Orthopedic Board Exam MCQs: OITE & AAOS | Part 112

About This Board Review Set

This is Part 112 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 112

This module focuses heavily on: Deformity, Elbow, Fracture, Infection, Nerve.

Sample Questions from This Set

Sample Question 1: What is the most frequent location of entrapment of the deep peroneal nerve?...

Sample Question 2: Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing ...

Sample Question 3: An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain...

Sample Question 4: A fracture of the radial head is surgically exposed using a posterolateral approach to the elbow. Once the radial head is exposed, how should the arm be positioned to best protect the posterior interosseous nerve from injury?...

Sample Question 5: Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

00:00

Start Quiz

Question 1

What is the most frequent location of entrapment of the deep peroneal nerve?

Explanation

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 2

Figures 34a and 34b show the clinical photograph and a weight-bearing radiograph of a patient with diabetes mellitus who has had recurrent ulcers under the head of the talus that have previously resolved with a series of non-weight-bearing total contact casts. The deformity does not correct passively. Dorsalis pedis and posterior tibial pulses are palpable. The patient is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. The ulcer is currently healed. What is the best option to prevent recurrent ulceration and infection?

Explanation

DISCUSSION: This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear.
REFERENCES: Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.
Pinzur M: Surgical versus accommodative treatment for Charcot arthropathy of the midfoot.

Foot Ankle Int 2004;25:545-549.

Question 3

An 80-year-old man with a history of chronic obstructive pulmonary disease (COPD) and dementia is involved in a fall from standing height, striking his forehead. He is seen in the emergency department with predominantly mechanical neck pain but no obvious neurologic deficits. Radiographs reveal a nondisplaced type II odontoid fracture. What is the most appropriate treatment? Review Topic

Explanation

The treatment options for a type II odontoid fracture include halo immobilization, odontoid screw fixation, and posterior atlantoaxial arthrodesis. However, surgical care at this time without attempting nonsurgical management is not warranted; therefore, the most appropriate management at this time is immobilization in a rigid cervical orthosis for 6 to 8 weeks. Halo vest fixation can lead to high healing rates but is generally contraindicated in elderly patients, especially one with COPD and dementia. Posterior surgical fusion techniques provide high fusion rates, but do so at the expense of loss of cervical rotation and surgical complications. Resection of a nondisplaced odontoid fracture without cord compression via a transoral approach is not necessary.

Question 4

A fracture of the radial head is surgically exposed using a posterolateral approach to the elbow. Once the radial head is exposed, how should the arm be positioned to best protect the posterior interosseous nerve from injury?

Explanation

DISCUSSION: As long as the dissection stays proximal to the annular ligament, the posterior interosseous nerve is not at risk for injury. However, to ensure that the nerve is as far removed from the surgical field as possible, the forearm should be placed in pronation. Forearm supination of any degree will bring the nerve toward the surgical field. A neutral position of the forearm or elbow extension with wrist extension will not protect the posterior interosseous nerve.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, Lippincott-Raven, 1992, p 100.
Tubiana R, McCullough CJ, Masquelet AC: An Atlas of Surgical Exposures of the Upper Extremity. Philadelphia, PA, JB Lippincott, 1990, p 106.

Question 5

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Explanation

Of the materials listed titanium (100GPa) has an elastic modulus closest to cortical bone (approximately 18GPa) as well as cancellous bone (approximately 2GPa).
Titanium is a material that is light, highly ductile, strong and corrosion resistant. However, titanium has poor wear resistance and is notch sensitive. It is commonly used as an orthopaedic implant materials because it has torsional and axial stiffness (moduli) that most closely mimics bone. Young’s modulus is constant and different for each material and represents the material's ability to maintain shape under external loading.
Rho et al found that the average Young's modulus for trabecular bone measured ultrasonically and mechanically was 14.8 GPa (S.D. 1.4) and 10.4 (S.D. 3.5), respectively. The average Young's modulus of microspecimens of cortical bone measured ultrasonically and mechanically was 20.7 GPa (S.D. 1.9) and 18.6 GPa (S.D. 3.5), respectively.
Illustration A depicts a stress vs. strain curve. The slope of the line in the elastic zone represents the Young Modulus of Elasticity.
Incorrect Answers:

Question 6

What is the most common problem seen following epiphysiodesis for limb-length discrepancy?

Explanation

DISCUSSION: Errors in timing are by far the most common in this technically safe procedure. Incomplete growth arrest has been reported in up to 15% of patients versus timing errors in 61%. Fracture through the site has been reported rarely. Neurovascular and cartilaginous injury are extremely uncommon but always need to be considered when performing surgery in the vicinity of these structures.
REFERENCES: Blair VP III, Walker SJ, Sheridan JJ, Schoenecker PL: Epiphysiodesis: A problem of timing. J Pediatr Orthop 1982;2:281-284.
Raney ER: Limb-length discrepancy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1519-1526.

Question 7

A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

Explanation

End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight
restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion- extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior
surgery was not deemed a contraindication.

Question 8

The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?

Explanation

DISCUSSION: The 1,2 intercompartmental supraretinacular artery is a branch of the radial artery. The vessel provides a reliable source of vascularized bone graft with an adequate pedicle length for use in scaphoid nonunions.
REFERENCES: Sheetz KK, Bishop AT, Berger RA: The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20:902-914.
Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg

2002;27:391-401.

Question 9

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

Explanation

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

Question 10

When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?

Explanation

DISCUSSION: The MRI scan shows a large mass (lipoma) in the thenar muscles of the palm. The recurrent motor branch of the median nerve innervates the thenar muscles. The anterior interosseous nerve (AIN) in the proximal forearm innervates the flexor pollicis longus, pronator quadratus, and flexor digitorum pollicis to the index and frequently the middle finger. The terminal branch of the AIN innervates only the wrist capsule. The palmar cutaneous branch of the ulnar nerve is a sensory structure to the hypothenar area. There is no commonly described recurrent branch of the ulnar nerve.
REFERENCE: Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg Am 1998;23:852-858.

Question 11

A 45-year-old male presented to the trauma department 10 hours after sustaining a fracture-dislocation of his ankle. The patient underwent an attempted closed reduction of his ankle which can be seen in Figures A and B. The splint was removed, and the appearance of the leg is shown in Figure C. Regarding the best next step in management and the intended goals, which of the following is most accurate?

Explanation

The patient has hemorrhagic fracture blisters overlying the expected locations of incisions for definitive fixation of his ankle fracture, and therefore the next best step in treatment is external fixation. An external fixator will reduce the joint and provide relative stability during appropriate blister care until definitive open reduction internal fixation (ORIF).
Patients with high-energy periarticular fractures in the lower extremity are at risk for surgical wound complications due to compromised soft tissues. As in this case, joint dislocations can place harmful tension on the skin that leads to blistering and/or skin necrosis. An urgent reduction is indicated, and if it cannot be obtained with a closed manipulation alone, percutaneous or open treatment is indicated. Staged joint-spanning external fixation can both hold a reduction and allow access for skin or wound care prior to a definitive open reduction of an articular fracture. Fracture healing during external fixation occurs by enchondral ossification by way of the relative stability.
Strauss et al. developed a treatment protocol for the treatment of fracture blisters. They used silver sulfadine to minimize soft tissue complications by promoting re-epithelialization. After providone-iodine prep, each blister was unroofed by removing the overlying epithelium of the fracture. Once the blister was unroofed, silver sulfadiazine was applied and covered with dry gauze. They would then perform bid dressing changes. Extremities were deemed operable when skin wrinkles were visible on the overlying skin of the injured extremity.
Anglen et al. in a review of external fixation, report that fractures of the lower extremity are frequently associated with soft tissue trauma that precludes safe surgical treatment in the early period. They present a technique of temporary joint-spanning external fixation which allows stabilization of length and alignment while awaiting resolution of soft tissue swelling. They report no differences between patients who had a temporary external fixator and those who did not with respect to healing time, time to partial or full weight bearing, or clinical score.
Figures A and B demonstrate a pronation-external rotation type fracture with disruption of the syndesmosis. Figure C demonstrates fracture blisters.
Illustration A demonstrates an ankle-spanning external fixator. Illustration B demonstrates skin wrinkling to indicate that the skin is safe to incise.
Incorrect Answers:

OrthoCash 2020

Question 12

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic

Explanation

Bone bruises are often noted on MRI after anterior cruciate and medial collateral ligament injuries. The significance of these injuries awaits long-term follow-up studies. The areas of increased signal on T2-weighted images represent areas of acute hemorrhage and are secondary to microfractures of the adjacent medullary trabeculae.

Question 13

A fracture in the following location is most commonly associated with procurvatum and valgus malalignment?

Explanation

Fractures of the proximal tibial shaft are associated with high rates of valgus and apex anterior (procurvatum) malalignment.
Proximal third tibial shaft fractures are often difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. Many different techniques have been devised to overcome the deforming forces. These include (1) Poller blocking screws posterior and lateral to the intramedullary nail (IMN), (2) utilizing a semiextended knee position during IMN of proximal tibia fractures (3) use of a suprapatellar approach for IMN, (4) usage of a slightly more lateral starting point during conventional IMN, and (5) application of unicortical plate.
Ricci et al. describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibia. Post-operatively, all patients in their series had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. At 6 months follow-up, 10/11 patients maintained this alignment.
Illustration A shows intra-operative sagittal radiographs of the proximal tibia. Note the use of Poller blocking screws in the posterior and lateral aspects of the proximal tibia.
Incorrect Answers:

Question 14

The histology of the lesion is shown in Figure 101d. What is the most likely complication after treatment of this lesion?

Explanation

DISCUSSION FOR QUESTIONS 101 THROUGH 103:
The MRI scans show a well-circumscribed inhomogenous mass at the anterior ankle joint consistent with a diagnosis of pigmented villonodular synovitis (PVNS), not an anatomic variant. An inflammatory mass,such as the pannus of rheumatoid arthritis, would reveal moderate signal intensity with relatively uniform signal throughout. The mass is well encapsulated, respecting tissue boundaries and not showing invasive characteristics as malignancies would. The arthroscopic image is also consistent with the reddish-brown frond-like tissue of PVNS. PVNS of the ankle can be treated arthroscopically. If this mode of treatment is chosen, a tissue sample should be sent to pathology for microscopic analysis; débridement should be performed on the remaining tissue. Removal of the instrumentation without débridement will not provide treatment and will result in disease progression. Tourniquet placement does not provide therapeutic benefit.
Brachytherapy has not been described for the treatment of PVNS of the ankle. The histologic image shows multiple multinucleated giant cells, hemosiderin, and very few mitotic figures – consistent with a diagnosis of PVNS. A common complication of PVNS treatment is local recurrence. Arthrofibrosis and chondrolysis are not seen with proper surgical care of these patients. Because this is not an infectious lesion, disseminated infection after treatment is highly unlikely. PVNS rarely metastasizes.
RESPONSES FOR QUESTIONS 104 THROUGH 106
Toe is fused too straight (plantar flexed)
Toe is fused in too much valgus
Toe is fused in too much dorsiflexion
There is a nonunion of the fusion
Excessive shortening of the first metatarsal during preparation for fusion What is the most likely diagnosis for each patient?

Question 15

A 47-year-old woman has a painful bunion of the right foot, and shoe wear modifications have failed to provide relief. Examination reveals a severe hallux valgus with dorsal subluxation of the second toe. Radiographs are shown in Figures 14a and 14b. The most appropriate management should include

Explanation

DISCUSSION: The radiographs do not show significant arthrosis of the hallux metatarsophalangeal joint; therefore, arthrodesis is unnecessary. Orthotics will not correct the deformity. A distally based osteotomy will not achieve sufficient correction of the incongruity of deformity, and a Keller resection is not indicated in the younger population. The treatment of choice is a proximal metatarsal osteotomy with second toe correction.
REFERENCE: Mann RA, Rudicel S, Graves SC: Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy: A long-term follow-up. J Bone Joint Surg Am 1992;74:124-129.

Question 16

Which of the following best describes the course of the ulnar nerve in the midforearm?

Explanation

DISCUSSION: In the midforearm, the ulnar nerve travels deep to the flexor carpi ulnaris muscle and ulnar to the ulnar artery as it lies on the flexor digitorum profundus muscle. In this region, the ulnar nerve and artery lie side-by-side, whereas more proximal in the forearm, the ulnar artery originates from the brachial artery in the antecubital fossa, and the ulnar nerve lies within the cubital tunnel.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics, ed 2. Philadelphia, PA, Lippincott-Raven, 1994, pp 118-131.
Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System: Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8,

pp 46-47.

Question 17

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Explanation

Articular cartilage in the knee adapts to exercise by increasing the glycosaminoglycan (GAG) content. Increased GAG content is important to cartilage health. There is a higher glycosaminoglycan content in the lateral femoral cartilage compared to the medial femoral cartilage. Using T1 gadolinium enhanced MRI, the GAG content is seen to be increased in moderate distance runners. Moderate exercise may be a good treatment, not only to improve joint symptoms and function, but also to improve the knee cartilage GAG content in patients at high risk of developing osteoarthritis.

Question 18

An 8-year-old girl sustained a displaced fracture at the base of the femoral neck in a motor vehicle accident. Management should consist of

Explanation

DISCUSSION: Pediatric intracapsular hip fractures are challenging because of the high rates of complications, including osteonecrosis and varus malunion. These patients should be treated as emergencies. Principles of treatment include anatomic reduction with internal fixation. Screw fixation short of the physis is preferred and may need to be supplemented with spica cast immobilization. Fixation may be achieved with smooth pins across the physis when little metaphyseal bone is available. Fixation across the physis with threaded screws is acceptable only when the patient is close to skeletal maturity. Pediatric hip screws are appropriate if immediately available. Emergent open reduction, capsulotomy, or joint aspiration may decrease the rate of osteonecrosis.
REFERENCES: Cheng JC, Tang N: Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999;19:338-343.
Azouz EM, Karamitsos C, Reed MH, et al: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Song KS, Kim YS, Sohn SW, et al: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210.
Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51.

Question 19

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

Explanation

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

Question 20

Figures 11a and 11b show the T 2 -weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?

Explanation

DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T₂-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option.
REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972.
Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160.
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.

Question 21

A 23-year-old male college quarterback presents with acute left shoulder pain after being tackled. A radiograph of the injury is shown in figure A. After successful closed reduction, what shoulder position should be avoided in order to minimize the risk of a repeat injury? Review Topic

Explanation

The patient presents with a traumatic posterior shoulder dislocation and radiographic evidence of a reverse Hill-Sachs type injury. The patient should avoid adduction, 90 degrees flexion, and internal rotation in order to decrease the risk of re-dislocation.
Shoulder stability is achieved through the both dynamic and static stabilizers. The static stabilizers include the bony morphology of the joint, glenoid labrum, capsule, and glenohumeral ligaments. The contributions of the glenohumeral ligaments to shoulder stability are dependent upon the position of the humerus relative to the glenoid. Posterior stability is afforded to the joint by the superior glenohumeral ligament (SGHL) and the posterior band of the inferior glenohumeral ligament (IGHL). The SGHL specifically is taught and provides posterior stability with the shoulder in flexion, adduction, and internal rotation.
Kim et. al. reviewed their experience treating 27 athletes diagnosed with traumatic posterior shoulder instability and treated with arthroscopic posterior labral repair and capsular shift. Most patients were found to have an incompletely stripped posterior capsulolabral complex. After arthroscopic repair and shift, all 26 of the 27 patients treated had improved shoulder function and objective scores, a stable shoulder, and were able to return to sport.
Millett et. al. reviewed posterior shoulder instability. They describe the static restraints of the posterior shoulder as the SGHL, posterior band of IGHL, and the coraohumeral ligament (CHL). The SGHL and CHL are both taught in the position of flexion, adduction, and internal rotation, whereas the posterior band of the IGHL is taught in abduction. They describe posterior instability occuring secondary to overhead sports due to repetitive microtrauma causing gradual capsular failure.
Figure A is an axillary radiograph of the left shoulder demonstrating a posterior dislocation and an engaging reverse Hill-Sachs lesion.
Incorrect Answers:

Question 22

A 10-year-old boy reports a gradual onset of weakness; however, he is fully ambulatory. History reveals that he has a 17-year-old brother who has just stopped walking because of a similar condition. Laboratory studies show a creatine kinase level of 5,480 IU/L (normal 25 to 232 IU/L), and examination shows a slightly positive Gower sign. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has Becker muscular dystrophy. Patients with this condition have a slower rate of progression of disease compared with patients who have Duchenne muscular dystrophy, and walking may continue into the late teens. The creatine kinase level is not as high as in Duchenne muscular dystrophy, which can range from 20,000 to 30,000 IU/L. Becker muscular dystrophy is allelic to Duchenne muscular dystrophy, resulting in a mutation in the dystrophin gene. Myotonic dystrophy is characterized by a progressive inability to relax the muscles after contracture. The Gower sign is not helpful in this disease. Patients with Charcot-Marie-Tooth disease, one type of which is also known as HMSN type II, do not have elevated creatine kinase levels and usually present with a foot deformity. Spinal muscular atrophy, type II, usually presents with severe weakness in the second year of life.
REFERENCES: Matsuo M: From molecular diagnosis to gene therapy. Brain Dev 1996;18:167-172.
Darras BT: Molecular genetics of Duchenne and Becker muscular dystrophy. J Pediatr 1990;117:1-15.
Gutmann DH, Fischbeck KH: Molecular biology of Duchenne and Becker’s muscular dystrophy: Clinical applications. Ann Neurol 1989;26:189-194.

Question 23

Figures 1 through 3 are the weight-bearing radiograph and MRI scans of a 27-year-old man who twisted his knee coming down awkwardly from a lay-up during a basketball game. He felt a sharp stabbing pain in the posterior aspect of his knee at the time of the injury. Physical examination reveals a trace effusion, full range of motion but pain with hyperflexion >90° degrees and tenderness over the affected joint line. What is the most appropriate treatment at this time?

Explanation

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more appropriate in the older patient with pre-existing advanced degenerative changes.

Question 24

When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?

Explanation

DISCUSSION:
Excluding a diagnosis of meniscal tear, loose body, or mechanical derangement, treating knee osteoarthritis of indeterminate cause with arthroscopic lavage and debridement has been found to provide no discernable benefit to offset the risk of surgery. The effects of arthroscopy have not been clinically significant in the vast majority of patient-oriented outcomes measures for pain and function at multiple
times between 1 week and 2 years after surgery.

Question 25

In which scenario is application of NPWT contraindicated?

Explanation

DISCUSSION
The most common complication associated with NPWT is a rash on the skin resulting from contact with a suction sponge. In a 2001 study by Webb and Schmidt, 2.2% of patients treated with NPWT had a rash that resolved within 48 hours. To minimize risk for this rash, care should be taken to avoid overlap of the sponge onto intact skin. If skin overlap is unavoidable, a lower-pressure setting should be used.
Acute bacterial infection is possible in this scenario, but there would likely be additional findings such as purulence in the wound itself. Similarly, an acute allergic reaction could be found within the wound and not just at the skin edge. Skin irritation from excessive adhesive plastic tension can result in blistering or shearing avulsion but not skin-edge erythema. Skin necrosis from the original trauma would result in skin-edge duskiness instead of erythema.
A study by Timmers and associates showed a statistically significant increase in microvascular blood flow to the skin under a sponge at subatmospheric pressures. Angiogenesis occurs in the area of the wound vacuum from the negative pressure and increased blood flow, not from the sponge material itself. There has been no indication that antibiotic concentration is increased in the setting of negative pressure therapy because antibiotics would be evacuated along with the fluid. NPWT does not result in increased temperatures that would kill pathogens.
NPWT is contraindicated in the setting of neoplasm because its effect on tumors is unknown. There is potential for increased angiogenesis in residual tumor cells, which could lead to recurrence or even metastasis. NPWT has been used safely and effectively for coverage of open fractures between initial debridement and definitive coverage. Fasciotomy wounds are frequently covered with NPWT dressings on a temporary basis with excellent results.
NPWT has been used to temporize wounds with exposed bone before flap coverage. Wounds with excessive tension frequently can be closed after short-term coverage with NPWT dressings.
RECOMMENDED READINGS
Webb LX, Schmidt U. [Wound management with vacuum therapy]. Unfallchirurg. 2001 Oct;104(10):918-26. German. PubMed PMID: 11699301.View Abstract at PubMed
Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11. PubMed PMID: 12374481. View Abstract at PubMed
Timmers MS, Le Cessie S, Banwell P, Jukema GN. The effects of varying degrees of pressure delivered bynegative-pressure wound therapy on skin perfusion. Ann Plast Surg. 2005 Dec;55(6):665-71. PubMed PMID: 16327472. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 68 AND 69

Figure 68 is the radiograph of a 17-year-old girl who is treated with closed reduction and percutaneous screw fixation for her displaced femoral neck fracture. Capsulotomy of the hip is not performed. After surgery, the patient is instructed to maintain touch-down weight-bearing status for 3 months.

Question 26

Which of the following preoperative findings is a predictor of poor outcome following arthroscopic debridement for glenohumeral arthritis? Review Topic

Explanation

Studies have shown that patients with moderate to severe degenerative changes of the glenohumeral joint fare worse than those with a concentric joint space. Preoperative stiffness and presence of loose bodies have correlated with successful results. A history of infection or instability, in the absence of degenerative changes has not been correlated with poorer outcomes.

Question 27

An 18-year-old high school football player sustains a left posterior hip dislocation that is reduced in the emergency department under IV sedation. Postreduction radiographs reveal a concentric reduction with no evidence of fracture or loose bodies within the joint. What is the most common complication of hip dislocations?

Explanation

DISCUSSION: Traumatic dislocation of the hip in sports injuries is uncommon, and 85% to 92% occur in a posterior direction. In dislocations without fractures, osteonecrosis is the most common complication occurring in 10% to 20% of patients. MRI should be performed at 3 months postreduction to rule out osteonecrosis. Nerve injuries are rare in this setting, and recurrent dislocations are unusual without acetabular fractures. Chondrolysis has been reported as a rare occurrence.
REFERENCES: Anderson K, Strickland S, Warren R: Hip and groin injures in athletes. Am J Sports Med 2001;29:521-533.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 407-416.

Question 28

A 51-year-old female presents with an acute inability to extend her thumb, four months after she was treated with cast immobilization for a minimally-displaced distal radius fracture. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: A rare complication of non-displaced or minimally displaced fractures of the distal radius treated with a cast is a delayed rupture of the extensor pollicis longus (EPL) tendon. The EPL is the primary extensor of the interphalangeal joint of the thumb and also assists with metacarpophalangeal extension. Extensor indicis proprius transfer to the EPL is the most widely used and reported treatment for this condition.
Magnussen et al. reviewed results of EIP transfer following ruptures of the EPL, with 19/21 good results. None of the cases had any loss of independent index finger extension although index extensor strength reduced to half of that of the contralateral side.
Hove et al. reported a similar satisfaction rate following treatment of 15 patients. In his series of 4,400 distal radius fractures treated over a 5 year period, the incidence of delayed tendon rupture following distal radius fracture was 0.3 percent.

Question 29

The MRI scans and diagnostic ultrasound shown in Figures 2a through 2c show what pathologic condition? Review Topic

Explanation

The MRI scans and ultrasound show an articular surface partial-thickness rotator cuff tear of the supraspinatus tendon. This condition most commonly involves the supraspinatus tendon and is usually found on the articular surface where the blood supply is less robust. There are multiple intrinsic and extrinsic factors contributing to this condition which include age-related metabolic and vascular changes that lead to degenerative tearing, subacromial impingement, shoulder instability (typically anterior), internal impingement, and repetitive microtrauma. Acute trauma is less often the cause. The physical examination for this condition is often nonspecific and requires supplemental imaging studies for diagnosis.

Question 30

A 74-year-old woman with rheumatoid arthritis has pain in the shoulder that has failed to respond to nonsurgical management. AP and axillary radiographs are shown in Figures 24a and 24b. Active forward elevation is 120 degrees and external rotation is 30 degrees. At the time of surgery, a 1-cm rotator cuff tear is found, which is repairable. Which of the following treatment options will result in the most predictable pain relief and function? Review Topic

Explanation

Most studies have shown that total shoulder arthroplasties yield better pain relief and improved forward elevation when compared with hemiarthroplasty in patients with rheumatoid arthritis. Patients with repairable rotator cuff tears should undergo repair at the time of surgery because good results have been shown. Reverse arthroplasties are not indicated with rotator cuff tears that are repairable, and interpositional arthroplasties are not indicated for elderly patients.

Question 31

-Figures a and b are the plain radiographs of a 26-year-old man with an elbow contracture. He denies any specific elbow trauma but reports a history of a closed-head injury sustained in a motor vehicle collision. Examination reveals the elbow lacked 55 degrees of extension and has flexion of 85 degrees.Supination and pronation are well preserved. Release of which structure is essential to restore elbow flexion?

Explanation

Question 32

A 20-year-old man has activity-related deep-seated shoulder pain in his dominant right shoulder. He has taken 3 months off training as a college javelin thrower, and management consisting of physical therapy has failed to provide relief. Shoulder arthroscopic views are shown in Figures 16a through 16c. What is the underlying association with this condition? Review Topic

Explanation

The patient is involved in overhead athletics and reports deep-seated pain. The arthroscopic views show a SLAP tear with posterior extension that is typical of internal impingement. The history lacks a component of gross instability expected in traumatic anterior dislocations or multidirectional instability associated with a connective tissue disorder, and it also lacks risk factors for osteonecrosis. The images do not show evidence of an unstable humeral cartilage flap or a supraspinatus tear.

Question 33

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Explanation

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 34

A 19-year-old woman reports lower back pain following a motor vehicle accident. Radiographs obtained immediately after the accident and a bone scan obtained 4 weeks later are shown in Figures 25a through 25c. The patient asks questions regarding the cause, genetics, and natural history of her condition. She should be informed that the condition was

Explanation

DISCUSSION: The radiographs show L5 spondylolysis without spondylolisthesis (slip). The bone scan is normal, indicating that the pars interarticularis fractures are not acute. The incidence of spondylolysis is approximately 5% in the general population. The lesion generally develops in children age 5 to 6 years, and there is a second peak in the adolescent population. There is a familial predisposition, with reported rates of 27% to 69% in close relatives. A recent long-term follow-up study found that 90% of the spondylolisthesis had occurred before the patient’s first visit to the physician. Spondylolisthesis tends to progress during the initial growth spurt and is similar in some respects to idiopathic scoliosis. Progression of a lytic spondylolysis to spondylolisthesis in adulthood has been reported; however, this is exceedingly rare.
REFERENCES: Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208.
Hensinger RN: Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Am 1989;71:1098-1107.
Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Fredrickson BE, Baker D, McHolik WJ, Yuan HA, Lubicky JP: The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 1984;66:699-707.

Question 35

Figures 16a and 16b are the radiograph and MR image of a 15-year-old dance athlete with 2 weeks of pain at the left distal femur, a limp, and an inability to dance. Knee motion is 0 to 135 degrees with minimal pain and there is no effusion. Her temperature is 37.0°C, WBC is 12000 /µL (rr, 4500-11000 /µL), CRP is 0.8 mg/L (rr, 0.08-3.1 mg/L), and ESR is 21 mm/h (rr, 0-20 mm/h).

Explanation

DISCUSSION
Figures 14a through 14e show a 13-year-old boy with osteomyelitis of the distal tibia and a large subperiosteal abscess. The patient has failed treatment with IV ceftriaxone, and methicillin-resistant Staphylococcus aureus infection is likely. Aspiration, cultures, irrigation and debridement, IV vancomycin, an infectious disease consult, and an evaluation for possible deep vein thrombosis is prudent initial treatment. Figure 15a through 15c show a 7-year-old girl who sustained a deer tick bite while vacationing in Connecticut. She has Lyme arthritis and a Lyme “bulls-eye” rash on the same leg. Aspiration, cultures, Lyme serology, and oral amoxicillin for 30 days is prudent initial treatment. Figures 16a and 16b are the radiograph and MR image of a 15-year-old dance athlete with a probable minor fracture via a benign cyst of the distal femur. The geographic cyst may be a nonossifying fibroma, eosinophilic granuloma, Brodie abscess, or simple bone cyst. Biopsy, culture, curettage and bone graft, and possible internal fixation is reasonable initial treatment.

Question 36

What type of medial collateral ligament tear heals the most reliably? Review Topic

Explanation

Proximal medial collateral ligament (MCL) injuries adjacent to the medial epicondyle heal robustly. These proximal injuries are more prone to calcification, characterized clinically with temporarily increased pain and stiffness. The distal MCL, despite its long attachment site on the proximal tibia, heals less well. MCL injuries associated with other ligament injuries heal less reliably.

Question 37

A 12-year-old girl has scoliosis at T5-T10 that measures 62°. A clinical photograph of the axilla is shown in Figure 56. Management should consist of

Explanation

DISCUSSION: Neurofibromatosis type 1 (NF-1) is an autosomal-dominant disorder affecting about 1 in 4,000 people. NF-1 causes tumors to grow along various types of nerves and affects the development of non-nervous tissues, such as bone and skin. The gene for NF-1 is located on the long arm of chromosome 17 and codes the protein neurofibromin. Research indicates that NF-1 acts as a tumor-suppressor gene and, as such, plays an important role in the control of cell growth and differentiation. Axillary and inguinal freckling is considered a good diagnostic marker for NF-1. The hyperpigmented spots that measure from 2 mm to 4 mm may be congenital, but these typically appear and increase later in life. Scoliosis is the most common musculoskeletal disorder of NF-1. The curves are frequently dystrophic, kyphotic, and have a high risk of pseudarthrosis following spinal fusion. Anterior and posterior spinal fusion with rigid posterior segmental instrumentation is the treatment of choice.
REFERENCES: Goldberg Y, Dibbern K, Klein J, Riccardi VM, Graham JM Jr: Neurofibromatosis type 1: An update and review for the primary pediatrician. Clin Pediatr 1996;35:545-561.
Kim HW, Weinstein SL: Spine update: The management of scoliosis in neurofibromatosis. Spine 1997;22:2770-2776.

Question 38

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Explanation

Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient's history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.

Question 39

A 17-year-old high school athlete comes in with a 6-month history of right midfoot pain. She has been treated with cast immobilization, crutches, and physical therapy. She still has significant pain with activities and cannot participate in sports. Her radiograph is shown in Figure 93a, and MR images are shown in Figures 93b and 93c. What is the most appropriate 79 next step? A B C

Explanation

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216. View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 40

What is the most appropriate orthosis for hallux rigidus?

Explanation

DISCUSSION: A Morton’s extension limits excursion of the first metatarsophalangeal joint. It also functions as a ground reaction stabilizer during the toe-off phase of gait and thus reduces torque and joint reaction force at the first metatarsophalangeal joint. The metatarsal arch pad and full-length semi-rigid longitudinal arch support may help by dorsiflexing the first metatarsal relative to the phalanx and thus decompress the first metatarsophalangeal joint. However, they are not as biomechanically effective as the Morton’s extension. Both medial hindfoot and lateral forefoot posting are contraindicated because they increase ground reaction at the first metatarsophalangeal joint.
REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 611.
Watson AD, Wapner KL: Foot and ankle reconstruction, in Baratz ME, Watson AD, Imbriglia JE (eds): Orthopaedic Surgery: The Essentials. New York, NY, Thieme, 1999, p 635.

Question 41

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Explanation

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T₁ and bright on T₂.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 42

below shows the abdominal radiograph obtained from a year-old woman who experiences nausea and abdominal tightness 48 hours following left total knee arthroplasty performed under general anesthesia. She received 24 hours of cefazolin antibiotic prophylaxis and a patient-controlled analgesia narcotic pump for pain management. She has been receiving warfarin for thromboembolic prophylaxis. Her severe abdominal distension and markedly decreased bowel sounds are most likely secondary to the administration of

Explanation

DISCUSSION:
The radiograph reveals severe intestinal dilatation, which has occurred as the result of acute colonic pseudo-obstruction and is associated with excessive narcotic administration following total joint arthroplasty. Anesthetic type, antibiotic administration, and warfarin have not been associated with this obstruction. Electrolyte imbalances such as hypokalemia have been associated with postsurgical acute colonic pseudo-obstruction.

Question 43

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

Explanation

DISCUSSION: The patient has respiratory distress as manifested by his difficulty in lying flat. In addition, the diaphoresis and the change in his voice indicate retropharyngeal edema or hematoma that is compressing his larynx. The only appropriate treatment is hospital admission and elective intubation. During intubation it is possible to cause laryngospasm in a patient with a hyperacute airway; therefore, the surgeon should be prepared to perform a cricothyroidotomy. Often a fiberoptically guided intubation is the only way to find the airway in the presence of retropharyngeal edema or hematoma.
REFERENCES: Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.
McAfee PC, Bohlman HH, Riley LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surg Am 1987;69:1371-1383.

Question 44

A 13-year-old premenarchal girl presents with back pain and scoliosis. Figures A through D are the bone scan, SPECT scan, axial and coronal images respectively. What is the most likely diagnosis? Review Topic

Explanation

This
patient
has
osteoid
osteoma
(OO).
OO and osteoblastoma (OB) of the spine commonly present in the 2nd decade of life. CT shows a low attenuation nidus with central mineralization and varying degrees of perinidal sclerosis. NSAIDS are thought to inhibit PGE 2 and PGI 2 produced within the nidus, and suppress perinidal edema arising from high levels of COX2 expression in neoplastic nidal osteoblasts.
Burn et al. reviewed pediatric OO and OB of the spine. OB is more likely to have neurological deficit because of spinal canal encroachment. Surgery involves complete resection. They recommend onlay fusion when the facet and pedicle have been resected, and instrumentation if resection of the vertebral body is carried out.
Jayakumar et al. discuss a case report of OO of the T6 vertebra that was treated successfully with NSAIDS alone. OOs of the spine are the most common cause of painful scoliosis in children and young adults. They caution against a non-operative course in patients with an immature skeleton, significant skeletal deformity or with a long delay before diagnosis.
Figures A and B are bone scan and SPECT scans respectively that demonstrate intense tracer uptake in the left transverse process of L3 characteristic of an osteoid osteoma. Dextroconvex scoliosis of the thoracic and levoconvex scoliosis of the lumbar spine is noted. Figures C and D are axial and coronal reconstructed CT images
showing show a lesion of the left transverse process of L3 with a dense "nidus" with surrounding lucency characteristic of osteoid osteoma. Illustration A is a table showing the characteristics of pediatric epidural spinal tumors.
Incorrect

Question 45

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Explanation

DISCUSSION
Complications are numerous in adult spinal deformity surgery. Many complications are related to the patient's sagittal balance following surgery and recognition of the potential to develop sagittal imbalance or flat-back syndrome following spinal fusion. The quality of bone density is important in spinal instrumented fusions, especially among older patients. Patients with osteopenia or osteoporosis have a higher incidence of proximal-level screw cut-out through the vertebral body into the cephalad disk space.
Proximal junctional kyphosis is common in longer instrumented fusions, especially when instrumented to the sacrum/pelvis; when the spine is fixed in a "flat" or hypolordotic position; when the thoracic spine is hyperkyphotic (ie, Scheuermann kyphosis); when the end instrumented vertebrae is kyphotic; or when the sagittal plumb line (measured from C7) is more than 4 cm forward of the posterior corner of the sacrum.
Sagittal imbalance is a common complication when the spine is instrumented in a hypolordotic position. This can occur with degenerative conditions that necessitate multilevel fusions or fusions to sacrum without recognition of the degree of lordosis the patient should have. Pelvic incidence (PI) is a spinopelvic measurement that is a constant that measures an angle from the hips to the midpoint of the sacral end plate. PI correlates to the amount of lumbar lordosis that a patient would typically have in an upright position (+/-10 degrees). If a patient has significant sagittal imbalance, he or she will have a forward lean and lack the ability to extend the spine to stand upright. In an attempt to stand upright, the patient may bend his or her knees or hips in a crouched position. When extending their knees, they again lean forward.
Pseudarthrosis is common with noninstrumented fusions. Deep surgical-site infections are uncommon but can be major complications that are difficult to treat, necessitating formal irrigation and debridement and long-term antibiotics. Patients with diabetes have a higher incidence of infection.
RECOMMENDED READINGS
Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-

Question 46

Mirror therapy is indicated for which of the following clinical conditions?

Explanation

Mirror therapy is a useful technique to improve phantom pain in amputees. Phantom limb pain is a painful sensation that is perceived within a body part that no longer exists.
Under mirror therapy, a patient is allowed to feel the imaginary movement of the removed body part behaving as normal body movement through a mirror. The mirror
image of the normal body part helps reorganize and integrate the mismatch between proprioception and visual feedback of the amputated segment.
Tilak et al. performed a randomized controlled trial of 26 patients with phantom limb pain, and found that mirror therapy as well as transcutaneous electrical nerve stimulation both significantly improved pain scores, but no difference was seen between the two groups. They recommend use of both modalities in treatment of phantom limb pain, as they are noninvasive and inexpensive.
Chan et al. reviewed 22 patients utilizing mirror therapy for amputation related phantom limb pain, and found that patients reported a significant decrease in pain when utilizing this treatment modality as compared to covered mirror therapy or mental imagery therapy.
Illustration A shows a patient with an upper extremity amputation using a mirror to perform movements during a mirror therapy session.
Incorrect Answers:

Question 47

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

Explanation

DISCUSSION
Autologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.
RECOMMENDED READINGS
Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005 May-Jun;13(3):152-8. Review. PubMed PMID: 15938604. View Abstract at PubMed
Mitchell ME, Giza E, Sullivan MR. Cartilage transplantation techniques for talar cartilage lesions. J Am Acad Orthop Surg. 2009 Jul;17(7):407-14. Review. PubMed PMID: 19571296. View Abstract at PubMed
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Review. PubMed PMID: 23780543. View Abstract at PubMed

Question 48

The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Explanation

After plain radiographs of the affected area have been obtained, magnetic resonance imaging modality is the best imaging modality for detecting and characterizing the lesion, regarding definition of normal muscle, fascial boundaries, and the tumor mass. Although MR imaging is not specific in determining whether lesions are benign or malignant, it can be useful in evaluation
other characteristics, such as size, pattern of growth, integrity of natural boundaries, and homogeneity.
Intravenous contrast agents are not necessary to evaluate neurovascular structures. Both the T1 & T2 weighted images are essential to detect and characterize soft tissue lesions.
Most Tumors have long T1 and T2 relaxation times, therefore, in most instances signal intensity alone is of limited benefit. Exceptions are lipoma, hematoma, intra-lesional hemorrhage.
Hemorrhage may occur in some soft tissue lesions, especially sarcomas, leading to the low T1 and high T2 intensity sound on MR. Miller, indicates that Water, CSF, acute hemorrhage and soft tissue tumors appear dark on T1 and light on T2.

Question 49

A 70-year-old man underwent primary total knee arthroplasty 3 months ago. Figures 7a and 7b show the radiograph and clinical photograph following incision and drainage of the wound 1 week ago. Aspiration of the joint reveals methicillin-sensitive Staphylococcus aureus. What is the next most appropriate step in management?

Explanation

DISCUSSION: The overriding factor determining treatment in this case is the appearance of the surgical wound. Based on MacPhearson’s work, this “C” wound is best managed with two-stage exchange. The functional outcome is markedly diminished following a knee arthrodesis compared to revision knee arthroplasty.
REFERENCES: Harwin SF: The diagnosis and management of infected total knee replacement. Seminars Arthroplasty 2002;13:9-22.
Goldmann RT, Scuderi GR, Insall JN: 2-stage reimplantation for infected total knee replacement. Clin Orthop 1996;331:118-124.
Morrey BF, Westholm F, Schoifet S, Rand JA, Bryan RS: Long-term results of various treatment options for an infected total knee arthroplasty. Clin Orthop 1989;248:120-128.

Question 50

A patient reports persistent pain in the wrist 6 months after undergoing open reduction and internal fixation of a Galleazi fracture. Radiographs of the wrist in a neutral position are normal. Which of the following studies would best evaluate the reduction of the distal radioulnar joint?

Explanation

If late instability is suspected after the associated fractures have healed, comparison scans in pronation (to detect volar subluxation) neutral (dorsal subluxation and diastasis of the DRUJ) and supination (to confirm the degree of reduction) If early a single axial CT in any position can aid in diagnosis. As described by Mino, a line drawn on both the dorsal and volar radial ulnar borders will place an adequately reduced ulna between them

Question 51

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present.
REFERENCES: McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.
Thometz J: Tarsal coalition. Foot Ankle Clin 2000;5:103-118.

Question 52

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause Review Topic

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 53

An 8-year-old boy has had pain and swelling around the right knee for the past 4 weeks. He recalls bumping it about 4 weeks ago. He has no pain in other joints, and denies any fevers, chills, or other symptoms. A radiograph is shown in Figure 13. Laboratory studies show a WBC count of 9,700/mm P 3 P , an erythrocyte sedimentation rate of 18 mm/h, and a C-reactive protein level of 3.7 mg/L. What is the next most appropriate step in management?

Explanation

DISCUSSION: The history and laboratory findings are consistent with osteomyelitis of the patella. The radiograph reveals bone destruction in the patella; therefore, the next most appropriate step is open biopsy and debridement of the site. Aspiration of the knee joint may be needed to rule out septic arthritis prior to patellar debridement. With this amount of bone destruction, surgical debridement is helpful to obtain cultures and to remove necrotic material. Administering antibiotics without any prior culture increases the risk of negative cultures later and a potentially incorrect choice of antibiotic. A neoplasm should be included in the differential. It would be inappropriate to initiate chemotherapy and radiation therapy without a biopsy-confirmed diagnosis. A bone scan is likely to demonstrate uptake, but radiographs have already localized the abnormality to the patella.
REFERENCES: Morrisy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 466-470.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis, and treatment. J Am Acad Orthop Surg 1994;2:333-341.

Question 54

A 20-year-old college soccer player comes for an evaluation 6 months after an injury during which he landed awkwardly from a jump. Although physical therapy, ice, and activity modification have helped him return to baseline motion, strength, and swelling, he continues to have lateral knee pain. He also notes a popping sensation on the lateral side of his knee with activity. A Lachman test, anterior and posterior drawer tests, a pivot shift test, and McMurray test findings are all negative. MR images reveal a 12-mm x 15-mm osteochondral defect in the lateral femoral condyle with full-thickness cartilage loss and approximately 4 mm of subchondral bone loss.

Explanation

DISCUSSION
Patellofemoral pain in a young athlete without patellar instability or a chondral or osteochondral defect often can be managed with nonsurgical treatment such as physical therapy and a home exercise program. Microfracture surgery is associated with good short-term results for younger athletes. Patients with no history of prior surgery, primary chondral rather than osteochondral lesions, and lesions smaller than 2 cm have experienced the best results. Microfracture surgery performed for chondral lesions of the central aspect of the medial femoral condyle is associated with worse results. Decreased activity levels over time of patients who undergo microfracture surgery are a concern. OAT provides good outcomes and return-to-sports rates for athletic people who are younger and have lesions smaller than 2 cm. Patients with lesions on the lateral femoral condyle have better success rates. Both microfracture surgery and OAT provide better results for chondral defects than osteochondral defects. OAT is associated with better results than microfracture for medium-sized lesions between 2 cm and 4 cm, while autologous chondrocyte implantation yields better improvement for patients with defects larger than 4 cm. All of the surgical techniques listed for articular cartilage repair are associated with better outcomes for patients younger than age 30.

Question 55

Which of the following anatomic structures is often difficult to visualize during elbow arthroscopy?

Explanation

DISCUSSION: The ulnar collateral ligament is often difficult to visualize during elbow arthroscopy. It can be seen clearly in only 10% to 30% of elbow arthroscopies. All of the other structures should be easily and thoroughly seen and palpated during elbow arthroscopy.
REFERENCES: Johnson LL: Arthroscopic Surgery: Principles and Practice. St Louis, MO, CV Mosby, 1988.
Morrey BF: Arthroscopy of the elbow. Instr Course Lect 1986;35:102-107.

Question 56

What is the primary reason for including the ilium in the distal fixation of long instrumentation constructs in adult scoliosis? Review Topic

Explanation

Studies have shown that when compared with fixation to the sacrum alone, the success rate of fusion across the lumbosacral junction increases when both the sacrum and ilium are included in the posterolateral construct. Curve correction, coronal balance, and pelvic balance are all attended to within the thoracolumbar spine and are not directly related to the pelvic fixation. Fretting and corrosion are a byproduct of metal-to-metal connections.

Question 57

A 31-year-old high school football coach has right medial knee pain that is made worse with prolonged standing. His knee is minimally painful in the morning but by the end of the school day, he must sit down. The pain often makes sleeping difficult. He states that several years ago he underwent a surgical procedure to "clean out" the cartilage of the knee; however, he only had several months of pain relief. He is noted to be an athletic male (BMI of less than 30). Knee examination is unremarkable except for medial joint line pain that is exacerbated with standing and walking. Radiographs, including a long-leg view, and MRI scans are seen in Figures 153a through 153d. He wishes to remain active and asks whether he would be a candidate for allograft meniscus transplantation. You advise him that Review Topic

Explanation

The patient's history, physical findings, and MRI scans indicate that a complete medial meniscectomy was performed. The meniscus provides an essential function in dissipating forces to the adjacent articular cartilage. Complete or partial meniscectomy has been shown to result in more rapid clinical and radiographic arthritis than if the meniscus is preserved. Allograft meniscal transplantation has been shown to be effective in the young patient with an absent meniscus, no or correctable limb malalignment, and minimal or correctable articular cartilage damage. His age would be appropriate for an allograft meniscus transplant. Based on the patient's long-leg radiograph, a valgus-producing high tibial osteotomy would be appropriate but alone would not address the absent meniscus in this young patient. Viscosupplementation may provide some temporary relief but is not an appropriate long-term solution. A staged valgus-producing osteotomy followed by an allograft meniscus transplant would be the most appropriate treatment.

Question 58

A 44-year-old recreational weight lifter reports chronic deep pain in his left shoulder that is aggravated by any pressing exercises. He also notes a painful catch in the shoulder occurring with rotational movements. Physical therapy and nonsteroidal anti-inflammatory drugs for 3 months have failed to provide relief. Examination reveals pain with O’Brien’s test but no signs of instability. MRI scans are shown in Figures 4a and 4b. Treatment should now consist of

Explanation

DISCUSSION: The MRI scans show a large paralabral ganglion cyst in the spinoglenoid notch that communicates with an extensive tear of the glenoid labrum. Snyder and associates have classified superior labral tears into several subtypes that reflect the location and extent of the injury. Arthroscopic repair of the labral tear and aspiration of the ganglion cyst is the treatment of choice. Open excision of the cyst does not address the underlying problem of the labral tear.
REFERENCE: Snyder SJ, Karzel RP, Delpizzo W: SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279.
Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch cysts. J Shoulder Elbow Surg 2002;11:600-604.
McFarland EG, Kim TK, Savino RM: Clinical assessment of three common tests for superior labral anterior-posterior lesions. Am J Sports Med 2002;30:810-815.
O’Brien SJ, Pagnani MJ, Fealy S, et al: The active compression test: A new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med

1998;26:610-613.

Question 59

Figure 8 shows the radiograph of a 72-year-old man who has had severe pain in the left hip for the past 3 weeks. History reveals alcohol abuse. The next most appropriate step should consist of

Explanation

DISCUSSION: The radiograph reveals destruction of the femoral head with loss of the articular cartilage. These findings are consistent with an infected hip, and aspiration will confirm the diagnosis. Although the patient could have advanced osteonecrosis, typically the cartilage interval is maintained and such destruction is rarely associated with osteonecrosis.
REFERENCE: Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 157-161.

Question 60

A 25-year-old athlete presents with symptoms attributed to injury to ligament D in Figure A. Which of the following symptoms and signs is characteristic of this injury? Review Topic

Explanation

This patient has rupture of the lateral ulnar collateral ligament (LUCL), producing posterolateral rotatory instability (PLRI). This is best demonstrated with a positive lateral pivot shift test.
PLRI can be diagnosed using the lateral pivot shift or posterolateral drawer. According to O’Driscoll, the elbow dislocates in 3 stages from lateral to medial (circle of Horii). Stage 1 involves disruption of the LUCL and partial/total disruption of the LCL complex (creating PLRI). Patients have pain with varus stress. Stage 2 includes disruption of the anterior capsule from incomplete elbow posterolateral dislocation. Stage 3 is divided into:
(a) Disruption of all soft tissues surrounding/ including the posterior MCL except for the anterior bundle. This bundle forms the pivot around which the elbow dislocates in a posterior direction by way of a posterolateral rotatory mechanism; and (b) complete disruption of the MCL.
O'Driscoll et al. describe PLRI diagnosed in 5 patients who had elbow dislocation using the posterolateral rotatory instability test, which they describe as being analogous to the test for lateral rotatory instability of the knee after ACL rupture. They believed the condition was laxity of the LUCL, which allowed transient rotatory subluxation of the ulnohumeral joint and secondary dislocation of the radiohumeral joint, without radio-ulnar joint dislocation. They recommended repair of the LUCL to eliminate PLRI.
Sanchez-Sotelo et al. retrospectively described 12 cases of direct repair and 33 ligamentous reconstructions for PLRI. 86% were satisfied with the procedure. Better results were obtained with patients with post-traumatic etiology, instability at presentation, and those with augmented reconstruction with tendon graft (compared with ligament repair alone).
Figure A shows structures on the lateral side of the elbow. The corresponding labels are seen in Illustration A. Illustration B shows the lateral pivot shift (also known as the posterolateral rotatory instability test).
Incorrect Answers:

Question 61

Figures 43a and 43b show the radiographs of an 8-year-old boy who was referred by his gym teacher because of an awkward running pattern. The patient denies any pain in his hips. Examination reveals a mild Trendelenberg gait and decreased internal rotation of the left hip to 25 degrees compared to 40 degrees on the right. What is the most likely diagnosis?

Explanation

The referenced article is a current concept review on the treatment of Legg-Calve-Perthes Disease and does not specifically mention diagnosis. Self limited non-inflammatory deformity of the weight-bearing portion of the femur, likely due to osteonecrosis. Usually seen in 4-8 year old males with delayed skeletal maturity. Family history, low birth weight, and abnormal birth presentation.
Symptoms include-pain, effusion (from synovitis), and a limp, decreased ROM especially Abduction internal rotation. Trendelenburg stance is common.
The key in this question is the age, decreased ROM, Trendelenburg gait. The prognosis is directly related to the age at presentation, after 8 years old the prognosis is poor. SCFE(Slipped Capital Femoral Epiphysis)-Usually seen in obese adolescent boys with a family history. African American more common. Often related to endocrine abnormalities, presenting with externally rotated gait, decreased internal rotation, thigh atrophy, with hip or knee pain, symptoms vary with the acuteness of the slip.
Hypothyroidism is often a finding with patients presenting with SCFE and chondrolysis is a known complication of SCFE.

Question 62

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no

Explanation

The hallmark of neurogenic shock is hypotension without tachycardia. It is associated most commonly with high cervical spinal cord injuries and results from loss of function of the sympathetic nervous system. Because the peripheral vasculature is dilated due to loss of its sympathetic tone, continued rapid administration of fluid corrects the hypotension and can quickly lead to fluid overload and congestive heart failure. Therefore, neurogenic shock is best treated by the use of pressors. Cardioversion or administration of antibiotics or systemic steroids is not appropriate treatment for this patient’s hypotension.

Question 63

What structure is located immediately posterior to the capsule at the posterior cruciate ligament tibial insertion?

Explanation

DISCUSSION: The popliteal artery lies just posterior to the posterior cruciate ligament

tibial insertion, separated only by the posterior capsule of the knee. When performing

a posterior cruciate ligament reconstruction, this artery is at risk for injury during creation

of the tibial tunnel.
REFERENCES: Jackson DW, Proctor CS, Simon TM: Arthroscopic assisted PCL reconstruction: A technical note on potential neurovascular injury related to drill bit configuration. J Arthroscopy 1993;9:224-227.
Malek MM, Fanelli GC: Technique of arthroscopically assisted PCL reconstruction. Orthopedics 1993;16:961-966.

Question 64

A 40-year-old man fell 10 feet from a tree and sustained the closed isolated injury shown in Figures 35a and 35b. Management consists of splinting. At his 2-week follow-up visit, he clinically passes the wrinkle test. He agrees to open reduction and internal fixation. What is the best surgical approach to obtain anatomic reduction and limit wound dehiscence?

Explanation

DISCUSSION: The approach to the calcaneus has evolved from several different patterns, driven by a high wound complication rate of 10%. The current extensile lateral approach was described by Zwipp and associates in 1988. The surgical exposure uses an L-shaped incision, with the vertical component positioned one half a finger’s breath anterior to the Achilles tendon and extending distally to the junction of the lateral skin and the plantar skin. Borrelli and Lashgari mapped the angiosome of the lateral calcaneal flap and found that the major arterial blood supply to this flap consisted of three arteries: the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery. The lateral calcaneal artery appeared to be responsible for most of the blood supply to the corner of the flap. This was found 1.5 cm anterior to the Achilles tendon. Division of this artery with inaccurate placement of the vertical limb of the incision can cause ischemia of the lateral skin flap.
REFERENCES: Borrelli J Jr, Lashgari C: Vascularity of the lateral calcaneal flap: A cadaveric injection study. J Orthop Trauma 1999;13:73-77.
Freeman BJC, Duff S, Allen PE, et al: The extended lateral approach to the hindfoot: An anatomical basis and surgical implications. J Bone Joint Surg Br 1998;80:139-142.
Zwipp H, Tscherne H, Wulker N: Osteosynthesis of dislocated intra-articular calcaneus fractures. Unfallchirurg 1988;91:507-515.

Question 65

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

Explanation

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

Question 66

A 66-year-old man who underwent shoulder arthroplasty 7 years ago reports progressively worsening shoulder pain for the past 4 weeks after hospital discharge for community-acquired pneumonia. He is afebrile and reports no chills or night sweats. Laboratory studies show a white blood cell count of 11,200/mm3 and an erythrocyte sedimentation rate of 25/h. Shoulder radiographs are negative for fracture, dislocation, or signs of implant loosening. What is the most appropriate management? Review Topic

Explanation

The patient may have hematologic spread of the pulmonary infection to the shoulder arthroplasty; however, further work-up is necessary at this point. The elevated laboratory studies may still be secondary to the pulmonary infection. Aspiration of the shoulder joint with stat Gram stain and culture of the fluid is indicated. If the aspirate shows signs of infection and irrigation and debridement is indicated, complete revision of the well-seated implants may not be necessary. Physical therapy and nonsteroidal anti-inflammatory drugs are not indicated until the possibility of a shoulder infection has been ruled out. A wait of 2 weeks to repeat the laboratory values, in the presence of new shoulder pain, is contraindicated.

Question 67

A 72-year-old woman with diabetes mellitus who underwent a total shoulder arthroplasty for degenerative arthritis 5 years ago now reports the sudden onset of shoulder pain following recent hospitalization for pneumonia. Laboratory values show a WBC count of 11,400/mm3 and an erythrocyte sedimentation rate of 52mm/h. What is the most appropriate action?

Explanation

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 68

Five weeks after the patient completes a 6-week course of antibiotics, his ESR is 24 mm/h and CRP level is 10 mg/L, which is similar to the levels at 6 weeks. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
This patient has both serologic and synovial fluid findings that are concerning for indolent infection. He was taking antibiotics at the time of aspiration. The AAOS clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee, suggests that patients discontinue antibiotics for a minimum of 2 weeks and that a repeat aspiration should be performed in cases of contradictory findings. In this situation, the cell count is elevated
along with an elevated ESR and CRP level. As a result, the appropriate treatment at this time is to reaspirate his hip.
This patient has a periprosthetic joint infection with a draining sinus tract. He has had symptoms for several months and, as a result, irrigation and debridement are not indicated. A single-stage surgery may be performed in some centers for healthy patients with susceptible organisms. However, single-stage reconstructions are generally performed with cemented implants in patients without a draining sinus tract. A 2-stage procedure with an antibiotic spacer is the surgical treatment modality most likely to eradicate this infection.
Serologic findings have significantly improved since the time of the prior surgical procedure. Surgical intervention does not need to be delayed until these values have completely normalized.

Question 69

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

Explanation

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 70

.What is the most appropriate treatment if instability is present at the time of evaluation?

Explanation

Question 71

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

Explanation

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 72

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

Explanation

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

Question 73

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Explanation

images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.
DISCUSSION: Anterior tibial pain can often be difficult to diagnose. A bone scan showing the tibial cortex in a diffuse, longitudinal orientation is consistent with shin splints compared to a more discreet, localized uptake more commonly seen with a stress fracture. Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but are also seem in otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient’s history of increased physical activity and on imaging findings.
The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis. If the diagnosis is made early, most bone stress injuries heal well without complications.
REFERENCES: Mubarak SJ, Gould RN, Lee YF, et al: The medial tibial stress syndrome: A cause of shin splints. Am J Sports Med 1982;10:201-205.
Knobloch K, Yoon U, Vogt PM: Acute and overuse injuries correlated to hours of training in master running athletes. Foot Ankle Int 2008:29:671-676.
Kiuru MJ, Pihlajamaki HK, Ahovuo JA: Bone stress injuries. Acta Radiol 2004;45:317-326.

Question 74

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

Explanation

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

Question 75

A 68-year-old patient undergoes total knee arthroplasty for end-stage degenerative joint disease. Two years later, she trips and falls at home and sustains a fracture seen in Figures A and B. Before her fall, she was a community ambulator and had no knee pain. The component is determined to be stable and the surgeon decides to treat this fracture with closed reduction and retrograde intramedullary fixation with a supracondylar nail. Which of the following statements is true?

Explanation

The patient has a cruciate-retaining (CR) prosthesis. The starting point for nail entry is more posterior than normal because of the femoral component. This leads to hyperextension at the fracture site.
Periprosthetic femur fractures above total knee implants occur in 2% of patients. It is important to note: (1) pre-injury function, to determine if the prosthesis was loose, (2) the type of implant (CR vs posterior stabilized, PS) as a PS implant with a closed box would make retrograde intramedullary nailing more difficult (the surgeon has to consider the size of the box vs size of the nail, and if the box is smaller than the nail,
must be prepared to enlarge the box with a metal-cutting burr, which has inherent problems of introducing wear debris into the joint), (3) pre-fracture radiographs help determine the position of the implants (flexion-extension, varus-valgus). These fractures can be treated with non-locking condylar buttress plates (not recommended today), fixed angle devices and intramedullary nailing.
McLaren et al. describe 7 osteopenic patients (mean age, 61yrs, range 47-84yrs) treated with retrograde supracondylar nailing. They suggest not reaming, and placing 2-3 screws in the distal fragment. This may require leaving the nail protruding by 1cm. They then suggest removing the protruding segment with a burr at the end of the procedure.
Haidukewych et al. debate plating vs nailing in a 80yr old osteopenic patient. It may be difficult to introduce retrograde intramedullary nails through the same incision if dense scar tissue is present. On the other hand, most plates require extensive dissection and do not respect the soft tissues and fracture biology, except for LISS plates and nails.
Figures A and B show a displaced Lewis and Rorabeck type II periprosthetic fracture. Illustration A shows the technique of retrograde supracondylar nailing. With the knee flexed, the fracture is reduced and the entry point is in the intercondylar notch. Illustration B shows a comparison between PS and CR implants. Note the "box" in the PS implant. This is absent in the CR implant. Illustration C shows the Lewis and Rorabeck classification.
Incorrect Answers:
1 (at most 2) point of fixation in the distal segment. Answer 5: The backup plan should include devices that resist varus collapse (especially in cases with medial comminution), such as angle-stable devices (ABP, DCS and locking plates). Non-locking condylar buttress plates will not resist varus collapse.

Question 76

A 42-year-old man sustained a burst fracture at L2 in a motor vehicle accident. Examination reveals that he is neurologically intact. Figure 18 shows a cross-sectional CT scan through the fracture. If the fracture is managed nonsurgically for the next 2 years, the retained fragments can be expected to

Explanation

DISCUSSION: Numerous articles have reported that both surgical and nonsurgical management of burst fractures are associated with resolution of impingement at long-term follow-up. If the patient is neurologically intact and appropriately treated at the time of injury, neurologic deterioration is not expected nor is there a risk of injury to the dural sac. The retained fragments can be expected to gradually resorb and widen the spinal canal.
REFERENCES: Mumford J, Weinstein JN, Spratt KF, et al: Thoracolumbar burst fractures: The clinical efficacy and outcome of nonoperative management. Spine 1993;18:955-970.
Wood KB, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurologic deficit: A prospective, randomized study. J Bone Joint Surg Am 2003;85:773-781.

Question 77

Figures below show the radiographs obtained from a 68-year old man with progressively worsening right side hip pain over the last 8 months. He is 6 feet tall, with a BMI of 51 kg/m 2 and reports that his index total hip arthroplasty was performed 8 years ago. The preoperative work-up includes negative infectious laboratory results. What is the most appropriate surgical plan for revision of the femoral component in this patient?

Explanation

DISCUSSION:
The patient’s radiographs demonstrate varus femoral remodeling around a broken cylindrical, distally fixed femoral stem. Proximal femoral remodeling around loose or fractured stems occurs in 21% to 42% of femoral revisions, based on the definitions outlined by Foran and associates. In definition 1, varus femoral remodeling occurs when the template falls within 2 mm of the endosteal cortex of the metaphysis on templating with a diaphyseal engaging stem. In definition 2, varus femoral remodeling = when the template crosses the lateral femoral cortex proximally. Based on the templating or drawing a line from the isthmus proximally along the lateral cortex, implantation of a straight stem would perforate the cortex proximally, indicating varus femoral remodeling. An extended trochanteric osteotomy would aid in the removal of the well-fixed distal segment and enable the safe insertion of the new femoral component. The approach is not the concern in this case, because extended trochanteric osteotomies have been described from the posterior and direct lateral approaches with excellent outcomes and union rates. The key is that the extended osteotomy is necessary and not a trochanteric slide or standard (shorter or incomplete trochanteric) osteotomy. These types would not provide access to the well-fixed distal stem, nor would they afford a straight tube in which to insert a new femoral component.

Question 78

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Explanation

DISCUSSION: The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.
REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.

Question 79

Figure 17 shows the radiograph of an 80-year-old woman who has left groin pain. She underwent a total hip arthroplasty 15 years ago and has no history of hip dislocation; however, she now reports that the pain results in functional impairment. Preoperative findings reveal that the component used has been discontinued, the locking mechanism is poor, and there is no replacement polyethylene available from the company. During surgery, the acetabular component is found to be well fixed, it is in satisfactory position, and adequate access can be obtained through the screw holes in the component to debride the osteolytic cavities. What is the best course of action for revision?

Explanation

DISCUSSION: The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip.
REFERENCES: Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.
Blaha JD: Well-fixed acetabular component retention or replacement: The whys and the wherefores. J Arthroplasty 2002;17:157-161.

Question 80

In patients with displaced radial neck fractures treated with open reduction and internal fixation with a plate and screws, the plate must be limited to what surface of the radius to avoid impingement on the proximal ulna?

Explanation

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 81

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Explanation

DISCUSSION: Impaired pronation/supination can be seen if the K-wire is advanced either too radial or too far through the volar (anterior) cortex of the proximal ulna. The anterior interosseous nerve is also at risk with overpenetration. Conversely, migration and loosening of the K-wire is reduced with involvement of the anterior cortex.
The referenced study by Candal-Couto et al is a cadaveric study that found that K-wire insertion in less than 30 degrees in an ulnar direction led to impingement of the K-wire on the radial head/neck, biceps or supinator. They recommend placing these wires away from this danger zone in order to minimize rotation blocks.
The referenced study by Matthews et al is a case series of two patients who had limited forearm rotation after K-wire fixation. The etiology of limited rotation was found to be from direct overpenetration of the K-wire, which led to a mechanical block.

Question 82

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Explanation

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 83

Which of the following is the strongest contraindication for expansive open door laminoplasty for cervical myelopathy? Review Topic

Explanation

Expansive open door laminoplasty is a method of posterior cervical decompression. It is contra-indicated for patients with cervical kyphosis unless the surgical plan includes concomitant correction of deformity.
Open door laminoplasty allows decompression direct posterior decompression of the neural elements, as well as an indirect anterior decompression by allowing the cord to drift posteriorly. Posterior drift of the cord relies upon the presence of natural cervical lordosis. In the setting of kyphosis, the cord is tensioned ventrally over the vertebral bodies and discs, and does not have the redundancy to drift backward. Patients without lordosis would therefore be expected to show less post-operative improvement than those with normal cervical curvature.
Chiba et al. performed a retrospective review of patients treated with expansive open door laminoplasty for cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL). They found that for patients with OPLL, cervical kyphosis was associated with lower recovery rates than those patients with pre-operative lordosis. The authors recommended against posterior decompression for CSM in the setting of OPLL with concomitant cervical kyphosis.
Suda et al. performed a retrospective review of 114 patients who underwent expansive
open door laminoplasty for cervical myelopathy in order to evaluate clinical outcomes and effects on cervical alignment. They found patients with C2-C7 kyphosis >13° had much lower rates of improvement compared with those patients with less kyphosis. The authors suggest an anterior decompression be used for patients with kyphosis greater than 13°, unless kyphotic correction was planned in addition to a laminoplasty.
Illustrations:
Illustration A demonstrates a lateral cervical spine x-ray which shows focal kyphosis at C4-5 and C5-6. Illustration B demonstrates the C7-sagittal vertical axis. Illustration C demonstrates the compression ratio.
Incorrect
<0.4 implies a poor prognosis.

Question 84

A 50-year-old patient underwent multiple débridements for an open radial shaft fracture with bone loss. The bed currently shows no evidence of infection but has a 14-cm diaphyseal bone defect. The most appropriate treatment includes open reduction and internal fixation along with

Explanation

EXPLANATION:
The patient developed a large bone defect after undergoing multiple débridements for an open fracture. The most appropriate graft in this setting is a vascularized bone graft. Considering the length of the defect, a free vascularized fibular graft would be a suitable graft. The indications for a vascularized bone graft include infection, inadequate vascularity of the surrounding tissues, bone defects larger than 6 centimeters, and previous failed bone grafts. The osteocytes survive in the vascularized graft, allowing primary bone healing and thereby limiting a loss of graft strength. In contrast, nonvascularized bone graft heals by creeping substitution with a loss of its initial strength. Calcium sulfate pellets and calcium phosphate cement are synthetic bone substitutes with osteoconductive properties. Their role in fracture healing is limited. Demineralized bone matrix is the matrix remaining after allograft undergoes decalcification processing. These products alone would not be optimal in the treatment of such a large bone defect.

Question 85

Figure 36 shows an AP radiograph of a 65-year-old man who reports activity-related groin pain. History reveals that he underwent total hip arthroplasty 12 years ago. What is the most likely diagnosis?

Explanation

DISCUSSION: The AP radiograph demonstrates extensive periacetabular osteolysis. The central hole eliminator has dissociated from the shell and migrated into a lytic defect in the ischium. In a retrieval study, most periacetabular osteolytic lesions had a clear communication pathway with the joint space. Lesions with communication to the joint via several pathways or through a central dome hole (as in this patient) were larger and more likely to be associated with cortical erosion. Although periprosthetic tumors have been described, they are rare and particle-induced inflammation around a prosthesis does not seem to increase the risk for carcinogenesis.
REFERENCES: Visuri T, Pulkkinen P, Paavolainen P: Malignant tumors at the site of total hip prosthesis: Analytic review of 46 cases. J Arthroplasty 2006;21:311-323.
Bezwada HP, Shah AR, Zambito K, et al: Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty. J Arthroplasty 2006;21:242-248.
Kitamura N, Naudie DD, Leung SB, et al: Diagnostic features of pelvic osteolysis on computed tomography: The importance of communication pathways. J Bone Joint Surg Am 2005;87:1542-1550.

Question 86

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Explanation

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 87

Figure 8 shows the CT scan of an 11-year-old boy who has had a 1-year history of worsening painful flatfeet. He reports pain associated with physical education at school, especially with running and jumping. Management consisting of activity restriction, anti-inflammatory drugs, and casting has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: In most patients with symptomatic talocalcaneal coalition involving less than 50% of the subtalar joint, resection with fat graft interposition is preferred over a subtalar or triple arthrodesis, especially if reasonable range of motion can be achieved. This patient has a synchondrosis that is partially cartilaginous. Although patients may have a residual gait abnormality, most report pain relief after surgery.
REFERENCES: Scranton PE Jr: Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am 1987;69:533-539.
Kitaoka HB, Wikenheiser MA, Schaughnessy WJ, et al: Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am 1997;79:369-374.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.

Question 88

Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?

Explanation

DISCUSSION: The patient has osteochondritis dissecans. While location, size, and knee stability are all relevant to the overall prognosis, studies have shown that younger patients with open growth plates have a better prognosis of healing when compared with patients who have closed growth plates. The degree of pain is also relevant to treatment, but it is subjective rather than objective and is not as reliable of a prognostic indicator as age.
REFERENCES: Stanitski CL: Osteochondritis dissecans of the knee, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, vol 3, pp 387-405.
Cahill B: Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee. Clin Sports Med 1985;4:367-384.
Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study. J Bone Joint Surg Am 1977;59:769-776.

Question 89

A 29-year-old man reports a 2-week history of severe neck pain after being struck sharply on the back of the head and neck while moving a refrigerator down a flight of stairs. Initial evaluation in the emergency department revealed no obvious fracture and he was discharged in a soft collar. Neurologic examination is within normal limits, and radiographs taken in the office are shown in Figures 21a through 21c. Subsequent MRI scans show intra-substance rupture of the transverse atlantal ligament. What is the most appropriate treatment option at this time? Review Topic

Explanation

Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
(SBQ13PE.82) A renal ultrasound should be obtained in a patient with which of the following diagnoses? Review Topic
Congenital pseudoarthrosis of the clavicle
Accessory navicular
Congenital scoliosis
Charcot-Marie-Tooth Disease
Congenital curly toe
A renal ultrasound should be obtained in a patient with congenital scoliosis.
Congenitial scoliosis has a prevalence that is estimated at 1% to 4% in general population. It is associated with systemic anomalies in up to 61% of cases. The most common anomalies are cardiac defects, genitourinary defects and spinal cord malformations. As such, additional imaging of these systems should be considered in the initial work-up of these patients.
Ruf et al. retrospectively investigated 56 consecutive operative cases of congenital scoliosis. The average age at surgery was 9.9 years (1.5–17 years). There was one wound complication, 2 hardware failures, 1 revision and no neurological complications. They concluded that one-stage posterior hemivertebra resection and instrumentation was safe in this population.
Xu et al. examined the efficacy of selective partial hemivertebra excision via posterior-only approach in 17 adolescent patients with congenital kyphoscoliosis. There were no postoperative infections and no neurological complications. They concluded that this approach may be most successful in patients aged 9 to 14 years old, with the Risser sign grades from 0–3 and Cobb angles <60°.
Illustration A from Erol et al (UPOJ, Vol 15, 2002;37-42) shows a diagram of 'types' of congenital scoliosis based on the morphology of the vertebrae.
Incorrect Answers:

Question 90

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 91

Figures 1 and 2 are the radiographs of a 36-year-old man who has had left wrist pain for the past 6 months following a fall onto his outstretched arm. Examination reveals a positive ballottement test, dorsal and ulnar carpal tenderness, and a painful snap with ulnar deviation, pronation, and axial compression. Injury to what ligament is the cause of this patient's pain?

Explanation

EXPLANATION:
The radiographs reveal a volarly tilted lunate on the lateral view (Figure 1) and an incongruous lunotriquetral articulation on the AP gripped view (Figure 2). The patient has what appears to be radiographic findings of volar intercalated segmental instability (VISI), a type of carpal instability, dissociative. An injury to the volar lunotriquetral ligament is the most important contributor to this type of instability. An injury to the dorsal scapholunate ligament typically leads to a dorsal intercalated segmental instability. Isolated injuries to the dorsal radiocarpal ligament and the radioscaphocapitate
ligament do not lead to VISI, although combined injuries may lead to instability between the radius and the proximal row.

Question 92

Which of the following radiographic findings would be characteristic of the knee joints of a patient with neuropathic osteoarthropathy of the knee?

Explanation

Neuropathic osteoarthropathy (a.k.a. Charcot joint) develops most often in weight-bearing joints. The most likely cause is diabetes mellitus, but it is also associated with syphilis, leprosy, yaws, congenital insensitivity to pain, spina bifida, myelomeningocele, syringomyelia, aerodystrophic neuropathy, amyloid neuropathy, peripheral neuropathy of alcoholism, spinal cord injury, peripheral nerve injury, post-transplant neuropathy, and intraarticular steroid injections.
The loss of sensation to the joint is followed by severe degenerative changes, osteophyte formation, articular and subchondral fractures, and often calcification of surrounding soft tissues. In the knee, this is a tricompartmental disease and will not selectively affect one compartment over another.

Question 93

Figure 7 shows the radiograph of a 64-year-old man who has neck pain and weakness of the upper and lower extremities following a motor vehicle accident. Examination reveals 3/5 quadriceps and 4/5 hip flexors but no ankle dorsiflexion or plantar flexion. His intrinsics are 1/5, with finger flexors of 3/5. He is awake, alert, and cooperative. Management should consist of

Explanation

DISCUSSION: In patients with facet dislocations and an incomplete neurologic deficit, early decompression of the canal via reduction of the dislocation generally is considered safe if the patient is alert and can cooperate. However, patients who cannot cooperate with serial neurologic examinations during the reduction are at risk for increased deficit secondary to herniated nucleus pulposus, and MRI should be performed prior to either closed or
open reduction.
REFERENCES: Star AM, Jones AA, Cotler JM, et al: Immediate closed reduction of cervical spine dislocations using traction. Spine 1990;15:1068-1072.
Cotler JM, Herbison GJ, Nasuti JF, et al: Closed reduction of traumatic cervical spine dislocations using traction weight up to 140 pounds. Spine 1993;18:386-390.

Question 94

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)?

Explanation

DISCUSSION: The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.
REFERENCES: Selecky MT, Tibone JE, Yang BY, et al: Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg 2003;12:139-143.
Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Question 95

The mother of a 26-month-old boy reports that he has been unwilling to bear weight on his left lower extremity since he awoke this morning. She denies any history of trauma. He has a temperature of 99.4°F (37.4°C), and examination reveals that abduction of the left hip is limited to 30°. Laboratory studies show a WBC of 11,000/mm 3 and an erythrocyte sedimentation rate of 22 mm/h. A radiograph of the pelvis is shown in Figure 13. Management should consist of

Explanation

DISCUSSION: The most likely diagnosis is transient synovitis. Initial management should consist of bed rest and serial observation to rule out atypical septic arthritis of the hip. In an unreliable family situation, hospitalization for bed rest and observation may be indicated. Other disorders such as proximal femoral osteomyelitis, leukemia, juvenile rheumatoid arthritis, pelvic osteomyelitis, diskitis, and arthralgia secondary to other inflammatory disorders should be considered. However, these disorders are unlikely because of the paucity of abnormal clinical signs exhibited by the patient. On the other hand, transient synovitis of the hip in children is a diagnosis of exclusion; other possibilities should be explored if the patient’s symptoms do not follow a typical course and resolve in 4 to 21 days.
REFERENCE: Frymoyer JW (ed): Orthopaedic Knowledge Update 4. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1993, pp 505-513.

Question 96

A 17-year-old basketball player and pole vaulter who has had anterior knee pain for the past 18 months now reports a recent inability to jump. Based on the MRI scan shown in Figure 11, management should consist of Review Topic

Explanation

The MRI scan reveals a partial patellar tendon rupture in conjunction with chronic patellar tendinitis. Mild and moderate patellar tendinitis may be treated nonsurgically with rest, stretching, strengthening, and anti-inflammatory drugs. Severe tendinopathy or extensor mechanism disruption is best treated surgically with tendon debridement and repair.

Question 97

A 10-year-old boy has a painful, swollen knee after falling off his bicycle. Examination reveals no other injuries. Radiographs are shown in Figures 35a and 35b. Initial management of this fracture should consist of

Explanation

DISCUSSION: The radiographs show a minimally displaced fracture of the tibial eminence, which is classified as a McKeever type II injury. In a number of studies, it has been found that most of these fractures will reduce with extension of the knee. This is often made easier with evacuation of the hemarthrosis. The position of knee immobilization is controversial, with some authors preferring full extension and others preferring 20 degrees of flexion. Flexion to 90 degrees will further displace the fragment. If the fragment does not reduce or if the patient has a McKeever type III or IV injury, reduction and internal fixation are required. This can be done with either an open or an arthroscopic procedure. Excision of the fragment is not indicated.
REFERENCES: Meyers MH, McKeever FM: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.
Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60
Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995;15:63-68.
Kuhn JE, Sailer MJ, Sterett WI, Hawkins RJ: Arthroscopic technique for the treatment of tibial spine fractures in the skeletally immature patient. J Ortho Tech 1995;3:7-12.

Question 98

What is an example of cognitive rest after concussion? Review Topic

Explanation

Physical and cognitive rest are recommended as treatment for sports-related concussion. Cognitive rest involves minimizing activities that require concentration and attention such as reading, schoolwork, video games, text messaging, working online, and playing games that require concentration such as chess. Limiting or eliminating video games after concussion is a form of cognitive rest.

Question 99

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

Explanation

The injury shown is a fracture-dislocation and it is highly unstable. In addition to this concern, spinal epidural hematomas have a much higher incidence in people with ankylosing spondylitis following spine fracture. It is felt to be due to disrupted epidural veins, with hypervascular epidural soft tissue in the setting of a rigid spinal canal. Patients with ankylosing spondylitis may have other significant comorbidities, especially cardiac and pulmonary, and these should be carefully assessed.

Question 100

What is the most common physical finding in a patient with femoroacetabular impingement (FAI)? Review Topic

Explanation

A loss of flexion and internal rotation are hallmarks of FAI. With the hip flexed 90 degrees, maximal internal rotation testing is also known as the anterior impingement test, causing deep groin pain and reproduction of symptoms. Occasionally, a posterior impingement test will be positive with extension and external rotation. There are a variety of causes of FAI; however, the pathology limits motion as the femur (cam) and acetabulum (pincer) contact one another. Also, only one location needs to be present, such as cam-type or pincer-type versus both cam-pincer lesions to cause symptoms.

Full Question & Answer Text (for Search Engines)

Question 1:

What is the most frequent location of entrapment of the deep peroneal nerve?

Options:

Tendon of the extensor hallucis brevis
Inferior extensor retinaculum
Osteophytes of the talonavicular joint
Os intermetatarseum
Base of the fifth metatarsal

Correct Answer: Inferior extensor retinaculum

Explanation:

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 2:

Options:

Therapeutic footwear/depth-inlay shoes and a custom accommodative foot orthosis
Charcot restraint orthotic walker (CROW)
Percutaneous Achilles tendon lengthening, a total contact cast, and a CROW walker
Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear
Ankle disarticulation (Syme) amputation

Correct Answer: Surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear

Explanation:

DISCUSSION: This is a nonplantigrade deformity in a patient with a Charcot foot deformity. Longitudinal studies have shown that recurrent ulceration/infection is likely unless the deformity is corrected. Achilles tendon lengthening is advised for simple forefoot ulcers. The current approach to this problem is best managed with surgical correction of the deformity, Achilles tendon lengthening, and therapeutic footwear.
REFERENCES: Bevan WP, Tomlinson MP: Radiographic measures as a predictor of ulcer formation in diabetic charcot midfoot. Foot Ank Int 2008;29:568-573.
Simon SR, Tejwani SG, Wilson DL, et al: Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot. J Bone Joint Surg Am 2000;82:939-950.
Pinzur M: Surgical versus accommodative treatment for Charcot arthropathy of the midfoot.
Foot Ankle Int 2004;25:545-549.

Question 3:

Options:

Immobilization in a rigid cervical orthosis for 6 to 8 weeks
Posterior occipital-cervical fusion with iliac crest bone graft
Open reduction and internal fixation of the odontoid process with an anterior odontoid screw
Resection of the odontoid process through a transoral approach
Halo skeletal fixation

Correct Answer: Immobilization in a rigid cervical orthosis for 6 to 8 weeks

Explanation:

Question 4:

Options:

Full elbow flexion and wrist extension
Full forearm supination
Full elbow extension and wrist extension
Forearm pronation
Neutral forearm rotation

Correct Answer: Forearm pronation

Explanation:

Question 5:

Which of the following materials best approximates the Young's modulus of elasticity of cortical bone?

Options:

Titanium
Cobalt-chrome alloy
Alumina
Zirconia
Stainless steel

Correct Answer: Cobalt-chrome alloy

Explanation:

Question 6:

What is the most common problem seen following epiphysiodesis for limb-length discrepancy?

Options:

Fracture through the site of the physeal resection
Direct neurovascular injury
Incomplete growth arrest from inadequate physeal excision
Persistent discrepancy from an error in the timing of the surgery
Cartilaginous injury because of inadvertent joint penetration

Correct Answer: Persistent discrepancy from an error in the timing of the surgery

Explanation:

Question 7:

Options:

Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability

Correct Answer: Evidence of presurgical elbow instability

Explanation:

Question 8:

Options:

Radial
Ulnar
Median
Posterior interosseous
Anterior interosseous

Correct Answer: Radial

Explanation:

Question 9:

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

Options:

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

Correct Answer: Anterior band of the inferior glenohumeral ligament complex

Explanation:

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

Question 10:

When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?

Options:

Deep branch of the ulnar nerve
Anterior interosseous branch of the median nerve
Recurrent branch of the median nerve
Recurrent branch of the ulnar nerve
Palmar cutaneous branch of the ulnar nerve

Correct Answer: Recurrent branch of the median nerve

Explanation:

DISCUSSION: The MRI scan shows a large mass (lipoma) in the thenar muscles of the palm. The recurrent motor branch of the median nerve innervates the thenar muscles. The anterior interosseous nerve (AIN) in the proximal forearm innervates the flexor pollicis longus, pronator quadratus, and flexor digitorum pollicis to the index and frequently the middle finger. The terminal branch of the AIN innervates only the wrist capsule. The palmar cutaneous branch of the ulnar nerve is a sensory structure to the hypothenar area. There is no commonly described recurrent branch of the ulnar nerve.
REFERENCE: Kozin SH: The anatomy of the recurrent branch of the median nerve. J Hand Surg Am 1998;23:852-858.

Question 11:

Options:

Repeat closed reduction and splinting under anesthesia to achieve absolute stability
Closed reduction and temporary transarticular fixation using 1.6 mm Kirschner-wires to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve absolute stability
Definitive open reduction and internal fixation of the ankle to achieve relative stability
Temporary external fixation of the ankle to achieve relative stability

Correct Answer: Definitive open reduction and internal fixation of the ankle to achieve absolute stability

Explanation:

Question 12:

A 28-year-old man has left knee pain after a snow skiing accident. The MRI scan shown in Figure 47 reveals which of the following? Review Topic

Options:

Osteosarcoma
Bucket-handle medial meniscal tear
Lateral collateral ligament tear
Bone bruise
Tibial spine avulsion

Correct Answer: Bone bruise

Explanation:

Question 13:

A fracture in the following location is most commonly associated with procurvatum and valgus malalignment?

Options:

Humeral shaft
Distal femur
Proximal tibia
Distal third tibia shaft with intact fibula
Subtrochanteric proximal femur

Correct Answer: Humeral shaft

Explanation:

Question 14:

The histology of the lesion is shown in Figure 101d. What is the most likely complication after treatment of this lesion?

Options:

Arthrofibrosis
Local recurrence
Chondrolysis
Disseminated infection
Metastasis

Correct Answer: Local recurrence

Explanation:

DISCUSSION FOR QUESTIONS 101 THROUGH 103:
The MRI scans show a well-circumscribed inhomogenous mass at the anterior ankle joint consistent with a diagnosis of pigmented villonodular synovitis (PVNS), not an anatomic variant. An inflammatory mass,such as the pannus of rheumatoid arthritis, would reveal moderate signal intensity with relatively uniform signal throughout. The mass is well encapsulated, respecting tissue boundaries and not showing invasive characteristics as malignancies would. The arthroscopic image is also consistent with the reddish-brown frond-like tissue of PVNS. PVNS of the ankle can be treated arthroscopically. If this mode of treatment is chosen, a tissue sample should be sent to pathology for microscopic analysis; débridement should be performed on the remaining tissue. Removal of the instrumentation without débridement will not provide treatment and will result in disease progression. Tourniquet placement does not provide therapeutic benefit.
Brachytherapy has not been described for the treatment of PVNS of the ankle. The histologic image shows multiple multinucleated giant cells, hemosiderin, and very few mitotic figures – consistent with a diagnosis of PVNS. A common complication of PVNS treatment is local recurrence. Arthrofibrosis and chondrolysis are not seen with proper surgical care of these patients. Because this is not an infectious lesion, disseminated infection after treatment is highly unlikely. PVNS rarely metastasizes.
RESPONSES FOR QUESTIONS 104 THROUGH 106
Toe is fused too straight (plantar flexed)
Toe is fused in too much valgus
Toe is fused in too much dorsiflexion
There is a nonunion of the fusion
Excessive shortening of the first metatarsal during preparation for fusion What is the most likely diagnosis for each patient?

Question 15:

Options:

hallux metatarsophalangeal arthrodesis.
custom orthotics.
Chevron osteotomy with second toe correction.
Keller resection arthroplasty with second toe correction.
proximal metatarsal osteotomy with second toe correction.

Correct Answer: proximal metatarsal osteotomy with second toe correction.

Explanation:

Question 16:

Which of the following best describes the course of the ulnar nerve in the midforearm?

Options:

Travels deep to the flexor carpi ulnaris muscle, radial to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels deep to the flexor carpi ulnaris muscle, radial to the ulnar artery, deep to the flexor digitorum profundus muscle
Travels deep to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels superficial to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle
Travels superficial to the flexor carpi ulnaris muscle, radial to the ulnar artery, superficial to the flexor digitorum profundus muscle

Correct Answer: Travels deep to the flexor carpi ulnaris muscle, ulnar to the ulnar artery, superficial to the flexor digitorum profundus muscle

Explanation:

Question 17:

Moderate distance running has what effect on knee articular cartilage in asymptomatic distance runners?

Options:

Increased loss of collagen tensile integrity in the superficial zone
Increased production of glycosaminoglycans
Decreased collagen in the middle zone
Loss of cartilage thickness that correlates with the total distance run during the course of adult life
Collagen loss in the medial compartment and collagen increase in the lateral compartment

Correct Answer: Increased production of glycosaminoglycans

Explanation:

Question 18:

An 8-year-old girl sustained a displaced fracture at the base of the femoral neck in a motor vehicle accident. Management should consist of

Options:

closed reduction and spica cast immobilization.
closed reduction and fixation of the femoral fracture with smooth pins across the physis.
open reduction and fixation with screws across the fracture and short of the growth plate, and a spica cast.
skeletal traction in a 90 - 90 position.
temporary traction until fixation with a specially ordered pediatric hip screw is possible.

Correct Answer: open reduction and fixation with screws across the fracture and short of the growth plate, and a spica cast.

Explanation:

DISCUSSION: Pediatric intracapsular hip fractures are challenging because of the high rates of complications, including osteonecrosis and varus malunion. These patients should be treated as emergencies. Principles of treatment include anatomic reduction with internal fixation. Screw fixation short of the physis is preferred and may need to be supplemented with spica cast immobilization. Fixation may be achieved with smooth pins across the physis when little metaphyseal bone is available. Fixation across the physis with threaded screws is acceptable only when the patient is close to skeletal maturity. Pediatric hip screws are appropriate if immediately available. Emergent open reduction, capsulotomy, or joint aspiration may decrease the rate of osteonecrosis.
REFERENCES: Cheng JC, Tang N: Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999;19:338-343.
Azouz EM, Karamitsos C, Reed MH, et al: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Song
KS
, Kim YS, Sohn SW, et al: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210.
Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51.

Question 19:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 20:

Figures 11a and 11b show the T 2 -weighted MRI scans of the lumbar spine of a 53-year-old woman who has low back and right lower extremity pain. What structure is the arrow pointing to in Figure 11a?

Options:

Ligamentum flavum
Lumbar synovial cyst
Tarlov cyst
Pseudomeningocele
Herniated nucleus pulposus

Correct Answer: Lumbar synovial cyst

Explanation:

DISCUSSION: The arrow is pointing to a cystic-appearing structure with high signal intensity on T
2
-weighted image sequencing. It appears to be contiguous with the hypertrophied right facet joint, which appears to also have high signal intensity. The mass significantly narrows the right lateral recess. The high signal intensity suggests that this is a fluid-filled mass. In addition, the facet joints are degenerative and there is a very mild degree of anterolisthesis on the sagittal image. These findings make a lumbar synovial cyst the most likely diagnosis. Most lumbar juxtafacet cysts are observed at the L4-5 level, extradurally and adjacent to the degenerative facet joint. They may contain synovial fluid and/or extruded synovium. Presentation is indistinguishable from that of a herniated disk. The etiology of spinal cysts remains unclear, but there appears to be a strong association between their formation and worsening spinal instability. They occasionally regress spontaneously and may respond to aspiration and injection of corticosteroids, though there is a high recurrence rate with nonsurgical management. Synovial cysts resistant to nonsurgical management should be treated surgically. If the patient’s symptoms can be attributable to radicular findings, a microsurgical decompression that limits further destabilization should suffice. However, if there is significant low back pain attributable to spinal instability, decompression and fusion remains an appropriate option.
REFERENCES: Banning CS, Thorell WE, Leibrock LG: Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969-972.
Deinsberger R, Kinn E, Ungersbock K: Microsurgical treatment of juxta facet cysts of the lumbar spine. J Spinal Disord Tech 2006;19:155-160.
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.

Question 21:

Options:

Abduction to 90 degrees with maximal external rotation
Forward elevation to 170 degrees with neutral rotation
Cross-body adduction at 90 degrees flexion, with internal rotation
Extension with maximal internal rotation
Flexion to 90 degrees with maximal external rotation

Correct Answer: Abduction to 90 degrees with maximal external rotation

Explanation:

Question 22:

Options:

Spinal muscular atrophy, type II
Myotonic dystrophy
Duchenne muscular dystrophy
Becker muscular dystrophy
Hereditary motor sensory neuropathy, type II (HMSN)

Correct Answer: Becker muscular dystrophy

Explanation:

Question 23:

Options:

Lateral meniscus repair
Corticosteroid injection and physical therapy
Medial meniscus repair
Unloader brace

Correct Answer: Medial meniscus repair

Explanation:

The MRI scan shows a posterior horn medial meniscus root avulsion with bony edema at the tibial root insertion. The radiograph shows no significant degenerative changes. If left untreated, posterior meniscal
root tears lead to progressive degenerative changes as a result of the altered tibiofemoral contact pressures and areas. Nonsurgical treatment including injections, physical therapy, and unloader braces are more
appropriate in the older patient with pre-existing advanced degenerative changes.

Question 24:

When comparing arthroscopic lavage and knee debridement with placebo in patients with chronic symptomatic osteoarthritis, what outcome has been demonstrated?

Options:

Reliable and durable pain relief
No significant benefit for chronic osteoarthritis
Up to 75% pain relief for 2 months, then variable response
Three-month measurable pain relief, followed by recurrence

Correct Answer: No significant benefit for chronic osteoarthritis

Explanation:

Question 25:

In which scenario is application of NPWT contraindicated?

Options:

- Fasciotomy wound after compartment syndrome
- Exposed bone after debridement
- Surgical wound that cannot be closed because of tension
- Surgical tumor bed after excision while awaiting final pathology and definitive closure

Correct Answer: - Surgical tumor bed after excision while awaiting final pathology and definitive closure

Explanation:

DISCUSSION
The most common complication associated with NPWT is a rash on the skin resulting from contact with a suction sponge. In a 2001 study by Webb and Schmidt, 2.2% of patients treated with NPWT had a rash that resolved within 48 hours. To minimize risk for this rash, care should be taken to avoid overlap of the sponge onto intact skin. If skin overlap is unavoidable, a lower-pressure setting should be used.
Acute bacterial infection is possible in this scenario, but there would likely be additional findings such as purulence in the wound itself. Similarly, an acute allergic reaction could be found within the wound and not just at the skin edge. Skin irritation from excessive adhesive plastic tension can result in blistering or shearing avulsion but not skin-edge erythema. Skin necrosis from the original trauma would result in skin-edge duskiness instead of erythema.
A study by Timmers and associates showed a statistically significant increase in microvascular blood flow to the skin under a sponge at subatmospheric pressures. Angiogenesis occurs in the area of the wound vacuum from the negative pressure and increased blood flow, not from the sponge material itself. There has been no indication that antibiotic concentration is increased in the setting of negative pressure therapy because antibiotics would be evacuated along with the fluid. NPWT does not result in increased temperatures that would kill pathogens.
NPWT is contraindicated in the setting of neoplasm because its effect on tumors is unknown. There is potential for increased angiogenesis in residual tumor cells, which could lead to recurrence or even metastasis. NPWT has been used safely and effectively for coverage of open fractures between initial debridement and definitive coverage. Fasciotomy wounds are frequently covered with NPWT dressings on a temporary basis with excellent results.
NPWT has been used to temporize wounds with exposed bone before flap coverage. Wounds with excessive tension frequently can be closed after short-term coverage with NPWT dressings.
RECOMMENDED READINGS
Webb LX, Schmidt U. [Wound management with vacuum therapy]. Unfallchirurg. 2001 Oct;104(10):918-26. German. PubMed PMID: 11699301.
View Abstract at PubMed
Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11. PubMed PMID: 12374481.
View Abstract at
PubMed
Timmers MS, Le Cessie S, Banwell P, Jukema GN. The effects of varying degrees of pressure delivered bynegative-pressure wound therapy on skin perfusion. Ann Plast Surg. 2005 Dec;55(6):665-71. PubMed PMID: 16327472.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 68 AND 69
Figure 68 is the radiograph of a 17-year-old girl who is treated with closed reduction and percutaneous screw fixation for her displaced femoral neck fracture. Capsulotomy of the hip is not performed. After surgery, the patient is instructed to maintain touch-down weight-bearing status for 3 months.

Question 26:

Which of the following preoperative findings is a predictor of poor outcome following arthroscopic debridement for glenohumeral arthritis? Review Topic

Options:

Shoulder stiffness
History of infection
Nonconcentric joint space on preoperative radiographs
Intra-articular loose bodies
History of instability

Correct Answer: Nonconcentric joint space on preoperative radiographs

Explanation:

Question 27:

Options:

Femoral nerve palsy
Sciatic nerve palsy
Recurrent hip dislocation
Osteonecrosis of the femoral head
Immediate chondrolysis of the hip joint

Correct Answer: Osteonecrosis of the femoral head

Explanation:

Question 28:

Options:

Occupational therapy for strengthening
Extensor carpi radialis longus transfer to extensor pollicus longus
Extensor pollicis brevis transfer to extensor pollicus longus
Extensor indicis proprius transfer to extensor pollicus longus
Primary repair of extensor pollicus longus

Correct Answer: Occupational therapy for strengthening

Explanation:

Question 29:

The MRI scans and diagnostic ultrasound shown in Figures 2a through 2c show what pathologic condition? Review Topic

Options:

Articular-sided supraspinatus tendon tear
Bursal-sided supraspinatus tear
Superior labral tear
Humeral avulsion of the anterior glenoid ligament
Avulsion of the anterior inferior glenohumeral ligament

Correct Answer: Articular-sided supraspinatus tendon tear

Explanation:

Question 30:

Options:

Total shoulder arthroplasty and rotator cuff repair
Rotator cuff repair
Reverse total shoulder arthroplasty
Interpositional arthroplasty and rotator cuff repair
Hemiarthroplasty and rotator cuff repair

Correct Answer: Total shoulder arthroplasty and rotator cuff repair

Explanation:

Question 31:

Options:

Radial head
Anterior capsule
Olecranon fossa osteophytes
Lateral ulnar collateral ligament
Posterior oblique band of the medial collateral ligament

Correct Answer: Posterior oblique band of the medial collateral ligament

Question 32:

Options:

Ehlers-Danlos syndrome
Traumatic anterior instability
Humeral head osteonecrosis
Internal impingement
Partial-thickness supraspinatus tear

Correct Answer: Internal impingement

Explanation:

Question 33:

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Options:

MRI
Fine-cut CT scan
Bone scan
AP radiograph of the femur
AP radiograph of the pelvis

Correct Answer: Fine-cut CT scan

Explanation:

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 34:

Options:

caused by the accident, exists in 5% of the population, has no familial predisposition, and is unlikely to progress.
caused by the accident, exists in 12% of the population, has no familial predisposition, and is unlikely to progress.
preexisting to her accident, exists in 3% of the population, has no familial predisposition, and should be monitored for progression yearly until age 25 years.
preexisting to her accident, exists in 5% of the population, has a familial predisposition, and is unlikely to progress.
preexisting to her accident, exists in 12% of the population, has a familial predisposition, and is likely to progress throughout adulthood.

Correct Answer: preexisting to her accident, exists in 5% of the population, has a familial predisposition, and is unlikely to progress.

Explanation:

Question 35:

Options:

Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test

Correct Answer: Biopsy, culture, curettage, bone graft, and possible internal fixation

Explanation:

Question 36:

What type of medial collateral ligament tear heals the most reliably? Review Topic

Options:

Proximal
Midsubstance
Distal
Associated with an anterior cruciate ligament tear
Associated with a posterior cruciate ligament tear

Correct Answer: Proximal

Explanation:

Question 37:

A 12-year-old girl has scoliosis at T5-T10 that measures 62°. A clinical photograph of the axilla is shown in Figure 56. Management should consist of

Options:

a thoracolumbosacral orthosis.
in situ posterior spinal fusion.
posterior spinal fusion with segmental instrumentation.
anterior spinal fusion with instrumentation.
anterior and posterior spinal fusion with posterior segmental instrumentation.

Correct Answer: anterior and posterior spinal fusion with posterior segmental instrumentation.

Explanation:

Question 38:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints? Review Topic

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed images with tibial stress fractures.
After activity, pain persists longer with tibial stress fractures.

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 39:

Options:

Repeat treatment with a nonweight-bearing cast
Percutaneous lag screw fixation
Addition of a bone stimulator
Injection of bone morphogenic protein

Correct Answer: Percutaneous lag screw fixation

Explanation:

This patient’s MR images are indicative of a nondisplaced navicular stress fracture, which is best treated with percutaneous lag screw fixation. She has persistent symptoms despite appropriate nonsurgical treatment. Although all of the above choices may allow successful healing of her navicular, surgery has been shown to result in a shorter recovery and a more predictable outcome, which is especially important to serious athletes. Use of bone morphogenic protein has not been established as a treatment for this injury.
RECOMMENDED READINGS
Lee S, Anderson RB. Stress fractures of the tarsal navicular. Foot Ankle Clin. 2004 Mar;9(1):85-104. Review. PubMed PMID: 15062216.
View Abstract at PubMed
Anderson RB, Cohen BE. Stress fractures of the foot and ankle. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1590-1597.

Question 40:

What is the most appropriate orthosis for hallux rigidus?

Options:

Morton’s extension
Metatarsal arch pad
Full-length semi-rigid longitudinal arch support
Full-length semi-rigid longitudinal arch support with medial hindfoot posting
Full-length semi-rigid longitudinal arch support with lateral forefoot posting

Correct Answer: Morton’s extension

Explanation:

Question 41:

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

Options:

Bright on T 1 and T 2
Dark on T 1 and T 2
Dark on T 1 , bright on T 2
Bright on T 1 , dark on T 2
Enhancement by gadolinium

Correct Answer: Dark on T 1 , bright on T 2

Explanation:

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses. The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs. MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T
1
and bright on T
2
.
REFERENCES: Miller MD: Review of Orthopaedics, ed 3. Philadelphia PA, WB Saunders, 2000, p 116.
Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review. Orthopedics 1994;17:327-330.

Question 42:

Options:

general anesthesia.
antibiotics.
warfarin.
narcotics.

Correct Answer: narcotics.

Explanation:

Question 43:

Options:

Reassure the patient that the symptoms should subside gradually and that he should remain as upright as possible and loosen his cervical collar.
Prescribe methylprednisolone and diazepam.
Admit the patient for observation.
Advise the patient to come to the office first thing in the morning for a lateral radiograph of the cervical spine.
Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Correct Answer: Advise immediate transport to the emergency department for evaluation of the airway, possible intubation, and possible cricothyroidotomy.

Explanation:

Question 44:

Options:

Metastasis
Aneurysmal bone cyst
Osteoblastoma
Osteoid osteoma
Eosinophilic granuloma

Correct Answer: Eosinophilic granuloma

Explanation:

Question 45:

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Options:

Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance

Correct Answer: Pseudarthrosis

Explanation:

Question 46:

Mirror therapy is indicated for which of the following clinical conditions?

Options:

Impaired proprioception after lower extremity injury
Two-stage flexor tendon reconstruction
Plumbism
Anterior cruciate ligament reconstruction
Phantom pain

Correct Answer: Impaired proprioception after lower extremity injury

Explanation:

Question 47:

Which repair technique for an osteochondral lesion of the medial talus shoulder produces hyaline cartilage that is similar to native cartilage and will not degrade over time?

Options:

Autologous osteochondral transplantation
Arthroscopic bone marrow stimulation
Chondroplasty
Osteochondral allograft transplantation

Correct Answer: Autologous osteochondral transplantation

Explanation:

DISCUSSION
Autologous osteochondral transplantation (typically involving tubular grafts harvested from the knee) has been shown to replace a talar defect with viable hyaline cartilage. The results over the medium term show good clinical outcomes, and MRI studies reveal cartilage repair similar to native cartilage. Chondroplasty and arthroscopic bone-marrow stimulation are both associated with good clinical results for smaller lesions, but these techniques develop fibrocartilaginous repair tissue composed of type I collagen instead of hyaline cartilage. Osteochondral transplantation of fresh allografts performed less than 14 days after harvest contains high chondrocyte viability. Few clinical studies report long-term results, but radiographic studies demonstrate high rates of collapse and resorption. Joint space narrowing has been noted in 60% of ankles treated with bulk grafts after an average of 44 months. Autologous chondrocyte implantation (both periosteum-covered and matrix-associated techniques) has been shown to create hyaline cartilage in some studies, but fibrocartilage creation has been reported in others.
RECOMMENDED READINGS
Schachter AK, Chen AL, Reddy PD, Tejwani NC. Osteochondral lesions of the talus. J Am Acad Orthop Surg. 2005 May-Jun;13(3):152-8. Review. PubMed PMID: 15938604.
View Abstract
at PubMed
Mitchell ME, Giza E, Sullivan MR. Cartilage transplantation techniques for talar cartilage lesions. J Am Acad Orthop Surg. 2009 Jul;17(7):407-14. Review. PubMed PMID: 19571296.
View Abstract at PubMed
Murawski CD, Kennedy JG. Operative treatment of osteochondral lesions of the talus. J Bone Joint Surg Am. 2013 Jun 5;95(11):1045-54. doi: 10.2106/JBJS.L.00773. Review. PubMed PMID: 23780543.
View Abstract at PubMed

Question 48:

- The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Options:

T1-low, T2-low.
T1-low, T2-high.
T1-moderate, T2-low.
T1-high, T2-low.
T1-high, T2-high.

Correct Answer: T1-low, T2-high.

Explanation:

Question 49:

Options:

Repeat debridement, followed by 6 weeks of IV antibiotics
Repeat debridement, followed by direct exchange arthroplasty
Delayed exchange reimplantation
Immediate knee arthrodesis
Amputation

Correct Answer: Delayed exchange reimplantation

Explanation:

Question 50:

- A patient reports persistent pain in the wrist 6 months after undergoing open reduction and internal fixation of a Galleazi fracture. Radiographs of the wrist in a neutral position are normal. Which of the following studies would best evaluate the reduction of the distal radioulnar joint?

Options:

Arthrogram of the wrist
MRI scan of both wrists
CT scan of both wrists in the same position
Radiographs of the wrist in supination and pronation
Radiographs of the opposite wrist in the same position

Correct Answer: CT scan of both wrists in the same position

Explanation:

Question 51:

Options:

Ankle ligament repair
Resection of the accessory navicular
Resection of the talocalcaneal coalition
Subtalar arthrodesis
Triple arthrodesis

Correct Answer: Resection of the talocalcaneal coalition

Explanation:

Question 52:

Options:

anterior translation of the humeral head.
loss of external rotation.
excessive tightening of the biceps tendon.
superior migration of the humeral head.
no excessive changes

Correct Answer: loss of external rotation.

Explanation:

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 53:

Options:

Chemotherapy and radiation therapy
Intravenous antibiotics, protected weight bearing, and a repeat C-reactive protein after improvement
Open biopsy and debridement of the site, followed by intravenous antibiotics
Technetium Tc 99m bone scan
Empiric oral antibiotics and repeat laboratory studies in 1 week

Correct Answer: Open biopsy and debridement of the site, followed by intravenous antibiotics

Explanation:

DISCUSSION: The history and laboratory findings are consistent with osteomyelitis of the patella. The radiograph reveals bone destruction in the patella; therefore, the next most appropriate step is open biopsy and debridement of the site. Aspiration of the knee joint may be needed to rule out septic arthritis prior to patellar debridement. With this amount of bone destruction, surgical debridement is helpful to obtain cultures and to remove necrotic material. Administering antibiotics without any prior culture increases the risk of negative cultures later and a potentially incorrect choice of antibiotic. A neoplasm should be included in the differential. It would be inappropriate to initiate chemotherapy and radiation therapy without a biopsy-confirmed diagnosis. A bone scan is likely to demonstrate uptake, but radiographs have already localized the abnormality to the patella.
REFERENCES: Morrisy RT: Bone and joint sepsis, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins, 2001, pp 466-470.
Dormans JP, Drummond DS: Pediatric hematogenous osteomyelitis: New trends in presentation, diagnosis, and treatment. J Am Acad Orthop Surg 1994;2:333-341.

Question 54:

Options:

Physical therapy and a home exercise program
Corticosteroid injection
Arthroscopic debridement
Microfracture
Osteochondral autograft transplantation (OAT)

Correct Answer: Osteochondral autograft transplantation (OAT)

Explanation:

Question 55:

Which of the following anatomic structures is often difficult to visualize during elbow arthroscopy?

Options:

Ulnar collateral ligament
Olecranon fossa
Radial head
Coronoid process
Anterior superior capsular attachment to the humerus

Correct Answer: Ulnar collateral ligament

Explanation:

Question 56:

What is the primary reason for including the ilium in the distal fixation of long instrumentation constructs in adult scoliosis? Review Topic

Options:

Better coronal balance
Better pelvic balance
Reduced fretting and corrosion
Improved curve correction
Improved fusion success

Correct Answer: Improved fusion success

Explanation:

Question 57:

Options:

the current literature does not support allograft meniscus transplantation.
allograft meniscus transplantation is a surgical option; however, he is beyond the age where the procedure will provide much lasting benefit.
you would recommend a course of viscosupplementation.
based on his age and limb alignment, you would not recommend an allograft meniscus transplant but would recommend a high tibial osteotomy.
based on his age and limb alignment, you would recommend a high tibial osteotomy and a staged allograft meniscal transplant after the osteotomy has healed.

Correct Answer: based on his age and limb alignment, you would recommend a high tibial osteotomy and a staged allograft meniscal transplant after the osteotomy has healed.

Explanation:

Question 58:

Options:

arthroscopic repair of a superior labral tear with cyst decompression.
open excision of the ganglion cyst.
proximal biceps tenodesis.
rotator cuff repair.
anterior stabilization.

Correct Answer: arthroscopic repair of a superior labral tear with cyst decompression.

Explanation:

Question 59:

Figure 8 shows the radiograph of a 72-year-old man who has had severe pain in the left hip for the past 3 weeks. History reveals alcohol abuse. The next most appropriate step should consist of

Options:

hip aspiration.
Doppler ultrasound.
AP tomograms.
a CT scan.
a technetium Tc 99m bone scan.

Correct Answer: hip aspiration.

Explanation:

Question 60:

A 25-year-old athlete presents with symptoms attributed to injury to ligament D in Figure A. Which of the following symptoms and signs is characteristic of this injury? Review Topic

Options:

Pain during late cocking and acceleration; milking maneuver.
Painful clicking during pushoff from armrests of a chair; milking maneuver.
Painful clicking during pushoff from armrests of a chair; lateral pivot shift.
Pain during late cocking and acceleration; lateral pivot shift.
Painful clicking during pushoff from armrests of a chair; moving valgus stress test.

Correct Answer: Pain during late cocking and acceleration; milking maneuver.

Explanation:

Question 61:

- Figures 43a and 43b show the radiographs of an 8-year-old boy who was referred by his gym teacher because of an awkward running pattern. The patient denies any pain in his hips. Examination reveals a mild Trendelenberg gait and decreased internal rotation of the left hip to 25 degrees compared to 40 degrees on the right. What is the most likely diagnosis?

Options:

SCFE
MED
Perthes disease
Hypothyroidism
Chondrolysis

Correct Answer: Perthes disease

Explanation:

Question 62:

Figure 31 shows the radiograph of a 64-year-old woman who is seen in the emergency department following a motor vehicle accident. She has no

Options:

continued rapid fluid infusion.
administration of broad-spectrum antibiotics.
administration of 30/mg/kg methylprednisolone over 1 hour.
administration of pressors.
cardioversion and implantation of a pacemaker.

Correct Answer: administration of pressors.

Explanation:

Question 63:

What structure is located immediately posterior to the capsule at the posterior cruciate ligament tibial insertion?

Options:

Popliteal artery
Popliteal vein
Tibial nerve
Peroneal nerve
Medial head gastrocnemius tendon

Correct Answer: Popliteal artery

Explanation:

DISCUSSION: The popliteal artery lies just posterior to the posterior cruciate ligament
tibial insertion, separated only by the posterior capsule of the knee. When performing
a posterior cruciate ligament reconstruction, this artery is at risk for injury during creation
of the tibial tunnel.
REFERENCES: Jackson DW, Proctor CS, Simon TM: Arthroscopic assisted PCL reconstruction: A technical note on potential neurovascular injury related to drill bit configuration. J Arthroscopy 1993;9:224-227.
Malek MM, Fanelli GC: Technique of arthroscopically assisted PCL reconstruction. Orthopedics 1993;16:961-966.

Question 64:

Options:

Closed reduction and percutaneous pinning
Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin
Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 2.0 cm anterior to the Achilles tendon, and horizontal limb 2.0 cm proximal to the line marking the plantar glabrous skin
Sinus tarsi approach
Ollier approach

Correct Answer: Open reduction and internal fixation with a lateral approach, extensile right-angled lateral incision, vertical limb 0.5 cm anterior to the Achilles tendon, and horizontal limb at the junction of the lateral skin and the plantar glabrous skin

Explanation:

Question 65:

Options:

Gender
Age
Race
Environment

Correct Answer: Race

Explanation:

Question 66:

Options:

Follow-up in 2 weeks with a repeat white blood cell count and erythrocyte sedimentation rate
Shoulder aspiration with Gram stain and culture of fluid
Prescription strength nonsteroidal anti-inflammatory drugs
Physical therapy for shoulder stretching and modalities
Emergent surgical irrigation, debridement, and revision shoulder arthroplasty

Correct Answer: Shoulder aspiration with Gram stain and culture of fluid

Explanation:

Question 67:

Options:

Begin a stretching program.
Obtain shoulder radiographs and aspirate the shoulder joint.
Obtain an MRI scan to evaluate for a rotator cuff tear.
Schedule for irrigation and debridement.
Schedule for revision shoulder arthroplasty.

Correct Answer: Obtain shoulder radiographs and aspirate the shoulder joint.

Explanation:

DISCUSSION: The patient has the preliminary diagnosis of an infected shoulder arthroplasty; therefore, shoulder radiographs and joint aspiration for organism identification should be the first steps in the work-up. The patient is at risk for hematogenous spread given the recent history of pneumonia and her history of diabetes mellitus. Although she has stiffness, a stretching program is not indicated with the possibility of infection. Scheduling for revision arthroplasty, or irrigation and debridement will depend on multiple factors including identification of the infecting organism, the organism’s susceptibility to antibiotics, and implant stability. An MRI scan to evaluate for a rotator cuff tear is not indicated at this time.
REFERENCES: Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 953-954.
Stinchfield FE, Bigliani LU, Neu HC, et al: Late hematogenous infection of total joint replacement. J Bone Joint Surg Am 1980;62:1345-1350.

Question 68:

Options:

Delay further surgical intervention until his ESR and CRP level normalize
Delay further surgical intervention until his ESR normalizes
Delay further surgical intervention until his CRP level normalizes
Proceed with surgical intervention if the patient’s condition is medically optimized

Correct Answer: Proceed with surgical intervention if the patient’s condition is medically optimized

Explanation:

Question 69:

Options:

plating of the radial shaft fracture and open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius and pinning of the DRUJ in pronation.

Correct Answer: plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).

Explanation:

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 70:

.What is the most appropriate treatment if instability is present at the time of evaluation?

Options:

TEA
Distal humeral replacement arthroplasty
Arthroscopic release with debridement
Soft-tissue interposition arthroplasty DISCUSSION.. The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

Correct Answer: Soft-tissue interposition arthroplasty DISCUSSION.. The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

Question 71:

Options:

physical therapy and bracing.
reassurance that these problems will resolve with time.
posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.
Achilles tendon lengthening, and flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot.
flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion.

Correct Answer: posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.

Explanation:

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 72:

Options:

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

Correct Answer: Hamstring autograft

Explanation:

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

Question 73:

Which of the following findings helps to distinguish between stress fractures of the tibia and shin splints?

Options:

With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.
With tibial shin splints, the bone scan is more intense.
A more diffuse area of tenderness is seen in tibial stress fractures.
A three-phase bone scan is positive in all phases with shin splints, but only positive in delayed

Correct Answer: With shin splints, a bone scan shows the posterior tibial cortex in a diffuse, longitudinal orientation.

Explanation:

Question 74:

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

Options:

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

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

Explanation:

Question 75:

Options:

The starting point tends to be more posterior than usual, resulting in hyperextension at the fracture site.
An arthrotomy is not necessary
A high-speed carbide burr is usually necessary to enlarge the box for nail entry.
The backup plan should include devices that allow multiple points of fixation in the distal segment, such as dynamic condylar screw and fixed angle blade plate.
The backup plan should include devices that resist varus collapse, such as condylar buttress plates.

Correct Answer: An arthrotomy is not necessary

Explanation:

Question 76:

Options:

remain essentially unchanged in size.
result in neurologic deterioration.
gradually resorb and widen the spinal canal.
potentially migrate within the spinal canal.
increase the risk of further injury to the adjacent dural sac.

Correct Answer: gradually resorb and widen the spinal canal.

Explanation:

Question 77:

Options:

Superior approach with trochanteric slide
Direct anterior approach with a chevron modification of the standard greater trochanteric osteotomy
Lateral approach with a partial greater trochanter osteotomy
Posterolateral approach with an extended trochanteric osteotomy Submit Answer

Correct Answer: Posterolateral approach with an extended trochanteric osteotomy Submit Answer

Explanation:

Question 78:

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Options:

Level of the fibular fracture
Lauge-Hansen fracture class
Intraoperative stress testing
Widening of the medial clear space
Talar dislocation

Correct Answer: Intraoperative stress testing

Explanation:

Question 79:

Options:

Remove the component and replace it with a “jumbo” cup with bone graft or substitute.
Remove the component and replace it with a bipolar component with bone graft or substitute.
Remove the component and replace it with a support ring with graft or graft substitute and cement a cup into the support ring.
Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.
Use a structural acetabular graft to reconstruct the acetabulum and cement a cup into the structural graft.

Correct Answer: Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.

Explanation:

Question 80:

Options:

2 cm distal to the articular surface of the radial head
1 cm distal to the articular surface of the radial head
Within a 90-degree arc or safe zone
Within a 120-degree arc or safe zone
Within a 180-degree arc or safe zone

Correct Answer: Within a 90-degree arc or safe zone

Explanation:

DISCUSSION: The radial head is covered by cartilage on 360 degrees of its circumference. However, with the normal range of forearm rotation of 160 to 180 degrees, there is a consistent area that is nonarticulating. This area is found by palpation of the radial styloid and Lister’s tubercle. The hardware should be kept within a 90-degree arc on the radial head subtended by these two structures.
REFERENCES: Smith GR, Hotchkiss RN: Radial head and neck fractures: Anatomic guidelines for proper placement of internal fixation. J Shoulder Elbow Surg 1996;5:113-117.
Caputo AE, Mazzocca AD, Santoro VM: The nonarticulating portion of the radial head: Anatomic and clinical correlations for internal fixation. J Hand Surg Am 1998;23:1082-1090.

Question 81:

There is a risk of impaired forearm rotation after tension band fixation of an olecranon fracture with which of the following?

Options:

Ipsilateral proximal humerus fracture
Protrusion of Kirschner wire fixation through the volar cortex of the proximal ulna
Use of ulnar intramedullary Kirschner wire fixation
Olecranon fracture comminution
Lack of triceps tendon repair

Correct Answer: Ipsilateral proximal humerus fracture

Explanation:

Question 82:

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Options:

Diminished revascularization of cancellous bone graft
Increased activity of osteoblasts
Increased activity of osteocytes
Antibody-induced necrosis
Inhibition of prostaglandins

Correct Answer: Diminished revascularization of cancellous bone graft

Explanation:

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 83:

Which of the following is the strongest contraindication for expansive open door laminoplasty for cervical myelopathy? Review Topic

Options:

Multi-level cervical spondylosis
C2-C7 rigid kyphosis of 15 degrees
Ossification of the posterior longitudinal ligament
C7 sagittal vertical axis of +5cm
Compression ratio of 0.3

Correct Answer: Multi-level cervical spondylosis

Explanation:

Question 84:

Options:

free vascularized fibula.
calcium sulfate pellets.
corticocancellous autograft.
demineralized bone matrix.

Correct Answer: free vascularized fibula.

Explanation:

Question 85:

Options:

Chondrosarcoma
Infection
Wear-induced osteolysis
Corrosive effect due to dissimilar metals
Metastatic tumor

Correct Answer: Wear-induced osteolysis

Explanation:

DISCUSSION: The AP radiograph demonstrates extensive periacetabular osteolysis. The central hole eliminator has dissociated from the shell and migrated into a lytic defect in the ischium. In a retrieval study, most periacetabular osteolytic lesions had a clear communication pathway with the joint space. Lesions with communication to the joint via several pathways or through a central dome hole (as in this patient) were larger and more likely to be associated with cortical erosion. Although periprosthetic tumors have been described, they are rare and particle-induced inflammation around a prosthesis does not seem to increase the risk for carcinogenesis.
REFERENCES: Visuri T, Pulkkinen P, Paavolainen P: Malignant tumors at the site of total hip prosthesis: Analytic review of 46 cases. J Arthroplasty 2006;21:311-323.
Bezwada HP, Shah AR, Zambito K, et al: Distal femoral allograft reconstruction for massive osteolytic bone loss in revision total knee arthroplasty. J Arthroplasty 2006;21:242-248.
Kitamura N, Naudie DD, Leung SB, et al: Diagnostic features of pelvic osteolysis on computed tomography: The importance of communication pathways. J Bone Joint Surg Am 2005;87:1542-1550.

Question 86:

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Options:

Total elbow arthroplasty
Functional hinge bracing
Long arm casting
Crossed Kirschner wires
Dual column plates

Correct Answer: Dual column plates

Explanation:

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 87:

Options:

a subtalar arthroereisis with a titanium implant.
triple arthrodesis.
resection of the accessory navicular and advancement of the posterior tibial tendon bilaterally.
resection of the talocalcaneal middle facet coalition in each foot.
resection of the calcaneonavicular coalition in both feet.

Correct Answer: resection of the talocalcaneal middle facet coalition in each foot.

Explanation:

Question 88:

Which of the following primary prognostic factors best predicts the outcome of the knee lesion shown in Figure 22?

Options:

Location
Size
Knee stability
Patient age
Degree of pain

Correct Answer: Patient age

Explanation:

Question 89:

Options:

Discontinue use of the soft collar and encourage range of motion
Semi-rigid collar immobilization for 6 to 8 weeks
Surgical stabilization
Halo skeletal fixation
Outpatient physical therapy with isometric neck exercises

Correct Answer: Discontinue use of the soft collar and encourage range of motion

Explanation:

Dickman and associates classified injuries of the transverse atlantal ligament into two categories. Type I injuries are disruptions through the substance of the ligament itself. Type II injuries render the transverse ligament physiologically incompetent through fractures and avulsions involving the tubercle of insertion of the transverse ligament on the C1 lateral mass. Type I injuries are incapable of healing without supplemental internal fixation. Type II injuries can be treated with a rigid cervical orthosis with a success rate of 74%. Surgery may be required for type II injures that fail to heal with 3 to 4 months of nonsurgical management.
(SBQ13PE.82) A renal ultrasound should be obtained in a patient with which of the following diagnoses?
Review Topic
Congenital pseudoarthrosis of the clavicle
Accessory navicular
Congenital scoliosis
Charcot-Marie-Tooth Disease
Congenital curly toe
A renal ultrasound should be obtained in a patient with congenital scoliosis.
Congenitial scoliosis has a prevalence that is estimated at 1% to 4% in general population. It is associated with systemic anomalies in up to 61% of cases. The most common anomalies are cardiac defects, genitourinary defects and spinal cord malformations. As such, additional imaging of these systems should be considered in the initial work-up of these patients.
Ruf et al. retrospectively investigated 56 consecutive operative cases of congenital scoliosis. The average age at surgery was 9.9 years (1.5–17 years). There was one wound complication, 2 hardware failures, 1 revision and no neurological complications. They concluded that one-stage posterior hemivertebra resection and instrumentation was safe in this population.
Xu et al. examined the efficacy of selective partial hemivertebra excision via posterior-only approach in 17 adolescent patients with congenital kyphoscoliosis. There were no postoperative infections and no neurological complications. They concluded that this approach may be most successful in patients aged 9 to 14 years old, with the Risser sign grades from 0–3 and Cobb angles <60°.
Illustration A from Erol et al (UPOJ, Vol 15, 2002;37-42) shows a diagram of 'types' of congenital scoliosis based on the morphology of the vertebrae.
Incorrect Answers:

Question 90:

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 91:

Options:

Short radiolunate
Dorsal scapholunate interosseous
Volar lunotriquetral interosseous
Radioscaphocapitate

Correct Answer: Volar lunotriquetral interosseous

Explanation:

Question 92:

- Which of the following radiographic findings would be characteristic of the knee joints of a patient with neuropathic osteoarthropathy of the knee?

Options:

Fragmentation and subluxation of the normal joint articulation
Varus deformity with medial subchondral sclerosis
Preferential narrowing of the medial tibiofemoral compartment
Narrowing of the medial, lateral, and patellofemoral compartments
Bone proliferation at the patellar tendon and ligament insertion sites

Correct Answer: Fragmentation and subluxation of the normal joint articulation

Explanation:

Question 93:

Options:

halo vest immobilization.
MRI.
Gardner-Wells tongs and closed reduction.
posterior open reduction and fusion.
observation until the patient’s general medical status improves, followed by closed reduction via Gardner-Wells tongs.

Correct Answer: Gardner-Wells tongs and closed reduction.

Explanation:

Question 94:

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)?

Options:

Inferior glenohumeral ligament
Superior glenohumeral ligament
Rotator cuff interval
Subscapularis recess
Interior recess

Correct Answer: Rotator cuff interval

Explanation:

DISCUSSION: The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.
REFERENCES: Selecky MT, Tibone JE, Yang BY, et al: Glenohumeral joint translation after arthroscopic thermal capsuloplasty of the rotator interval. J Shoulder Elbow Surg 2003;12:139-143.
Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66.

Question 95:

Options:

aspiration of the hip.
a bone scan.
an MRI scan.
bed rest, frequent temperature checks, and reevaluation in 24 to 48 hours.
hospital admission and placement in traction.

Correct Answer: bed rest, frequent temperature checks, and reevaluation in 24 to 48 hours.

Explanation:

Question 96:

Options:

debridement and repair.
cast immobilization.
aggressive overload eccentric strengthening.
ice massage and continued athletic participation.
steroid injection.

Correct Answer: debridement and repair.

Explanation:

Question 97:

Options:

open reduction and internal fixation.
arthroscopic reduction and internal fixation.
closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.
closed reduction and casting in 90 degrees of flexion.
excision of the fragment.

Correct Answer: closed reduction following evacuation of the hemarthrosis and casting in extension if reduction is adequate.

Explanation:

Question 98:

What is an example of cognitive rest after concussion? Review Topic

Options:

Playing chess
Increasing reading
Working online
Limiting video games

Correct Answer: Limiting video games

Explanation:

Question 99:

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

Options:

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

Correct Answer: Epidural hematoma

Explanation:

Question 100:

What is the most common physical finding in a patient with femoroacetabular impingement (FAI)? Review Topic

Options:

Increased external rotation
Increased abduction
Decreased external rotation
Decreased flexion and internal rotation
Decreased adduction

Correct Answer: Decreased flexion and internal rotation

Orthopedic Surgery Board Review MCQs: Arthroplasty, Ligament & Spine | Part 149

Orthopedic Board Exam MCQs: Upper Extremity, Spine & Foot/Ankle | Part 112

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 112

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index