiograph is shown in Figure 31. Treatment should consist of

Explanation

DISCUSSION: The patient has subtalar arthrosis, a loss of heel height with anterior ankle impingement. The mechanics of the ankle are impaired, and dorsiflexion is painful and limited. The talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20 . By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement. Tibiotalocalaneal fusion would be inappropriate because the patient does not have arthritic symptoms in the ankle. Ankle arthroscopy or in situ arthrodesis would not reestablish appropriate ankle mechanics, and the osteophytes would be prone to redevelop. Lateral wall ostectomy may help with impingement at the level of the fibula or the lateral ankle but would provide no benefit to anterior ankle impingement.
REFERENCES: Carr JB, Hansen ST, Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Myerson M, Quill GE Jr: Late complications of fractures of the calcaneus. J Bone Joint Surg Am 1993;75:331.

Question 80

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Explanation

DISCUSSION: It is generally accepted that reconstructions of the proximal tibia are associated with the highest incidence of failure, probably because of poor soft-tissue coverage, the need for extensor mechanism reconstruction, and other anatomic issues. It also may be related to the fact that patients with tumors of the proximal tibia, in general, have a better prognosis and better survival rates than patients with tumors located elsewhere in the body. Reconstructions of the proximal humerus may be more durable because they are not involved in weight-bearing activities.
REFERENCE: Horowitz SM, Glasser DB, Lane JM, Healey JH: Prosthetic and extremity survivorship after limb salvage for sarcoma: How long do the reconstructions last? Clin Orthop 1993;293:280-286.

Question 81

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Explanation

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed . 26

Question 82

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Explanation

DISCUSSION: Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-3% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Recommended treatment in the pre-rupture setting includs a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be
clinically satisfactory.
The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.

Question 83

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

Explanation

DISCUSSION: Radiographic findings in patients with rheumatoid arthritis include symmetric joint space narrowing, periacetabular and femoral head erosions, and diffuse periarticular osteopenia. In advanced stages, protrusio acetabuli is a common finding. Ranawat and associates have shown a rate of superior femoral head migration of 4.5 mm per year and medial (axial) migration of 2.5 mm per year. Asymmetric joint space narrowing is a classic radiographic finding of degenerative arthrosis. Sacroiliac joint ankylosis commonly occurs in ankylosing spondylitis. Hip synovitis is a pathologic diagnosis, not a radiographic finding.
REFERENCES: Lachiewicz PF: Rheumatoid arthritis of the hip. J Am Acad Orthop Surg 1997;5:332-338.
Stuchin SA, Johanson NA, Lachiewicz PF, Mont MA: Surgical management of inflammatory arthritis of the adult hip and knee, in Zuckerman JS (ed): Instructional Course Lectures 48. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-109.

Question 84

A 56-year-old man has had a 2-year history of slowly progressive neck pain and bilateral arm aching. Over the past year, he has noticed intermittent, diffuse numbness in both hands, with decreased grip strength and mild hand clumsiness. He denies any problems with balance. Examination shows a wide-based gait, intrinsic wasting, and a postive Hoffman's sign bilaterally. An MRI scan of the cervical spine is shown in Figure 16. What is the most appropriate treatment? Review Topic

Explanation

The patient has classic symptoms of myelopathy with upper motor neuron signs on examination. His symptoms have been present for years, and are getting worse. The cervical spine MRI scan shows spinal stenosis with multilevel spondylosis causing spinal cord compression at multiple levels. With the longstanding duration of the patient's signs and symptoms, combined with involvement of multiple levels in the cervical spine, posterior multilevel laminectomy and fusion is the best treatment option. Two-level anterior diskectomy and fusion would address the two areas of most severe narrowing, but it would fail to decompress the other stenotic areas which also require decompression. Posterior cervical foraminotomies would only address radicular symptoms, which are not present in this patient, and would not succeed in decompression of the spinal cord. Cervical epidural injections are not indicated for myelopathy symptoms, and may in fact place this patient at risk for neurologic deterioration.

Question 85

Performance parameters developed by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention regarding prophylactic antibiotics include

Explanation

There are over 500,000 surgical site infections each year in the U.S. Patients with a surgical site infection are 60% more likely to spend time in an intensive care unit, and are twice as likely to die during the perioperative period. In 2002, the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention initiated the National Surgical Infection Prevention Project to decrease morbidity and mortality in surgical site infections by promoting the appropriate use of perioperative antibiotics. The three performance parameters they developed are initiation of parenteral antibiotics within 1 hour of surgical incision, selection of an appropriate antibiotic, and discontinuation within 24 hours. The entire dose of antibiotics should be administered prior to tourniquet inflation. For total joint arthroplasty, cefazolin or cefuroxime is the preferred prophylactic antibiotic. Vancomycin or clindamycin is indicated for patients with severe allergies or adverse reactions to beta-lactams. Vancomycin can also be used for prophylaxis in hospitals with a "high" frequency of methicillin-resistant Staphylococcus aureus. There is no evidence that the continuation of antibiotics until surgical drains have been removed provides any additional protection against surgical site infection.

Question 86

A 28-year-old man sustained a shoulder dislocation 2 years ago. It remained dislocated for 3 weeks and required an open reduction. He now reports constant pain and has only 60 degrees of forward elevation and 10 degrees of external rotation. He desires to return to some sporting activities. An AP radiograph and intraoperative photograph (a view of the humeral head through a deltopectoral approach) are shown in Figures 31a and 31b. What is the best treatment option to decrease pain and improve function? Review Topic

Explanation

The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.

Question 87

A 58-year-old woman with rheumatoid arthritis and a severe hindfoot valgus deformity now reports recurrent lateral ankle pain. Examination reveals pain over the fibula and sinus tarsi, with a valgus hindfoot that is passively correctable. Despite the use of an ankle-foot orthosis, this is the second time this problem has occurred. Radiographs and a clinical photograph are shown in Figures 28a through 28c. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Excessive hindfoot valgus can lead to abutment between the calcaneus and fibula. This valgus force can lead to a stress fracture of the distal fibula. Surgery may be required if an insufficiency fracture recurs despite orthotic management. Of the choices listed, a subtalar arthrodesis is most likely to achieve rebalancing of the foot at the level of the deformity.
REFERENCES: Stephens HM, Walling AK, Solmen JD, Tankson CJ: Subtalar repositional arthrodesis for adult acquired flatfoot. Clin Orthop 1999;365:69-73
Easley ME, Trnka HJ, Schon LC, Myerson MS: Isolated subtalar arthrodesis. J Bone Joint Surg Am 2000;82:613-624.

Question 88

While under a physician’s care, a 45-year-old man verbally abuses the staff and nurses who are attempting to carry out orders. A decision to discharge the patient is best carried out by

Explanation

The other foils in this answer would be both unethical and would be a violation of “anti-dumping” laws. This would further open the physician, hospital and staff to possible litigation.

Question 89

A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal images shown in Figure A (left, pre-operative; right, post-operative). Which of the following pre-operative physical examination findings may have been positive? Review Topic

Explanation

This patient has internal snapping hip (coxa saltans), which is caused by the psoas tendon sliding over femoral head, iliopectineal ridge, lesser trochanter exostoses, or iliopsoas bursa.
Snapping hip exists in 3 forms: (1) external snapping hip, which is caused by the iliotibial band (ITB) sliding over the greater trochanter, (2) internal snapping hip, and
(3) intraarticular snapping hip, which is caused by loose bodies (traumatic, or from synovial chondromatoses) or labral tears. While painless snapping hip requires no treatment, painful snapping hip may be addressed with activity modification, physical therapy, steroid injections. Surgical release (ITB z-plasty or psoas tenotomy) is indicated if nonoperative management is unsuccessful.
Ilizaliturri et al. evaluated the results of endoscopic iliopsoas tendon release at the lesser trochanter (10 patients) vs endoscopic transcapsular psoas release from the peripheral compartment (9 patients). There were improvements in WOMAC scores in both groups, and no difference between groups. They conclude that both techniques are equally effective.
Marquez Arabia et al. evaluated if the psoas tendon regenerates after tenotomy in 27 patients. At 23 months, they found that tendon regeneration occurred in all patients, to
a mean circumference of 84% of the original. One patient had persistent pain, but all had 5/5 hip flexion strength. They hypothesize that the bulk of iliopsoas muscle fibers attaches directly to the proximal femoral shaft without a tendon, preventing retraction and allowing regeneration to occur easily.
Figure A shows pre- and post-operative arthroscopic psoas tenotomy magnetic resonance sagittal images. Illustration A shows the psoas tendon (white arrows) prior to transection. Illustration B shows the psoas tendon after transection (green arrows, proximal tendon segment; yellow arrows, distal segment). Illustration C and D are diagrams showing release at the level of the lesser trochanter and hip joint respectively.
Incorrect
90 degrees, but full external rotation. Answer 2: Decreased internal rotation and a positive impingement test (forced
flexion, adduction, femoroacetabular Answer 4: These
and internal
rotation) are classic findings
findings may
be found with intra-articular
for cam-type impingement loose bodies.

Question 90

What is the most likely consequence of a vertebral compression fracture associated with osteoporosis?

Explanation

DISCUSSION: After an osteoporotic vertebral compression fracture, the risk of subsequent fractures at adjacent levels increases. This is felt to be the result of a shifting of the sagittal alignment more anteriorly, putting more stress on the osteopenic vertebral bodies and their anterior cortices. Pain generally resolves with rest, but this may take weeks or months. It has been demonstrated experimentally that osteoporotic vertebral bodies are actually less stiff and weaker after a compression fracture; therefore, deformity predisposes to further deformity. The extensor musculature often fatigues over time and usually does not hypertrophy. Frontal plane deformity is a rare development.
REFERENCES: Heaney RP: The natural history of vertebral osteoporosis: Is low bone mass an epiphenomenon? Bone 1992;13:S23-S26.
Tohmeh AG, Mathias JM, Fenton DC, et al: Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine 1999;24:1772-1776.

Question 91

Figures 25a and 25b show the radiographs of a 66-year-old man who has had a long history of bilateral painful flatfoot deformities. Examination reveals that his foot is partially correctable passively, albeit with discomfort, and he has an Achilles tendon contracture. An ankle-foot orthosis has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,

pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 92

Figure 1 shows the clinical photograph obtained from a child with a congenital difference of the hand. What clinical feature(s) is/are characteristic of this condition?

Explanation

EXPLANATION:
The clinical photograph reveals a child with amniotic band syndrome or constriction band syndrome. If a band causes an autofusion of the digits without amputation, acrosyndactyly can occur, as demonstrated in the clinical photograph. Typically, a proximal sinus tract with a distal syndactyly is present. Radial deviation of the thumb can be seen most frequently in Apert syndrome. Cardiac anomalies are associated with many congenital upper extremity differences but are not characteristic of amniotic band syndrome. Ulnar longitudinal deficiency is characterized by hypoplasia or complete absence of the ulna.

Question 93

A 38-year-old man who is an avid tennis player has had persistent pain over the medial aspect of his knee for the past 6 years. He notes that the pain occurs on a daily basis with any significant activity. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 22a and 22b. What is the best course of action?

Explanation

DISCUSSION: In a relatively young patient who is an avid tennis player, the treatment of choice is a joint preserving procedure. The radiographs reveal varus alignment with loading of the medial compartment. After all nonsurgical management options have been used, the best treatment option is a medial opening wedge osteotomy. A lateral closing wedge osteotomy of the proximal tibia is also a reasonable option, but it is not one of the choices. A unicompartmental arthroplasty or a total knee arthroplasty would place significant restrictions in this patient. A unispacer may be a temporizing procedure but is controversial and without substantial data in the literature. The knee arthroscopy will not address the medial compartment osteoarthritis.
REFERENCES: Nagel A, Insall JN, Scuderi GR: Proximal tibial osteotomy: A subjective outcome study. J Bone Joint Surg Am 1996;78:1353-1358.
Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Manifold SG, Kelly MA, Richardson L, et al: Osteotomies about the knee, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 947-961.

Question 94

Figure 50 shows the AP radiograph of an asymptomatic 82-year-old woman who underwent total hip arthroplasty 16 years ago. What is the most likely diagnosis?

Explanation

DISCUSSION: Pelvic osteolysis in the presence of a well-fixed porous-coated socket is a recognized complication in total hip arthroplasty. The radiograph shows large lytic lesions superiorly adjacent to an acetabular screw and inferiorly extending into the ischium. It also reveals eccentricity of the femoral head with respect to the acetabular component, consistent

with polyethylene wear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 440.
Dowd JE, Sychterz CJ, Young AM, et al: Characterization of long-term femoral-head-penetration rates: Association with and prediction of osteolysis. J Bone Joint Surg Am 2000;82:1102-1107.

Question 95

A 3-year old child from an isolated mountain area is evaluated for multiple medical problems, including vomiting, loss of appetite, polyuria, and failure to thrive. History reveals the child was normal at birth. The parents, who appear healthy, are second cousins and have two other children who are normal. The parents state that they know of another family member who died at age 6 years after a similar medical history. Radiographs of the lower extremities show bowing of the long bones with cupping and widening of the physes. What is the most likely diagnosis?

Explanation

Hypophosphatemia-The patients who were symptomatic had obtundation,
hemolytic anemia, rhabdomyolysis, and hepatocellular injury that began during refeeding and resolved with treatment. The signs and symptoms, pathophysiology, and treatment of refeeding hypophosphatemia are reviewed.
Renal Osteodystrophy-Musculoskeletal complications in patients with chronic renal failure are common and may be related to the disease itself or to treatment. The altered metabolism in patients with chronic renal failure leads to renal osteodystrophy, which consists of osteomalacia and secondary hyperparathyroidism [1]. Erosive changes attributable to secondary hyperparathyroidism may be easily confused with rheumatoid arthritis, seronegative spondyloarthropathies, infection, or even malignancy.
Primary Hyperparathyroidism-Preferential involvement of cortical bone with apparent preservation of cancellous bone in primary hyperparathyroidism was confirmed by percutaneous bone biopsy. Over 80% of patients had a mean cortical width below the expected mean, whereas cancellous bone volume in over 80% of patients was above the expected mean.
Skeletal disease in primary hyperparathyroidism J Bone Miner Res 1989 Jun; 4(3):283-91
Nutritional vitamin D deficiency-Rickets, osteomalacia, and renal osteodystrophy are disorders of the mineralization of bone that result from a lack of available calcium, phosphorus, or both. The diseases that result from numerous mechanisms present with a symptom-sign-radiographic complex with such a high degree of stereotypy that laboratory investigation is often required to distinguish one form from another. The disorders in children, known as rickets, produce bowing and other deformities of the long bones and dwarfism. These disorders are principally related to the profound effect of the deficiency states on the epiphyseal plate; whereas the same disorders in adults produce an often severe osteopenia and pathologic fractures. Because of newer developments in our understanding of the factors affecting calcium-phosphorus
hemostasis and vitamin D metabolism, many of the children and Rickets, osteomalacia, and renal osteodystrophy.

Question 96

A 7-year-old boy is seen in the emergency department with an isolated and displaced supracondylar humerus fracture and absent radial and ulnar pulses. Despite a moderately painful attempt at realignment, examination reveals that his hand remains pulseless. What is the next most appropriate step in management?

Explanation

DISCUSSION: Displaced supracondylar humerus fractures in children may have associated vascular compromise. Decreased blood flow may be due to vessel injury, entrapment within the fracture site, kinking from fracture displacement, or from vessel spasm. Optimal initial treatment in the emergency department includes gentle realignment of the limb and vascular assessment. Angiography is not required in isolated injuries as the level of the vessel compromise is always at the site of the fracture. When blood flow is not restored, the next best step in treatment is to proceed urgently to the operating room. A formal closed reduction and pinning is performed, and then the vascular status is reassessed. Exploration and vascular repair is required if the hand is cool, white, and without pulses.
REFERENCES: Ay S, Akinci M, Kamiloglu S, et al: Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Dormans JP, Squillante R, Sharf H: Acute neurovascular complications with supracondylar humerus fractures in children. J Hand Surg Am 1995;20:1-4.

Question 97

Figure 1 is the right hand of a 65-year-old man with a history of hypertension and rheumatoid arthritis. He is taking immunosuppressive disease-modifying antirheumatic drugs (DMARDs) and is seen in the emergency department with rapid progression of erythema from his right thumb to his right arm during the last 12 hours. He is confused, lethargic, and has these vital signs: blood pressure 92/40, respiratory rate 45, temperature 39.7°C, pulse 135, and oxygen saturation 90% on 4 liters of oxygen by face mask. An examination of his right upper extremity reveals black bulla extending from the metacarpophalangeal down to the tip and no capillary refill at the pulp. Immediate treatment should consist of

Explanation

EXPLANATION:
This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of an infection, and revascularization is not indicated.

Question 98

Which factor is a contraindication to surgical treatment of a symptomatic CAM deformity?

Explanation

DISCUSSION
Multiple studies have confirmed that CAM or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, CAM deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion was higher than 50% in the subgroup of athletes.
Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in the majority of nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between CAM deformity and hip osteoarthritis, a corresponding link between correction of the deformity and prevention of osteoarthritis has never been proven.
Results of CAM deformity correction, typically including repair of the degenerative labral tear, are much poorer when there is significant joint space loss. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 99

If the quality of the tendon is poor at the lateral attachment of a partial articular side rotator cuff tear (more than 6 mm of footprint exposure or greater than 50% thickness), what should the surgeon do? Review Topic

Explanation

Generally, partial articular side rotator cuff tears are treated by either debridement or repair. The decision to repair depends on the "thickness" of the tear and the retraction of the undersurface of the rotator cuff as well as the quality of the remaining tissue. More than 6 mm of footprint exposure suggests a 50% thicknes tear. If it is poor quality as in this case, the surgeon should complete the tear and repair the tendon as in a small full-thickness tear. Intrasubstance tears with an intact footprint can be treated with trans-tendon repair.

Question 100

The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?

Explanation

DISCUSSION: The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
REFERENCES: Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273.
Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.
Kim WY, Hearn TC, Seleem O, et al: Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res 1999;361:237-244.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Anatomic alignment
Indirect reduction
Anatomic reduction of the fragments
Relatively stable fixation
Functional aftercare

Correct Answer: Anatomic reduction of the fragments

Explanation:

DISCUSSION: Although the original concept of internal fixation was one of anatomic reduction and stable fixation, over the past 10 to 15 years there has been a change based on the advent of intramedullary nailing and bridge plating. It is now appreciated that in a multifragmentary diaphyseal fracture, particularly of the lower extremity, the achievement of axis alignment (mechanical and anatomic axis) is all that is required. Healing will occur by callus. Relatively stable fixation is achieved through intramedullary nailing or bridge plating, providing adequate pain relief for functional aftercare.
REFERENCES: Perren SM, Claes L: Biology and mechanics of fracture management, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000,
pp 7-32.
deBoer P: Diaphyseal fractures: Principles, in Ruedi TP, Murphy WM (eds): AO Principles of Fracture Management. Stuttgart, Thieme, 2000, pp 93-104.
Mast J, Jakob R, Ganz R: Planning and Reduction Techniques in Fracture Surgery. Berlin, Springer-Verlag, 1989.

Question 2:

Options:

Snug fitting shoe to block side-to-side motion that is common after this procedure
Leather sole shoe to prevent catching the shoe on carpet which is common with crepe-soled shoes
Lateral wedge on the shoe to offset the external rotation during the toe-off phase of gait commonly seen after this procedure
Steel shank to extend the foot lever and prevent deformity at the toe break
Custom-made shoe to provide the best possible fit and function

Correct Answer: Steel shank to extend the foot lever and prevent deformity at the toe break

Explanation:

DISCUSSION: The steel shank is a flat 1-inch steel strip placed between layers of the shoe to extend the foot lever and prevent deformity at the toe break seen following a partial first ray amputation. A rocker sole may be added as well to facilitate transition from foot flat to the toe-off phase of gait. Proper shoe fit is important, but “snug” fitting shoes in a patient with peripheral neuropathy and likely fluctuations in volume from intermittent swelling are to be avoided. A custom shoe is an unnecessary expense. The patient has at least 10 degrees of dorsiflexion at the ankle with an intact anterior tibialis muscle; therefore, catching the sole on carpeting should not be a problem.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, et al: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Pinzur MS, Dart HC: Pedorthic management of the diabetic foot. Foot Ankle Clin 2001;6:205-214.

Question 3:

Which of the following findings is more suggestive of neurogenic rather than vascular claudication in the differential diagnosis of leg pain?

Options:

Loss of skin hair on the feet
Absent pulses on vascular examination
Pain that originates proximally and spreads distally
Pain that is relieved by stopping and standing
Pain that is worse when the patient walks uphill rather downhill

Correct Answer: Pain that originates proximally and spreads distally

Explanation:

Question 4:

Options:

Recurrent branch of the deep peroneal
Recurrent branch of the sural
Terminal cutaneous branch of the saphenous
Dorsomedial cutaneous branch of the superficial peroneal
Medial plantar

Correct Answer: Dorsomedial cutaneous branch of the superficial peroneal

Explanation:

DISCUSSION: Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.
REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.
Sarrafian
SK
: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 5:

A 23-year-old woman with recurrent anterior instability undergoes an open Bankart procedure. Six months after surgery the patient reports shoulder

Options:

Physical therapy
Biceps tenolysis
Subscapularis repair
Supraspinatus repair
Pectoralis major repair

Correct Answer: Subscapularis repair

Explanation:

Question 6:

In the anterior cruciate ligament (ACL)-deficient knee, which of the following variables has the highest correlation with the development of arthritis?

Options:

Duration of time since the injury
Patient age
Additional ligament injury
Degree of laxity
Meniscal integrity

Correct Answer: Meniscal integrity

Explanation:

Question 7:

Figures 11a and 11b show the clinical photograph and radiograph of a newborn. Based on these findings, what is the best course of action?

Options:

Genetic testing
Stretching exercises performed by the parents
A series of corrective plaster casts
A long leg orthosis to control the foot and leg
Surgical lengthening of the anterior tibial tendon and a short leg cast

Correct Answer: Stretching exercises performed by the parents

Explanation:

Question 8:

Bioabsorbable polymers are used in a wide range of orthopaedic devices, including anchors, staples, pins, plates, and screws. What is the primary drawback for bioabsorbable implants?

Options:

High cost
Increased rates of infection
High elastic modulus
Brittleness
Foreign body reaction

Correct Answer: Foreign body reaction

Explanation:

DISCUSSION: A number of bioabsorbable polymers are used in orthopaedic applications, and all have in common reports of foreign body reactions, which occur in more than 50% of patients in some series. In general, the high cost of these polymers is offset by the elimination of a second surgery to remove the implant. Bioabsorbable polymers are low strength in comparison to metallic alloys but of sufficient strength for many orthopaedic applications. The elastic modulus is not as high as many other orthopaedic biomaterials, making them suitable for applications where lower stiffness is an asset.
REFERENCES: Ambrose CG, Clanton TO: Bioabsorbable implants: Review of clinical experience in orthopedic surgery. Ann Biomed Eng 2004;32:171-177.
Bergsma JE, de Bruijn WC, Rozema FR, et al: Late degradation tissue response to poly
(L-lactide) bone plates and screws. Biomaterials 1995;16:25-31.

Question 9:

Options:

Deltoid ligament
Calcaneofibular ligament
Anterior tibiofibular ligament
Posterior tibiofibular ligament

Correct Answer: Calcaneofibular ligament

Explanation:

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The
anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. The diagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization
and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 10:

Options:

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

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

Explanation:

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

Question 11:

An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?

Options:

Transverse
Both column
Anterior column posterior hemitransverse
Posterior column with posterior wall
Anterior column with anterior wall

Correct Answer: Transverse

Explanation:

Question 12:

Options:

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

Correct Answer: no differences in long-term results.

Explanation:

DISCUSSION FOR QUESTIONS 44 AND 45
The Lachman test is the most sensitive examination for acute ACL injuries. ACL injury rates are higher in women than in men. This likely is attributable to anatomic differences (smaller notches, smaller ligaments, and different landing biomechanics). Lateral meniscal tears are more common than medial tears. The anterior drawer test is accentuated with 30 degrees of external rotation of the tibia. The MRI scan shows bone bruises consistent with an ACL tear. It is also always necessary to examine other structures of the knee in patients with ACL tears. All ligaments of the affected knee should be assessed.Lateral meniscal tears are frequently associated with ACL tears. Medial meniscal tears and posterolateral corner deficiency are also possible. Randomized clinical trials comparing an early accelerated vs nonaccelerated rehabilitation have demonstrated no significant differences in long-term results. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 13:

What is the most common causative bacteria in septic arthritis in children?

Options:

Staphylococcus aureus
Brucella melitensis
Haemophilus influenzae
Kingella kingae
Streptococcus pneumonia

Correct Answer: Staphylococcus aureus

Explanation:

Question 14:

Options:

Long-arm cast
Percutaneous screw fixation
Open reduction and internal fixation (ORIF) with bone graft
Proximal row carpectomy

Correct Answer: Open reduction and internal fixation (ORIF) with bone graft

Explanation:

Question 15:

Options:

pseudarthrosis.
hypertrophic nonunion.
healed fracture.
atrophic nonunion.

Correct Answer: hypertrophic nonunion.

Explanation:

Question 16:

- A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Options:

Labral repair
acromioplasty
excision of the coracoid process
an arthroscopic Bankart procedure
subscapularis repair

Correct Answer: subscapularis repair

Explanation:

Question 17:

- A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 18:

Options:

Chemotherapy alone
Surgery alone
Radiation therapy alone
Chemotherapy and surgery
Radiation therapy and surgery

Correct Answer: Surgery alone

Explanation:

DISCUSSION: This is a conventional chondrosarcoma. The radiograph and the CT scan show a lesion arising from the inferior pubic ramus with a large soft-tissue mass. Abundant punctate, stippled, or “popcorn-like” calcification is present. The photomicrograph demonstrates hypercellular cartilage. Surgical resection is the only effective treatment. Whereas chemotherapy might play a role in the treatment of a dedifferentiated chondrosarcoma, it has no role in the treatment of a conventional chondrosarcoma. Chondrosarcomas are relatively radioresistant.
REFERENCES: Donati D, El Ghoneimy A, Bertoni F, et al: Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br 2005;87:1527-1530.
Lee FY, Mankin HJ, Fondren G, et al: Chondrosarcoma of bone: An assessment of outcome.
J Bone Joint Surg Am 1999;81:326-338.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.

Question 19:

Options:

Antibiotic coverage for pseudomonas
Tetanus booster
Radiographs of the foot
MRI to evaluate for possible abscess or osteomyelitis
Surgical debridement of the wound

Correct Answer: Radiographs of the foot

Explanation:

Question 20:

Which of the following variables has been shown to have the greatest influence on the higher rate of anterior cruciate ligament (ACL) tears in women when compared to men for similar sports?

Options:

Hormones
ACL strength
Notch width
Neuromuscular training
Leg alignment

Correct Answer: Neuromuscular training

Explanation:

Question 21:

Options:

hemivertebra excision.
anterior and posterior spinal fusion with instrumentation from T4 to L4.
convex anterior hemiepiphyseodesis.
convex posterior hemiarthrodesis.
an orthosis.

Correct Answer: hemivertebra excision.

Explanation:

Question 22:

When using highly cross-linked ultra-high molecular weight polyethylene as an articulating surface for total knee arthroplasty, what property of the material raises concern?

Options:

Decreased volumetric wear
Decreased ductility
Increased mobility of the ultra-high molecular weight polyethylene chains in the material
Increased fatigue resistance
Increased fracture toughness

Correct Answer: Decreased ductility

Explanation:

Question 23:

Hamstring lengthening and posterior transfer of the rectus femoris will be most successful in a patient with cerebral palsy who has which of the following gait abnormalities?

Options:

Excessive knee flexion through stance, stiff knee during swing, and rectus femoris activity in swing
Excessive knee flexion through stance and continuous quadricep activity in stance and swing
Excessive knee flexion through stance, short stride length, and continuous hamstring activity in swing
Knee hyperextension in stance, knee extension during swing, and rectus femoris activity in swing
Knee hyperextension in stance, continuous rectus femoris activity in stance and swing, and drop foot

Correct Answer: Excessive knee flexion through stance, stiff knee during swing, and rectus femoris activity in swing

Explanation:

Question 24:

Options:

Positive froment sign with the ulnar palm flat on a table
Weak thumb abduction with the dorsal palm flat on a table
Inability to flex the thumb with the palm flat on a table
Inability to extend the thumb with the palm flat on a table

Correct Answer: Inability to extend the thumb with the palm flat on a table

Explanation:

Question 25:

Options:

Examination of the pedal pulses
Ankle-brachial pressure index
Duplex ultrasound
Arteriography
Exploration of the popliteal artery

Correct Answer: Examination of the pedal pulses

Explanation:

Question 26:

When the great toe deviates into a valgus position, the action of the abductor hallucis muscle becomes one of

Options:

increased abduction.
pronation.
flexion.
flexion and pronation.
extension.

Correct Answer: flexion and pronation.

Explanation:

DISCUSSION: The abductor hallucis muscle inserts together with the medial tendon of the flexor hallucis brevis into the medial base of the proximal phalanx of the great toe. When the hallux assumes a valgus position, the action of the abductor becomes one of flexion and pronation of the first metatarsal.
REFERENCES: Resch S: Functional anatomy and topography of the foot and ankle, in Myerson M (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, vol 1, pp 25-49.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 27:

Figure 11 shows the anatomic dissection of the medial side of the knee joint after removal of the superficial fascia. The arrow is pointing to what structure?

Options:

Semitendinosus tendon
Gracilis tendon
Sartorius tendon
Semimembranosus tendon
Medial collateral ligament

Correct Answer: Semitendinosus tendon

Explanation:

Question 28:

Options:

Wedge the cast to correct angulation.
Accept the present alignment and continue follow-up.
Perform open reduction and internal fixation of both the radius and ulna with plates and screws.
Perform open reduction and internal fixation of both the radius and ulna with intramedullary rods.
Remanipulate both the radius and ulna and stabilize with an external fixator.

Correct Answer: Accept the present alignment and continue follow-up.

Explanation:

Question 29:

Options:

extended trochanteric osteotomy and revision to a cementless long-stem prosthesis.
extended trochanteric osteotomy and revision to a cemented long-stem prosthesis.
revision to a cementless long-stem prosthesis without use of an extended trochanteric osteotomy.
revision to a cemented long-stem prosthesis without use of an extended trochanteric osteotomy.

Correct Answer: extended trochanteric osteotomy and revision to a cementless long-stem prosthesis.

Explanation:

Question 30:

Options:

Inadequate graft strength
Failure to restore graft length
Malposition of the femoral tunnel
Malposition of the tibial tunnel

Correct Answer: Malposition of the femoral tunnel

Explanation:

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to
63
the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056.
View
Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068.
View Abstract at PubMed

Question 31:

Options:

Bed rest for 6 weeks, followed by a thoracolumbosacral orthosis (TLSO) until the fracture is healed
TLSO and or body cast for 3 to 6 months with mobilization when comfortable
Posterior spinal fusion and instrumentation
Anterior decompression with spinal fusion and instrumentation
Anterior decompression and anterior-posterior spinal fusion and instrumentation

Correct Answer: TLSO and or body cast for 3 to 6 months with mobilization when comfortable

Explanation:

Question 32:

- An infected total knee replacement with symptoms occurring within 4 weeks of surgery and no radiographic signs of osteomyelitis would be best managed with

Options:

Knee fusion
Open irrigation and debridement
Arthroscopic irrigation and debridement
One-stage exchange arthroplasty
Two-stage exchange arthroplasty

Correct Answer: Open irrigation and debridement

Explanation:

Question 33:

Options:

a non-weight-bearing cast for 4 weeks.
eccentric calf stretching and physical therapy.
a cortisone injection.
tendon debridement.
tendon debridement and augmentation.

Correct Answer: eccentric calf stretching and physical therapy.

Explanation:

Question 34:

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Options:

Radial nerve injury
1 cm shortening
20 degree varus deformity
Brachial plexus injury
Comminuted fracture pattern

Correct Answer: Radial nerve injury

Explanation:

Question 35:

Options:

Hooke's law
Kirchhoff's law
Wolff's law
Heuter-Volkmann principle

Correct Answer: Heuter-Volkmann principle

Explanation:

Question 36:

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

Options:

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

Correct Answer: Pectoralis major

Explanation:

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

Question 37:

What is the goal of surgical treatment in this scenario?

Options:

To cure cancer
To prolong life
To relieve pain
To reverse neurologic symptoms

Correct Answer: To relieve pain

Explanation:

DISCUSSION
This patient has a metastatic neuroendocrine tumor. Surgical treatment should prioritize palliation of her symptoms. She has high-grade spinal cord compression without neurologic signs or symptoms. Steroids are beneficial for patients with high-grade spinal cord compression caused by tumors, and these drugs should be administered in the acute setting. This patient was appropriately initially treated with conventional radiation. However, she is not a candidate for further radiation because of spinal cord tolerance limits and insufficient clearance between the tumor and spinal cord. Consequently, stereotactic radiation is not an option.
The goal of surgical treatment of this tumor should be palliation of her symptoms rather than cure. A costotransversectomy approach offers the advantage of ventral and dorsal spinal cord access, which is necessary in this case. A sternotomy or transthoracic approach would offer ventral access, but dorsal access would be less than optimal.
RECOMMENDED READINGS
Rose PS, Buchowski JM. Metastatic disease in the thoracic and lumbar spine: evaluation and management. J Am Acad Orthop Surg. 2011 Jan;19(1):37-48. Review. PubMed PMID: 21205766.
View Abstract at PubMed
Rades D, Abrahm JL. The role of radiotherapy for metastatic epidural spinal cord compression. Nat Rev Clin Oncol. 2010 Oct;7(10):590-8. doi: 10.1038/nrclinonc.2010.137. Epub 2010 Aug

Question 38:

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

Options:

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

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

Explanation:

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

Question 39:

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

Options:

Saphenous vein
Saphenous nerve
Posterior tibial nerve
Sural nerve
Plantaris muscle

Correct Answer: Sural nerve

Explanation:

Question 40:

Options:

He can expect complete resolution of his symptoms during the first month.
All patients experience relief within 3 months and continue to improve over the next 4 years.
Most patients experience some pain relief within the first 3 months.
He may experience some improvement but if he requires surgery at a later date he will have a poorer result because of the delay.
The patient requires immediate surgery to avoid permanent nerve damage.

Correct Answer: Most patients experience some pain relief within the first 3 months.

Explanation:

DISCUSSION: The patient has lumbar spinal stenosis and the MRI scans reveal the pathology at L4-5, which is secondary to posterior disk bulging and hypertrophy and infolding of the ligamentum flavum, as well as degenerative facet arthrosis. The degree of spinal stenosis is moderate and his symptoms are positional in nature. Tadokoro and associates reported on a prospective study of 89 patients older than 70 years of age who underwent nonsurgical management for lumbar spinal stenosis. They found the prognosis to be relatively good with patients scoring at “excellent” or “good” for activities of daily living at final follow-up. However, they did note that patients with a complete block on myelography did not respond favorably to nonsurgical management. Amundsen and associates reported on a 10-year prospective study comparing surgical care to nonsurgical management. They concluded that, while the long-term results largely favored surgical treatment, more than half of the nonsurgically managed patients had a satisfactory outcome. They also concluded that a delay of surgery for some months did not worsen the prognosis. Therefore, their recommendation was for an initial primarily nonsurgical approach.
REFERENCES: Amundsen T, Weber H, Nordal HJ, et al: Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine 2000;25:1424-1435.
Hilibrand AS, Rand N: Degenerative lumbar stenosis: Diagnosis and management. J Am Acad Orthop Surg 1999;7:239-249.
Tadokoro K, Miyamoto H, Sumi M, et al: The prognosis of conservative treatments for lumbar spinal stenosis: Analysis of patients over 70 years of age. Spine 2005;30:2458-2463.

Question 41:

Suprapatellar intramedullary nailing for tibia fractures when compared to infrapatellar nailing is associated with

Options:

decreased knee range of motion.
increased incidence of malalignment.
less anterior knee pain.
changes in the patellofemoral joint.

Correct Answer: less anterior knee pain.

Explanation:

Question 42:

Options:

Observation
Physical therapy
Epidural steroid injections
Cervical laminectomy
Anterior cervical diskectomy and fusion

Correct Answer: Anterior cervical diskectomy and fusion

Explanation:

DISCUSSION: The patient has obvious signs of progressive myelopathy. Based on her significant physical examination findings, nonsurgical management will not significantly impact her outcome. Cervical decompression alone is contraindicated in patients with cervical kyphosis such as seen here. Anterior cervical fusion is the best option.
REFERENCES: Emery SE, Bohlman HH, Bolesta MJ, et al: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: Two to seventeen-year follow-up. J Bone Joint Surg Am 1998;80:941-951.
Ferguson RJ, Caplan LR: Cervical spondylotic myelopathy. Neurol Clin 1985;3:373-382.
Herkowitz HN: A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine 1988;13:774-780.

Question 43:

Options:

The examiner brings a finger from medial to lateral across the antecubital fossa, feeling for a cord-like structure.
The examiner brings a finger from lateral to medial across the antecubital fossa, feeling for a cord-like structure.
With the elbow flexed to 90°and the forearm pronated, the examiner resists patient supination, evaluating for pain at the bicipital groove.
With the patient’s arm elevated to 90° of forward flexion, the elbow extended, and the forearm supinated, the examiner resists elevation distal to the elbow, evaluating for pain at the bicipital groove.

Correct Answer: The examiner brings a finger from lateral to medial across the antecubital fossa, feeling for a cord-like structure.

Explanation:

EXPLANATION:

Question 44:

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Options:

Isotonic
Isokinetic
Isometric
Open kinetic chain
Dynamic variable resistance

Correct Answer: Open kinetic chain

Explanation:

Question 45:

A patient has a tibial shaft fracture and is suspected of having a compartment syndrome involving the deep posterior compartment. Associated signs and symptoms would include paresthesias over the

Options:

dorsum of the foot and pain with passive toe flexion.
dorsum of the foot and pain with passive toe extension.
plantar foot and pain with passive toe flexion.
plantar foot and pain with passive toe extension.
entire foot and pain with active toe extension.

Correct Answer: plantar foot and pain with passive toe extension.

Explanation:

Question 46:

- What is the primary mechanism of wear of polyethylene acetabular components?

Options:

Crevice corrosion
Oscillatory fretting
Oxidative degradation
Adhesion and abrasion
Fatigue and delamination

Correct Answer: Adhesion and abrasion

Explanation:

Question 47:

Options:

Arthroscopic rotator cuff repair
Shoulder hemiarthroplasty
Anatomic total shoulder arthroplasty
Anatomic total shoulder arthroplasty and pectoralis major transfer
Reverse total shoulder arthroplasty and latissmus dorsi transfer

Correct Answer: Anatomic total shoulder arthroplasty and pectoralis major transfer

Explanation:

Question 48:

Options:

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

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

Explanation:

Question 49:

What is the main mechanism for nutrition of the adult disk?

Options:

Capillary network from the adjacent segmental arteries
Capillary network from the arterioles in the vertebral body
Diffusion through the anulus fibrosus
Diffusion through pores in the end plates
Diffusion through nerves in the dorsal root ganglion

Correct Answer: Diffusion through pores in the end plates

Explanation:

Question 50:

During primary total knee arthroplasty, the trial components are in place. The extensor space is tight, but the flexion space is normal. What is the best gap balancing solution?

Options:

Decrease the thickness of the tibial insert.
Upsize the femoral component and distally augment the femur.
Resect additional distal femoral bone.
Resect additional distal femoral bone and proximal tibial bone.
Resect the proximal tibial bone and distally augment the femoral component.

Correct Answer: Resect additional distal femoral bone.

Explanation:

Question 51:

To preserve blood supply to the fractured bone seen in Figures 12a and 12b, care should be taken when exposing which of the following areas?

Options:

Anterolateral aspect of the distal humerus
Posterolateral aspect of the distal humerus
Medial epicondyle
Lateral epicondyle
Radial neck

Correct Answer: Posterolateral aspect of the distal humerus

Explanation:

Question 52:

Options:

Single factor analysis of variance
Chi-square test
Student t-test
Mann-Whitney rank sum test
Wilcoxon rank sum test

Correct Answer: Mann-Whitney rank sum test

Explanation:

Question 53:

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

Options:

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

Correct Answer: Flexor hallucis longus

Explanation:

Question 54:

Options:

Sex of the patient
Type of health insurance
Child greater than 10 years of age
Acute knee injuries requiring operative treatment
Timing of the referral

Correct Answer: Sex of the patient

Explanation:

Question 55:

Use of prophylactic knee bracing in contact sports participants results in which of the following?

Options:

Decreased incidence of anterior cruciate ligament injuries
Decreased incidence of posterior cruciate ligament injuries
Decreased incidence of medial collateral ligament injuries
Decreased incidence of meniscal tears
Decreased incidence of ankle injuries

Correct Answer: Decreased incidence of medial collateral ligament injuries

Explanation:

Question 56:

Options:

Forward elevation in the scapular plane
External rotation and abduction
Flexion, adduction, and internal rotation
Flexion and abduction

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 57:

Options:

at least two more attempts at closed reduction in the emergency department before the patient’s sedation wears off.
at least two attempts at closed reduction in the operating room under general anesthesia with muscle relaxation.
acceptance of the reduction because the alignment is satisfactory and growth problems are rare with Salter-Harris type I fractures.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to prevent nonunion.
open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Correct Answer: open reduction, extraction of any interposed periosteum, and smooth wire fixation to decrease the chance of premature physeal closure.

Explanation:

DISCUSSION: The widening of the physis associated with incomplete reduction of this fracture suggests that periosteum is interposed at the fracture site. Clinical and animal study findings suggest that the interposed periosteum may lead to premature physeal closure. Repeated forceful attempts at reduction may subject the physis to further injury and should be avoided. Growth problems are common in children with Salter-Harris type I fractures of the lower extremities. Nonunions are rare in children with Salter-Harris type I fractures.
REFERENCES: Barmada A, Gaynor T, Mubarak SJ: Premature physeal closure following distal tibial physeal fractures: A new radiographic predictor. J Pediatr Orthop 2003;23:733-739.
Gruber HE, Phieffer LS, Wattenbarger JM: Physeal fractures: Part II. Fate of interposed periosteum in a physeal fracture. J Pediatr Orthop 2002;22:710-716.

Question 58:

Options:

Pseudoparalysis secondary to fracture of the proximal humerus
Cervical myelomeningocele
Erb palsy
Arthrogryposis
Cerebral palsy and spastic hemiplegia

Correct Answer: Erb palsy

Explanation:

Question 59:

Options:

A genetic problem
Repetitive activities involving an open proximal femoral physis
Early closure of the proximal femoral physis
Hip dysplasia

Correct Answer: Repetitive activities involving an open proximal femoral physis

Explanation:

Question 60:

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Options:

An electric wheelchair with puffer control
An electric wheelchair with hand controls
A manual wheelchair and sliding board transfers
A manual wheelchair and independent transfers
Crutches with long leg braces for short distance ambulation

Correct Answer: A manual wheelchair and sliding board transfers

Explanation:

Question 61:

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Options:

Incidental finding on imaging tests
Pain
Presence of a mass
Deformity
Neurologic symptoms

Correct Answer: Presence of a mass

Explanation:

Question 62:

Options:

Lumbar laminectomy with synovial cyst excision
Repeat epidural steroid injection
Microdiskectomy at L4-5
Nonsteroidal medication and outpatient physical therapy
Left-sided facet blocks at L4-5 and L5-S1

Correct Answer: Lumbar laminectomy with synovial cyst excision

Explanation:

DISCUSSION: Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42 point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
REFERENCES: Lyons MK, Atkinson JL, Wharen RE, et al: Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic Experience. J Neurosurg
2000;93:53-57.
Khan AM, Synnot K, Cammisa FP, et al: Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131.
Epstein NE: Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: An outcome study. Spine 2004;29:1049-1055.

Question 63:

Options:

calcaneal lengthening osteotomy with reefing of the tibialis posterior tendon.
excision of the ossicle in the navicular and tibialis posterior tendon advancement.
talonavicular joint arthrodesis.
open reduction and internal fixation of the navicular.
activity and shoe modification and non-narcotic analgesics.

Correct Answer: activity and shoe modification and non-narcotic analgesics.

Explanation:

Question 64:

Options:

Flexor pollicis longus rupture
Median nerve palsy
Ulnar nerve palsy
Anterior interosseous nerve palsy
Posterior interosseous nerve palsy

Correct Answer: Ulnar nerve palsy

Explanation:

The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.
(SBQ12TR.54) A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

Question 65:

In addition to the radiographic features seen in Figures 49a and 49b, this patient will most likely have which of the following findings?

Options:

Microcephaly
1,25 dihydroxy vitamin D deficiency
Normal dentition
Anemia
Developmental delays

Correct Answer: Anemia

Explanation:

Question 66:

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

Options:

Spica cast immobilization
Rigid reamed nailing of the femur and a short leg cast
Flexible nailing of the femur and tibia
Reamed nails of the femur and tibia
Spanning external fixator

Correct Answer: Flexible nailing of the femur and tibia

Explanation:

Question 67:

Options:

no weight bearing.
weight bearing as tolerated in a hard-soled shoe.
a short leg walking cast.
second metatarsophalangeal joint debridement and metatarsal osteotomy.
a longitudinal arch support with metatarsal head relief.

Correct Answer: a short leg walking cast.

Explanation:

DISCUSSION: Freiberg’s infraction is believed to be an osteochondrosis of the second metatarsal head. It is the only osteochondrosis that has a predilection for females. The typical patient is an athletically active adolescent female. The radiograph shows stage II disease wherein reossification is occurring; it is at this time that the second metatarsal head is most susceptible to deformation. Therefore, initial management should consist of a short leg
walking cast.
REFERENCE: Mann RA, Coughlin MJ: Keratotic disorders of the plantar skin, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 413-415.

Question 68:

Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation? Review Topic

Options:

Apprehension sign
Jobe relocation test
Sulcus sign
Jerk test
Lack of external rotation

Correct Answer: Lack of external rotation

Explanation:

Question 69:

Options:

angiography.
curettage and cementation.
resection and modular distal femoral knee replacement.
radiation therapy.
a technetium Tc 99m bone scan and AP and lateral radiographs of the entire right femur.

Correct Answer: a technetium Tc 99m bone scan and AP and lateral radiographs of the entire right femur.

Explanation:

Question 70:

Options:

Proceed with implantation of the final components.
Perform a Z-lengthening of the patellar tendon.
Increase the size of the femoral component and use posterior femoral augments to decrease the size of the flexion gap.
Increase the size of the femoral component and use augments both distally and posteriorly to lower the joint line and decrease the size of the flexion gap.
Place distal femoral augments on the femoral component to lower the joint line.

Correct Answer: Perform a Z-lengthening of the patellar tendon.

Explanation:

Question 71:

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

Options:

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

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

Explanation:

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

Question 72:

Prescribing touch (10 to 15 kg) weight-bearing would be most appropriate in the following scenario?

Options:

Acute grade II anterior talofibular ligament ankle sprain
Partial lateral menisectomy for incomplete radial tear
Open reduction internal fixation for comminuted calcaneus fracture
Cemented hemiarthroplasty for displaced femoral neck fracture
Open reduction internal fixation for transtectal transverse posterior wall fracture

Correct Answer: Acute grade II anterior talofibular ligament ankle sprain

Explanation:

Question 73:

Options:

A 270-degree labral tear
His intention to continue contact sport activities
Anterior bony loss measuring 30% of inferior glenoid width
An inferior glenohumeral ligament avulsion (HAGL) lesion

Correct Answer: Anterior bony loss measuring 30% of inferior glenoid width

Explanation:

DISCUSSION
There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Although some studies suggest that open stabilization may result in lower recurrence rates in contact athletes, this approach is now under scrutiny. Extensive labral involvement (posterior labral involvement in this scenario) is likely more accessible via arthroscopic methods. Although HAGL lesions may be more easily accessible via an open approach (particularly for inexperienced arthroscopists), numerous authors describe successful repair via arthroscopic techniques. Among these responses, the strongest indication for an open approach, including possible bony transfer, is high-grade glenoid bone loss. Although the critical amount of bone loss is a topic of debate, most surgeons and authors suggest a cutoff of 20% to 25%.
CLINICAL SITUATION FOR QUESTIONS 90 THROUGH 92
Figure 90 is the radiograph of a 14-year-old pitcher who plays in a year-round baseball program and has vague pain in his dominant shoulder. The pain occurs with throwing, and it has been worsening for 2 months. Pain typically occurs during the late cocking phase of throwing. He has no tenderness of the rotator cuff and 5/5 rotator cuff strength. His arc of motion is symmetric between his dominant and nondominant arms. The sulcus sign is negative.

Question 74:

Options:

Higher risk of infection
Lower risk of C5 radiculopathy
Higher over-all complication rate
Lower average blood loss
Increased rate of numbness to the long finger and wrist flexion weakness

Correct Answer: Higher risk of infection

Explanation:

Question 75:

Results of a study demonstrating no difference between treatments when a difference truly exists is an example of which of the following?

Options:

Statistical insignificance
Type I error
Type II error
Fragile p-values
Negative predictive value

Correct Answer: Type II error

Explanation:

A type II error (also known as a beta error) occurs when results demonstrate that two groups are similar when, in reality, they are different (with regard to the statistic being measured). Type I errors show that a difference exists when, in reality, no difference exists. A statistically insignificant result may lead an investigator to conclude that no difference exists between two groups; this may be correct (and therefore not a type II error). The concept of `fragile` p-values is that small sample sizes may result in wide variability of p-values with only one change in a data point for a given group. This singular change could be a chance occurrence, but it still can affect the statistical
significance of the outcomes analysis. Fragility of p-values is limited by increasing sample sizes. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

Question 76:

The natural history of cervical spondylolytic myelopathy is best described as

Options:

slow, steady deterioration.
rapid deterioration.
stable over time.
stable for long periods with stepwise deterioration.
significant improvement after an initial episode of severe symptoms.

Correct Answer: stable for long periods with stepwise deterioration.

Explanation:

Question 77:

Figure 17 shows the AP radiograph of a 5-year old child who has mild short stature and a painless bilateral gluteus medius lurch. Initial work-up should include

Options:

a bone scan.
a skeletal survey.
MRI of the hips.
CT of the hips.
a CBC count and a C-reactive protein.

Correct Answer: a skeletal survey.

Explanation:

DISCUSSION: Bilateral flattening of the femoral heads suggests multiple epiphyseal dysplasia; therefore, a skeletal survey is indicated to look for involvement of other epiphyses. Unilateral flattening of the femoral head would suggest Legg-Perthes disease.
REFERENCES: Sponseller PD: Skeletal dysplasias, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 269-270.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 1, pp 689-691.

Question 78:

Options:

Conversion to a halo vest
Closed reduction and conversion to a halo vest
Posterior atlantoaxial arthrodesis
Odontoid screw fixation
Continued halo immobilization

Correct Answer: Conversion to a halo vest

Explanation:

DISCUSSION: The traditional treatment of a reduced type II fracture is a halo vest. A 20-year-old man will tolerate a halo vest better than the elderly or women. Anterior screw fixation has gained increasing support; however, it too has risks and requires a significant learning curve. More recently, C1 lateral mass screws have become more popular. The long-term results and benefits have not yet been determined.
REFERENCES: Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 193.
Kiovikko MP, Kiuru MJ, Koskinen SK, et al: Factors associated with nonunion in conservatively-treated type-II fractures of the odontoid process. J Bone Joint Surg Br 2004;86:1146-1151.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, p 1091.
Fiore AJ, Haid RW, Rodts GE, et al: Atlantal lateral mass screws for posterior spinal reconstruction: Technical note and case series. Neurosurg Focus 2002;12:E5.

Question 79:

Options:

in situ subtalar fusion.
tibiotalocalcaneal arthrodesis using an intramedullary rod.
ankle arthroscopy with debridement of osteophytes.
subtalar distraction bone block arthrodesis.
lateral wall ostectomy of the calcaneus.

Correct Answer: subtalar distraction bone block arthrodesis.

Explanation:

Question 80:

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Options:

Proximal femur
Proximal humerus
Proximal tibia
Distal femur
Distal humerus

Correct Answer: Proximal tibia

Explanation:

Question 81:

With respect to the structure identified by the arrow in Figure 22b, the meniscofemoral 25 ligaments are

Options:

uniformly present, and are positioned posterior to the injured ligament.
uniformly present, with one positioned anterior and the other positioned posterior to the injured ligament.
variably present, and are positioned posterior to the injured ligament.
variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Correct Answer: variably present, with one positioned anterior and the other positioned posterior to the injured ligament.

Explanation:

DISCUSSION
The stress radiographs demonstrate posterior instability of the right knee in flexion. The MR images demonstrate injury to both the anterior and posterior cruciate ligament (PCL), with the stump identified with the arrow on the MR image (Figure 22b). The PCL has 2 functional bands. The anterolateral bundle originates from the roof of the intercondylar notch. It runs in a posterolateral direction onto the tibial crest between the posterior attachment of the medial and lateral menisci. During a double-bundled posterior ligament reconstruction, the
anterolateral bundle is tensioned with the knee in a position of mid flexion. The posteromedial bundle has a variable pattern of tension both in extension and in high flexion. Tensioning of the posteromedial bundle in extension may contribute to resistance against knee hyperextension.
The meniscofemoral ligaments are variably present. Although 93% of knees have been reported to have at least 1 meniscofemoral ligament present, both ligaments are simultaneously present in approximately 50% of knees. The ligament of Humphrey (anterior meniscofemoral ligament) and ligament of Wrisberg (posterior meniscofemoral ligament) are delineated by their anatomic relationship to the posterior cruciate.
RECOMMENDED READINGS
Amis AA, Bull AM, Gupte CM, Hijazi I, Race A, Robinson JR. Biomechanics of the PCL and related structures: posterolateral, posteromedial and meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2003 Sep;11(5):271-81. Epub 2003 Sep 5. Review. PubMed PMID: 12961064.
View Abstract at PubMed
Amis AA, Gupte CM, Bull AM, Edwards A. Anatomy of the posterior cruciate ligament and the meniscofemoral ligaments. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):257-63. Epub 2005 Oct 14. Review. PubMed PMID: 16228178.
View Abstract at PubMed
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26

Question 82:

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Options:

Nondisplaced distal radius fracture
Nondisplaced Rolando fracture
Second metacarpal base fracture
Boxer's fracture
Nondisplaced radial styloid fracture

Correct Answer: Nondisplaced distal radius fracture

Explanation:

Question 83:

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

Options:

Asymmetric joint space narrowing
Sacroiliac joint ankylosis
Progressive superior and lateral migration of the femoral head
Periarticular osteopenia
Hip synovitis

Correct Answer: Periarticular osteopenia

Explanation:

Question 84:

Options:

Anterior diskectomy without fusion at C4-C5
Epidural injections
Anterior diskectomy and fusion at C4-C5 and C5-C6
Multilevel laminectomy and fusion
Multilevel posterior foraminotomies

Correct Answer: Multilevel laminectomy and fusion

Explanation:

Question 85:

Performance parameters developed by the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention regarding prophylactic antibiotics include

Options:

initiation within 1 hour of incision, use of an appropriate antibiotic, and continuation of antibiotics until all surgical drains are removed.
initiation within 1 hour of incision, use of an appropriate antibiotic, and continuation of antibiotics for 48 hours postoperatively for all joint arthroplasty patients.
initiation within 1 hour of incision, use of vancomycin for all patients having hardware inserted, and continuation of antibiotics for 24 hours postoperatively.
initiation within 1 hour of incision, use of an appropriate antibiotic, and continuation of antibiotics for 24 hours postoperatively.
initiation within 1 hour of incision, use of vancomycin for all patients having hardware inserted, and continuation of antibiotics until all surgical drains are removed.

Correct Answer: initiation within 1 hour of incision, use of an appropriate antibiotic, and continuation of antibiotics for 24 hours postoperatively.

Explanation:

Question 86:

Options:

Resurfacing hemiarthroplasty
Resurfacing hemiarthroplasty with fascial glenoid resurfacing
Resurfacing hemiarthroplasty with cemented glenoid component
Stemmed hemiarthroplasty
Stemmed total shoulder arthroplasty

Correct Answer: Stemmed hemiarthroplasty

Explanation:

Question 87:

Options:

Intramedullary screw fixation of the fibula
Plating of the fibula with a one third tubular plate
Subtalar arthrodesis with deformity correction
Varus producing distal tibial osteotomy
Ankle arthrodesis

Correct Answer: Subtalar arthrodesis with deformity correction

Explanation:

Question 88:

- While under a physician’s care, a 45-year-old man verbally abuses the staff and nurses who are attempting to carry out orders. A decision to discharge the patient is best carried out by

Options:

Asking the legal staff to seek a court injunction
Copying the patient’s chart and giving it to him as he leaves
Having the patient sign a written legal contract that specifies acceptable behavior
Continuing care of the patient until an appropriate referral can be arranged
Transferring the patient to another orthopaedic surgeon without disclosing the real reason for why the patient is being transferred

Correct Answer: Continuing care of the patient until an appropriate referral can be arranged

Explanation:

The other foils in this answer would be both unethical and would be a violation of “anti-dumping” laws. This would further open the physician, hospital and staff to possible litigation.

Question 89:

Options:

Pain with internal and external rotation of her hip with her hip and knee in an extended position
Limited motion when moving the hip from flexion-abduction-external rotation to flexion-adduction-internal rotation
Moving from hip flexion-abduction-external rotation to neutral triggers a popping sensation
Limitation in active hip range of motion with catching, locking and grinding noted on passive motion
Pain with a half sit-up and tenderness at the pubic ramus

Correct Answer: Pain with a half sit-up and tenderness at the pubic ramus

Explanation:

Question 90:

What is the most likely consequence of a vertebral compression fracture associated with osteoporosis?

Options:

The fractured vertebral body gradually becomes more stiff than before the fracture.
Scoliosis develops.
There is an increased risk of more vertebral fractures.
Overall sagittal alignment remains stable because the adjacent segments of the spine are able to compensate.
The extensor musculature will often hypertrophy in an attempt to stabilize the painful fracture.

Correct Answer: There is an increased risk of more vertebral fractures.

Explanation:

Question 91:

Options:

UCBL orthoses.
triple arthrodesis with Achilles tendon lengthening.
medial calcaneal osteotomy with posterior tibial tendon reconstruction and flexor digitorum longus tendon transfer.
medial calcaneal osteotomy with posterior tibial tendon reconstruction, flexor digitorum longus tendon transfer, and lateral column lengthening.
gastrocnemius lengthening and serial casting.

Correct Answer: triple arthrodesis with Achilles tendon lengthening.

Explanation:

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 92:

Figure 1 shows the clinical photograph obtained from a child with a congenital difference of the hand. What clinical feature(s) is/are characteristic of this condition?

Options:

Cardiac anomalies
Radial deviation of the thumb
Acrosyndactyly with proximal sinus tracts
Absence of the ulna

Correct Answer: Acrosyndactyly with proximal sinus tracts

Explanation:

EXPLANATION:
The clinical photograph reveals a child with amniotic band syndrome or constriction band syndrome. If a band causes an autofusion of the digits without amputation, acrosyndactyly can occur, as demonstrated in the clinical photograph. Typically, a proximal sinus tract with a distal syndactyly is present. Radial deviation of the thumb can be seen most frequently in Apert syndrome. Cardiac anomalies are associated with many congenital upper extremity differences but are not characteristic of amniotic band syndrome.
Ulnar longitudinal deficiency is characterized by hypoplasia or complete absence of the ulna.

Question 93:

Options:

Total knee arthroplasty
Unicompartmental arthroplasty
Insertion of a unispacer
Tibial osteotomy
Knee arthroscopy

Correct Answer: Tibial osteotomy

Explanation:

DISCUSSION: In a relatively young patient who is an avid tennis player, the treatment of choice is a joint preserving procedure. The radiographs reveal varus alignment with loading of the medial compartment. After all nonsurgical management options have been used, the best treatment option is a medial opening wedge osteotomy. A lateral closing wedge osteotomy of the proximal tibia is also a reasonable option, but it is not one of the choices. A unicompartmental arthroplasty or a total knee arthroplasty would place significant restrictions in this patient. A unispacer may be a temporizing procedure but is controversial and without substantial data in the literature. The knee arthroscopy will not address the medial compartment osteoarthritis.
REFERENCES: Nagel A, Insall JN, Scuderi GR: Proximal tibial osteotomy: A subjective outcome study. J Bone Joint Surg Am 1996;78:1353-1358.
Rinonapoli E, Mancini GB, Corvaglia A, et al: Tibial osteotomy for varus gonarthrosis: A 10- to 21-year followup study. Clin Orthop 1998;353:185-193.
Manifold SG, Kelly MA, Richardson L, et al: Osteotomies about the knee, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 947-961.

Question 94:

Figure 50 shows the AP radiograph of an asymptomatic 82-year-old woman who underwent total hip arthroplasty 16 years ago. What is the most likely diagnosis?

Options:

Wear-induced osteolysis
Infection
Metastatic tumor
Loosening of the femoral component
Hip subluxation

Correct Answer: Wear-induced osteolysis

Explanation:

DISCUSSION: Pelvic osteolysis in the presence of a well-fixed porous-coated socket is a recognized complication in total hip arthroplasty. The radiograph shows large lytic lesions superiorly adjacent to an acetabular screw and inferiorly extending into the ischium. It also reveals eccentricity of the femoral head with respect to the acetabular component, consistent
with polyethylene wear.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 440.
Dowd JE, Sychterz CJ, Young AM, et al: Characterization of long-term femoral-head-penetration rates: Association with and prediction of osteolysis. J Bone Joint Surg Am 2000;82:1102-1107.

Question 95:

Options:

Cystinosis
Hypophosphatemia
Renal osteodystrophy
Primary hyperparathyroidism
Nutritional vitamin D deficiency

Correct Answer: Cystinosis

Explanation:

Question 96:

Options:

Order an urgent angiogram and then proceed to the OR.
Repeat the reduction in the emergency department and reassess.
Perform open reduction through an anterior approach.
Perform closed reduction and pinning in the OR and reassess the vascular status.
Perform arterial repair and then stabilize the fracture.

Correct Answer: Perform closed reduction and pinning in the OR and reassess the vascular status.

Explanation:

DISCUSSION: Displaced supracondylar humerus fractures in children may have associated vascular compromise. Decreased blood flow may be due to vessel injury, entrapment within the fracture site, kinking from fracture displacement, or from vessel spasm. Optimal initial treatment in the emergency department includes gentle realignment of the limb and vascular assessment. Angiography is not required in isolated injuries as the level of the vessel compromise is always at the site of the fracture. When blood flow is not restored, the next best step in treatment is to proceed urgently to the operating room. A formal closed reduction and pinning is performed, and then the vascular status is reassessed. Exploration and vascular repair is required if the hand is cool, white, and without pulses.
REFERENCES: Ay S, Akinci M, Kamiloglu S, et al: Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach. J Pediatr Orthop 2005;25:149-153.
Sabharwal S, Tredwell SJ, Beauchamp RD, et al: Management of pulseless pink hand in pediatric supracondylar fractures of humerus. J Pediatr Orthop 1997;17:303-310.
Dormans JP, Squillante R, Sharf H: Acute neurovascular complications with supracondylar humerus fractures in children. J Hand Surg Am 1995;20:1-4.

Question 97:

Options:

intravenous (IV) antibiotics and admission to a medical intensive care unit.
emergent radical debridement including thumb amputation.
emergent revascularization of the thumb with a vein graft.
urgent irrigation of the thumb flexor tendon sheath.

Correct Answer: emergent radical debridement including thumb amputation.

Explanation:

EXPLANATION:
This patient has multiple criteria for necrotizing soft-tissue infection (NSTI, also known as necrotizing fasciitis) including rapidly progressive infection, black bulla, hypotension and hypoxia, and a history of immune compromise. Aggressive emergent debridement including the removal of all necrotic tissue and IV antibiotics can decrease morbidity and mortality. Not all patients will have such obvious NSTI findings. In less clear cases, a scoring system using laboratory values (the Laboratory Risk Indicator for Necrotizing Fasciitis) can help clarify the diagnosis. IV antibiotics are key to treatment as well, but any delay in surgical treatment can increase morbidity and mortality. The black bulla and necrotic-appearing thumb indicate that this infection is not confined to the flexor sheath, therefore irrigation of the tendon sheath alone would be insufficient treatment. Although the thumb is dysvascular, this is because of an
infection, and revascularization is not indicated.

Question 98:

Which factor is a contraindication to surgical treatment of a symptomatic CAM deformity?

Options:

Degenerative tear of the anterosuperior acetabular labrum
Superior hip joint space of 2 mm or less on radiographs
Ipsilateral knee instability
Lumbar spondylolisthesis

Correct Answer: Superior hip joint space of 2 mm or less on radiographs

Explanation:

Question 99:

Options:

Use an autogenous fascial graft.
Use an allograft augmentation.
Complete the tear and then repair the tendon.
Perform a trans-tendon repair.
Biopsy the tissue.

Correct Answer: Complete the tear and then repair the tendon.

Explanation:

Question 100:

The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?

Options:

Anterior superior iliac spine
Sciatic buttress
A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
The most superior portion of the roof of the acetabulum
Iliopectineal line

Correct Answer: A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)

Explanation:

DISCUSSION: The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
REFERENCES: Gardner MJ, Nork SE: Stabilization of unstable pelvic fractures with supra-acetabular compression external fixation. J Orthop Trauma 2007;21:269-273.
Haidukewych GJ, Kumar S, Prpa B: Placement of half-pins for supra-acetabular external fixation: An anatomic study. Clin Orthop Relat Res 2003;411:269-273.
Kim WY, Hearn TC, Seleem O, et al: Effect of pin location on stability of pelvic external fixation. Clin Orthop Relat Res 1999;361:237-244.

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

OITE & ABOS Orthopedic Board Prep MCQs: Foot & Ankle, Trauma & Shoulder | Part 110

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 110

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index