OITE & ABOS Orthopedic Board Prep: 100 High-Yield MCQs

About This Board Review Set

This is Part 12 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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

Topics Covered in Part 12

This module focuses heavily on: Fracture, Hip, Knee, Nerve.

Sample Questions from This Set

Sample Question 1: In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of...

Sample Question 2: Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with amonth history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?...

Sample Question 3: Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient’s knee joint. What is the most likely diagnosis?...

Sample Question 4: When performing surgical excision of the lesion shown in the MRI scan in Figure 3, what nerve is most likely at risk?...

Sample Question 5: An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injur...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Explanation

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 2

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?

Explanation

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Question 3

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient’s knee joint. What is the most likely diagnosis?

Explanation

DISCUSSION: The scans show a lipohemarthrosis. There is the characteristic layering of a superior zone containing fat (high signal intensity), a central zone containing serum (low signal intensity), and an inferior zone that contains red blood cells (low signal intensity). The most common cause of a lipohemarthrosis is an intra-articular fracture with leakage of marrow fat into the joint.
REFERENCES: Resnick D, Kang HS: Synovial joints, in Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 49-53.
Kier R, McCarthy SM: Lipohemarthrosis of the knee: MR imaging. J Comput Assist Tomogr 1990;14:395-396.

Question 4

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 5

An 18-year-old man sustained closed humeral shaft and forearm fractures of his dominant arm in a motor vehicle accident. Neurovascular examination is intact, and his condition is stable. The best course of action for management of the injuries should be

Explanation

DISCUSSION: Fractures above and below the elbow constitute floating elbow injuries and are best treated with internal fixation to allow early range of motion and to prevent elbow stiffness. Use of a long arm cast would promote elbow stiffness. External fixation is indicated primarily for open injuries.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Bell MJ, Beachamp CG, Kellam JK, McMurtry RY: The results of plating humeral shaft fractures in patients with multiple injuries: The Sunnybrook experience. J Bone Joint Surg Br 1985;67:293-296.

Question 6

What role does quorum sensing play in the development of a bacterial biofilm?

Explanation

The development of a bacterial biofilm is a 2-stage process. The first step is the adhesion of individual bacteria to a substrate regulated by adhesions. After several bacteria have attached, quorum sensing (cell-to-cell communication) allows maturation of the biofilm and expression of genes that activate virulence factors. This can also increase the antibacterial resistance of the bacteria. Planktonic bacteria are individual free-moving bacteria.

Question 7

A 68-year-old woman who underwent a right total hip arthroplasty 1 year ago has dislocated her hip five times since surgery. Radiographs show a retroverted acetabular component. What is the best treatment for this patient?

Explanation

DISCUSSION: The most common cause of recurrent dislocation following total hip arthroplasty continues to be component malposition. Component malposition should be addressed prior to any other treatment options, such as increasing soft-tissue tension with increased femoral offset or greater trochanteric advancement. A larger femoral head size may help, but correcting the component malposition should give more predictable results. A retroverted acetabular component should be revised to 15 degrees to 20 degrees of anteversion, matching the patient’s anatomy with an abduction angle close to 45 degrees.
REFERENCES: Daly PJ, Morrey BF: Operative correction of an unstable total hip arthroplasty. J Bone Joint Surg Am 1992;74:1334-1343.
Jolles BM, Zangger P, Leyvraz PF: Factors predisposing to dislocation after primary total hip arthroplasty: A multivariate analysis. J Arthroplasty 2002;17-282-288.
Hamilton W, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect 2004;53:87-92.

Question 8

A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include

Explanation

The radiograph illustrates a middle third clavicular fracture with bone loss. According to Jupiter and associates, the biomechanics of the clavicle predisposes the middle third to be prone for fracture secondary to both moments of tension and bending and also torsional forces. In their study, fixation was best accomplish with plate fixation and a bone graft.[JBJS 1987, 69-A pg. 753-759]
Selection (1) would not provide adequate fixation to promote healing. (2) Electrical stimulation would not be sufficient for the above reasons. (3) Resection of the distal clavicle would not be indicate for this case because it promote further instability of the clavicle and increasing the affected forces to the clavicle.
(5) Kirschner wire fixation with bone graft, the author stated would provide fixation, but they achieved better results with plate fixation and bone graft Question 6 -
A 75-year-old woman sustains a fracture below the level of a total hip prosthesis. Radiographs demonstrate loosening of the prosthetic component. Treatment should consist of
a cast brace
a spica cast
plate fixation
allograft strut fixation
long stem revision
The key to this question lies in the radiographic evidence of loosening of the prosthetic component. The long stem revision is clearly indicated in this case because of various factors, one decreases impingement of the loose stem against the lateral femoral cortex. A non-surgical approach in the elderly patient will only increase the many risk factors such as atelectasis, pneumonia, and thromboembolic disease.[Instructional Course 44 pg. 293-303]

Question 9

A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of Review Topic

Explanation

Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.

Question 10

What is the primary immediate source of energy for muscle?

Explanation

The basic source of energy for muscle contraction is ATP. ATP is also the immediate energy source for muscle. The body then utilizes glucose to produce ATP. Glycolysis splits glucose to form two molecules of pyruvic acid and two ATP.
Almost 90% of the total ATP formed by glucose metabolism is formed during oxidative phosphorylation. This is accomplished by a series of enzymatically catalyzed reactions in the mitochondria. When the body’s stores of carbohydrates decrease below normal, glucose can be formed from the breakdown of protein and fat via gluconeogenesis to yield more ATP.

Question 11

Flow cytometry of tumors measures the

Explanation

Flow cytometry is a method of quantitating components or structural features of cells primarily by optical means. Ploidy and cell cycle analysis of cancers is the major diagnostic use. Cells are passed single file through a laser beam by continuous flow and several parameters are measured including Cell Diameter, proportional quantity of granular (DNA) within the cell, and using fluorescent probes the total DNA or a specific DNA/mRNA sequence can be counted. In examining tumors the amount of DNA in each cell is important for determining neoplasia.

Question 12

Figure 16 shows the radiograph of a 56-year-old man who has neck pain after a rollover accident on his lawnmower. The injury appears to be isolated, and he is neurologically intact. Management of the fracture should consist of

Explanation

DISCUSSION: The radiograph shows a type IIa Hangman’s fracture, and the classic treatment is halo vest immobilization. Traction should be avoided in type IIa injuries because of the risk of overdistraction. A lesser form of immobilization such as a hard collar or a Minerva jacket can be used for nondisplaced (type I) fractures. Surgery generally is reserved for type III fractures (includes C2-3 facet dislocation), or extenuating circumstances such as multiple trauma or other fractures of the cervical spine that require surgical stabilization.
REFERENCES: Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.
Jackson RS, Banit DM, Rhyne AL III, et al: Upper cervical spine injuries. J Am Acad Orthop Surg 2002;10:271-280.

Question 13

A 35-year-old man who is an avid weight lifter competing in local tournaments reports new onset pain and loss of motion in his dominant right shoulder. Examination reveals joint line tenderness, active elevation to 100 degrees, and external rotation to 10 degrees. His contralateral shoulder reveals 170 degrees forward elevation and 50 degrees external rotation. Radiographs are shown in Figures 46a and 46b. What is the next most appropriate step in management? Review Topic

Explanation

New onset pain and stiffness in the young arthritic shoulder is a difficult problem to treat. Initial management should be aimed at reducing pain and improving motion in all planes. This patient’s activities and age preclude a shoulder arthroplasty at this time. If nonsurgical management fails to provide relief, then arthroscopic debridement and capsular release may be beneficial.

Question 14

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 15

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Explanation

DISCUSSION: Based on the MR arthrogram in which gadolinium (bright on T1-weighted images) was injected into the joint space prior to imaging, the study shows a tear of the anterior band of the ulnar collateral ligament (UCL). The disruption in the distal end of the UCL is outlined by contrast. A small collection of contrast extravasation into the flexor musculature further confirms the presence of a tear. The UCL has a broad-based attachment on the medial epicondyle and has a pointed or tapered attachment distally on the ulna. Most UCL tears occur distally at the ulnar (coronoid) attachment.
MR arthrography provides improved sensitivity compared to conventional MRI, without contrast, for the detection of UCL pathology, particularly in the subacute or chronic setting. After the soft-tissue edema and joint fluid associated with the injury have resolved, the torn end of the ligament may lie in contact with its adjacent attachment and create a false-negative appearance. In this patient, a noncontrasted MR arthrogram showed no tear, yet the tear is apparent with intra-articular contrast and distention. MR arthrography of the elbow also may be useful in detecting intra-articular bodies or in evaluation for loose osteochondral fragments or flaps.
REFERENCES: Morrey BF: Acute and chronic instability of the elbow. J Am Acad Orthop Surg 1996;4:117-128.
Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 200-210.

Question 16

A 40-year-old right hand-dominant construction worker has had a 6-month history of aching left shoulder pain that is worse after working a long day. Examination reveals limited range of motion and good strength when compared to his asymptomatic right arm. He has not had any orthopaedic intervention to date. Radiographs are shown in Figures 43a and 43b. What is the most appropriate treatment?

Explanation

DISCUSSION: The patient is a young laborer with osteoarthritis. Initial treatment should begin with nonsurgical management that may include anti-inflammatory drugs, cortisone injections, and physical therapy to diminish pain and improve motion. The other choices may eventually be necessary but should only follow a course of nonsurgical management.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 17

Figures 45a and 45b show the radiographs of a 46-year-old man who reports the acute onset of right knee pain and is unable to bear weight on the extremity. His medical history is unremarkable. The next most appropriate step in management should consist of

Explanation

DISCUSSION: The patient has a pathologic fracture of the right distal femur; therefore, given the patient’s age, the most likely diagnosis is metastatic carcinoma. Staging studies should be obtained prior to surgical treatment. Immediate intramedullary fixation is contraindicated before a diagnosis is made by biopsy. Surgical stabilization should be performed prior to radiation therapy.
REFERENCE: Rougraff BT, Kneisl JS, Simon MA: Skeletal metastases of unknown origin: A prospective study of a diagnostic strategy. J Bone Joint Surg Am 1993;75:1276-1281.

Question 18

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Explanation

Figure A shows a minimally displaced Weber B ankle fracture. The need for operative treatment would be dependent on fracture stability. A gravity stress test would best demonstrate fracture displacement, syndesmotic injury and medial sided ligamentous integrity.
In patients who present with no medial widening on standard ankle radiographs and no clinical symptoms of deltoid ligament injury, the integrity of the deltoid ligament remains unknown. The gravity stress radiograph may be used to help identify a deltoid ligament injury in association with an isolated distal fibular fracture. Stage-IV supination-external rotation fractures, which involve the deltoid ligament, are more likely to be treated operatively as they are often considered unstable ankle fractures.
Egol et al. reviewed 101 patients with isolated fibular fracture and an intact mortise. They found that medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. Interestingly, they report that good functional results can be obtained in patients with widening of the medial clear space on a stress radiograph in the absence of medial signs.
Gill et al. compared the effectiveness of gravity stress radiograph as compared to manual stress radiograph for the detection of deltoid ligament injury in isolated fibular fracture. A total of twenty-five patients with SER type-II fracture and SER Type IV-equivalent fractures were enrolled. They found the gravity stress radiograph was equivalent to the manual stress radiograph for determining deltoid ligament injury.
Figure A shows a mortise radiograph displaying a minimally displaced Weber B ankle fracture. Illustration A shows the positioning for a gravity stress radiograph. The patient is in the lateral decubitus position with the injured leg dependent and off the end of the table, a mortise view is taken in 10° of internal rotation of the tibia.
Incorrect Answers:

Question 19

A 45-year-old woman has a distal radius fracture, which is treated with open reduction and internal fixation. The surgery was uncomplicated, and the patient is discharged to home. At the first follow-up appointment, the patient demonstrates signs that are concerning for complex regional pain syndrome (CRPS). What factor is included in the International Association for the Study of Pain (IASP) criteria (Budapest criteria) for the diagnosis of CRPS?

Explanation

EXPLANATION:
The diagnosis of CRPS is complex. The IASP has approved diagnostic criteria to standardize both the diagnosis and the study of CRPS. The criteria are:
Continuing pain disproportionate to any inciting event
At least one symptom in three of the following four categories
Sensory: reports of hyperesthesia and/or allodynia
Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
Sudomotor/edema: reports of edema and/or sweating changes and/or sweating asymmetry
Motor/trophic: reports of decreased range of motion (ROM) and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, skin, nails)
At least one sign at the time of evaluation in two (for clinical diagnosis) or three (for inclusion in scientific studies) of the following categories
Sensory: evidence of hyperesthesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or skin color asymmetry
Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry
Motor/trophic: evidence of decreased ROM and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, skin, nails)
No other diagnosis better explains the signs and symptoms.
Decreased sensation and focal numbness are not consistent with CRPS. Laboratory and imaging studies can be helpful in evaluating for the exclusion of differential diagnoses for CRPS, including infection, rheumatic disease, fracture, nonunion, tenosynovitis, or osteomyelitis.

Question 20

A 6-year-old child has a fixed flexion deformity of the interphalangeal (IP) joint of the right thumb. The thumb is morphologically normal, with a nontender palpable nodule at the base of the metacarpophalangeal joint. Clinical photographs are shown in Figures 42a and 42b. Based on these findings, what is the treatment of choice?

Explanation

DISCUSSION: The child has a trigger thumb deformity. A trigger thumb is a developmental mechanical problem rather than a congenital deformity. The anomaly generally is not noted at birth. A fixed flexion deformity of the IP joint of the thumb most commonly occurs in children in the first 2 years of life. A stretching and splinting program may correct the deformity in the first year of life, but nonsurgical management after age 3 years results in a success rate of only 50%. Release of the proximal annular pulley of the flexor sheath is recommended at this age.
REFERENCES: Tan AH, Lam KS, Lee EH: The treatment outcome of trigger thumb in children. J Pediatric Orthop B 2002;11:256-259.
Slakey JB, Hennrikus WL: Acquired thumb flexion contracture in children: Congenital trigger thumb. J Bone Joint Surg Br 1996;78:481-483.
Herring JA: Disorders of the upper extremity: Thumb dysplasia, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, p 445.

Question 21

A 22-year-old patient has had severe groin pain for many months and is unable to engage in any physical activity. The AP radiograph of the pelvis shows minimal arthritis. The lateral radiograph of the hip is shown in Figure 33a. An MR-arthrogram is shown in Figure 33b. What is the most appropriate treatment at this stage? Review Topic

Explanation

The patient has femoroacetabular impingement. The prominence on the femoral neck has resulted in a labral tear and detachment. An MR-arthrogram is the most appropriate modality for diagnosis of a labral tear. The diagnosis of a labral tear per se is not an indication for surgical intervention because the natural incidence of this condition is not known. Labral debridement without addressing the underlying anatomic abnormality is likely to result in a suboptimal outcome. The most appropriate treatment, when indicated, is shaving down of the femoral neck to remove the bony prominence and attachment of the labrum. Femoral osteotomy has no role in the treatment of this condition. The patient has minimal arthritis; therefore, arthroplasty is not indicated.

Question 22

A 27-year-old right hand dominant construction worker falls off a scaffold onto his outstretched arm. Figure A exhibits the radiograph taken at a local emergency room. Following treatment, he is placed in a sling and follows up at your office two weeks later. He complains of a feeling that his arm is going to 'pop out'. Which specific physical examination finding is likely to be present? Review Topic

Explanation

The patient suffered a posterior shoulder dislocation, likely injuring the posterior capsule and/or labrum. Out of all the answer choices, Kim's test assesses posterior structures. Thus, Kim's test is the physical examination finding most likely to be present.
Posterior dislocations occur less frequently than anterior dislocations, and are often missed. Following closed reduction, persistent instability can occur, usually associated with posterior capsular or labral pathology. Posteriorly directed provocative maneuvers, such as the Kim test can be positive.
Robinson et al. performed an epidemiologic analysis on 120 posterior dislocations. Recurrent instability occurred at a rate of 17.7%. Risk factors for recurrent instability included age less than 40-years-old, dislocation during seizure, and a large reverse Hill-sachs (>1.5 cm3).
Kim et al. describe the Kim lesion, a separation between the posteroinferior labrum and the articular cartilage without complete detachment of the labrum, which cause persistent posterior instability.
Figure A depicts a posterior dislocation on xray. Illustration A depicts the Kim test, which is performed by having the patient seated, arm at 90° abduction, followed by flexing the shoulder to 45° forward flexion while simultaneously applying axial load on the elbow and posterior-inferior force on the upper humerus. The test is positive when there is pain. Video 1 depicts the proper way to perform a Kim Test.
Incorrect answers:

Question 23

When treating a proximal tibia fracture, the surgeon decides to (1) use blocking screws in the proximal fragment, and (2) pick the intramedullary nail based on the location of the Herzog curve. Which of the following combinations will best prevent the classic deformity associated with this fracture?

Explanation

Proximal tibial fractures develop an apex anterior (procurvatum) and valgus malalignment. Blocking (poller) screws should be placed in the concavity of the deformity, thus posterior and lateral to the nail. The Herzog curve should be proximal to the fracture site.
Up to 58% of proximal tibial fractures are malaligned. Malalignment arises because the nail fits loosely in the wide metaphyses and cannot control alignment. Without close fit of the nail at the fracture site, the nail will not align the fracture independent of a stable reduction and careful nail path. Blocking screws serve to reduce the size of the proximal metaphyseal canal and guide final nail passage.
Stinner et al. discuss strategies in proximal tibial fracture nailing. They describe an accurate starting point (using the twin peaks AP view or fibular bisector AP view, and flat plateau lateral view). They emphasize fracture reduction prior to reaming and implant placement.
Hiesterman reviewed nailing of extra-articular proximal tibial fractures. Techniques described include blocking screws, unicortical plating, using a universal distractor, nailing in flexion/locking in extension, semiextended nailing (including percutaneous suprapatellar quads-splitting approaches), multiple proximal interlocking screws (>=3).
Illustration A shows placement of a coronal blocking screw. Illustration B shows placement of a sagittal blocking screw. Illustration C shows the effect of the Herzog curve. A more distal Herzog curve leads to a "wedge" effect and fracture displacement whereas a proximal Herzog curve contains the fracture. The "wedge" effect occurs as the nail is seated and impinges on the posterior cortex of the distal segment accentuating an apex anterior deformity because of the effective widening of the nail above the bend and posterior force on the distal segment to match the nail shape.
Incorrect Answers:

Question 24

A 22-year-old competitive volleyball player has shoulder pain, and rest and a cortisone injection have failed to provide relief. Examination reveals atrophy along the posterior scapula, but an MRI scan does not reveal a rotator cuff tear or labral cyst. What is the most likely cause for the shoulder weakness?

Explanation

DISCUSSION: Repetitive overhead slams and serves may produce a traction injury to the distal branch of the suprascapular nerve. Bankart, biceps, and superior labrum anterior and posterior injuries can occur but usually do not produce visible atrophy. Muscle avulsion is uncommon.
REFERENCES: Ferretti A, Cerullo G, Russo G: Suprascapular neuropathy in volleyball players. J Bone Joint Surg Am 1987;69:260-263.
Bigliani LU, Dalsey RM, McCann PD, April EW: An anatomical study of the suprascapular nerve. Arthroscopy 1990;6:301-305.

Question 25

When performing a posterior cruciate ligament reconstruction with a tibial inlay-type approach, what is the approximate anatomic distance of the popliteal artery from the screws used for fixation of the bone block?

Explanation

DISCUSSION: Miller and associates reported the results of a cadaveric study of the vascular risk of a posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. The average distance from the screw to the popliteal artery was 21.1 mm
(range, 18.1 mm to 31.7 mm). Other approaches, such as the transtibial tunnel technique which involves drilling an anterior-posterior tunnel, have also been studied in cadavers. Matava and associates noted that increasing flexion reduces but does not completely eliminate the risk of arterial injury during arthroscopic posterior cruciate ligament reconstruction. However, this study did not use the small, medial utility incision recommended by Fanelli and associates, which creates an interval for the surgeon’s finger between the medial gastrocnemius and the posteromedial capsule so that any migration of the guidepin can be palpated and changed prior to any injury to the posterior neurovascular bundle.
REFERENCES: Matava MJ, Sethi NS, Totty WG: Proximity of the posterior cruciate ligament insertion to the popliteal artery as a function of the knee flexion angle: Implications for posterior cruciate ligament reconstruction. Arthroscopy 2000;16:796-804.
Miller MD, Kline AJ, Gonzales J, et al: Vascular risk associated with posterior approach for posterior cruciate ligament reconstruction using the tibial inlay technique. J Knee Surg 2002;15:137-140.
Johnson DH, Fanelli GC, Miller MD: PCL 2002: Indications, double-bundle versus inlay technique and revision surgery. Arthroscopy 2002;18:40-52.

Question 26

98 degrees (range, 0 degrees to 9 degrees). In knees with varus joint lines

Explanation

Question 27

Figures 55a through 55c are the clinical photograph and radiographs of a 5-year-old boy who fell and injured his right elbow. His radial pulse is thready. Which neurologic deficit most commonly is associated with this injury?

Explanation

DISCUSSION
This injury is a type III supracondylar humerus fracture with posterolateral displacement. The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral metaphysis. The brachial artery is likely tented over this spike, leading to diminished perfusion. The median nerve also resides in this area, and any neurological deficit is likely in its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which most often is injured in flexion injuries and iatrogenically by medially placed pins.

Question 28

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

Explanation

DISCUSSION: The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.
REFERENCES: Bishop JY, Flatow EL: Pediatric shoulder trauma. Clin Orthop Relat Res 2005;432:41-48.

Question 29

A 77-year-old man with a history of mild renal insufficiency and atrial fibrillation on warfarin therapy is scheduled to undergo a left total hip arthroplasty. He previously underwent a right total hip arthroplasty with development of significant heterotopic bone that resulted in limitation of motion. What is the most appropriate form of prophylactic treatment to minimize the formation of heterotopic bone on his left hip?

Explanation

DISCUSSION: This question centers on the prophylactic treatment to reduce the risk of heterotopic bone formation. Prophylaxis is indicated because he has already demonstrated bone formation with his prior hip arthroplasty, which places him at increased risk for developing heterotopic bone on the contralateral side. He is on warfarin and has renal insufficiency, which makes the use of NSAIDs contraindicated. The recommended dose is 600 to 800 centigrey of radiation given within 24 hours of surgery preoperatively or 72 hours postoperatively.
REFERENCES: Kolbl O, Knelles D, Barthel T, et al: Preoperative irradiation versus the use of nonsteroidal anti-inflammatory drugs for prevention of heterotopic ossification following total hip replacement: The results of a randomized trial. Int J Radiat Oncol Biol Phys 1998;42:397-401.
Pakos EE, Ioannidis JP: Radiotherapy vs nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip surgery: A meta-analysis of randomized trials. Int J Radiat Oncol Biol Phys 2004;60:888-895.
Seegenschmiedt MH, Makoski HB, Micke O, et al: Radiation prophylaxis for heterotopic ossification about the hip joint: A multicenter study. Int J Radiat Oncol Biol Phys 2001 ;51:756-765.

Figure 23 a Figure 23b

Question 30

An obese 4-year-old boy has infantile Blount’s disease. Radiographs reveal a metaphyseal-diaphyseal angle of 18 degrees and a depression of the medial proximal tibial physis. Management should consist of

Explanation

DISCUSSION: The deformity is too severe for observation, and at age 4 years, the child is too old for orthotic treatment. To prevent recurrence, surgery should be performed before irreversible changes occur in the medial physis. A proximal tibial osteotomy should overcorrect the mechanical axis to 10 degrees of valgus. Bar resection has not been shown to be as effective in this severe deformity, especially without a concomitant osteotomy.
REFERENCES: Raney EM, Topoleski TA, Yaghoubian R, Guidera KJ, Marshall JG: Orthotic treatment of infantile tibia vara. J Pediatr Orthop 1998;18:670-674.
Loder RT, Johnston CE: Infantile tibia vara. J Pediatr Orthop 1987;7:639-646.

Question 31

Reverse total shoulder arthroplasty improves kinematics in the rotator cuff deficient joint by what directional change to the center of rotation? Review Topic

Explanation

Surgical indications for reverse total shoulder arthroplasty are expanding. In the setting of rotator cuff tear arthroplasty in which the native humeral head migrates superiorly, these implants impart several kinematic advantages. Implant center of rotation medial to the former joint surface improves glenoid component stability as the resultant force vector passes through the component throughout the arc of motion. A stable and fixed fulcrum for elevation is provided by matched radius of curvature between the glenoid and humeral components. A more distal center of rotation increases resting length and tone of the deltoid muscle, improving its effectiveness as a shoulder elevator. Medialized joint center of rotation increases the moment arm of the deltoid, requiring less muscle force to produce a given torque. This results in decreased articular shear stress.

Question 32

Which of the following conditions is associated é the highest mortality in patients é a pelvic fracture?

Explanation

The highest rate of mortality rate after a pelvic fracture is associated with hypovolemic shock. Most of which is secondary to extensive intrapelvic arterial injuries.

Question 33

A 21-year-old female college athlete sustained a stress fracture of the fifth metatarsal 1 year ago which was treated successfully with surgical stabilization and she returned to normal activities. She now has a tension-sided femoral neck fracture. Along with surgical fixation of the fracture, what is the next step in management? Review Topic

Explanation

Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients. Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.

Question 34

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Explanation

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.

J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 35

What is the main benefit of using metal-backed tibial components in total knee arthroplasty?

Explanation

DISCUSSION: In a normal knee, the hard subchondral bone helps to distribute loads across the joint surface. A metal-backed tibial component in total knee arthroplasty decreases the compressive stresses on the underlying, softer cancellous bone by distributing the load over a larger surface area, particularly when one condyle is loaded. Although metallic base plates also increase the tensile forces on the other condyle when one is loaded and may decrease the thickness of the polyethylene tray, these are not benefits. Compressive forces on the polyethylene tray are increased with metal backing. The conformity of the articular surfaces is not affected by metal backing of the tibial component.
REFERENCE: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 265-274.

Question 36

A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his shoulder. He now has anterior shoulder pain, weakness, and the sensation of instability. Examination reveals tenderness just lateral to the coracoid and bicipital groove. An MRI scan is shown in Figure 31. Management should now consist of

Explanation

DISCUSSION: Subscapularis tendon tears are being recognized with increasing frequency, and the mechanism of injury involves hyperabduction and external rotation. The patient will have anterior shoulder pain and may report a sensation of instability. Examination will reveal anterior shoulder tenderness over the lesser tuberosity and bicipital groove, and the Gerber lift-off test usually is positive. The MRI scan shown here reveals an intact anterior labrum. The subscapularis tendon is avulsed and retracted, with no evidence of the biceps tendon within the groove; this implies dislocation of the biceps, a common accompanying feature of a subscapularis tear. This injury is also recognized as a complication after open anterior shoulder stabilizations where the subscapularis has been incised as part of the approach. Therefore, the appropriate management involves repair of the subscapularis. The injury does not represent a recurrence so immobilization or revision stabilization, which may be reasonable treatment for recurrent instability, is not indicated. The findings are not consistent with a superior labral tear.
REFERENCES: Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Gerber C, et al: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 37

Figure 55 shows the radiograph of a 30-year-old man who sustained a closed comminuted fracture of the right clavicle. Examination reveals decreased sensation in the radial nerve distribution. Weakness is noted with shoulder abduction, internal rotation, and wrist extension. A displaced bone fragment is most likely pressing on what portion of the brachial plexus? Review Topic

Explanation

Clavicular fractures are occasionally complicated by injury to the brachial plexus. A displaced bone fragment pressing on the posterior cord proximal to the upper subscapularis nerve would account for these findings.

Question 38

A 13-year-old girl is referred for a painful progressive valgus deformity of the right knee. Examination reveals an antalgic gait with an obvious valgus deformity. The right distal femur has a palpable, tender mass with erythema and warmth. Figures 4a and 4b show a clinical photograph and a radiograph. Management should consist of

Explanation

DISCUSSION: The radiograph shows a pathologic fracture through a destructive lesion of the distal femur metaphysis with osteolytic and osteoblastic features. The lateral cortex is destroyed, and there is periosteal new bone formation. These findings are consistent with malignancy, most likely an osteogenic sarcoma. Patients with suspected malignant tumors are best managed by surgeons with specific expertise in orthopaedic oncology. The biopsy of a malignant lesion should be deferred to the surgeon who is capable of definitive management of the patient.
REFERENCES: Enneking W: Principles of musculoskeletal oncologic surgery, in Evarts C (ed): Surgery of the Musculoskeletal System. New York, NY, Churchill Livingston, 1990.
Herring JA: General principles of tumor management, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, from the Texas Scottish Rite Hospital for Children, ed 3. Philadelphia, PA, WB Saunders, 2002, pp 1897-1900.

Question 39

Figure 10 shows patellar radiographs of a 68-year-old woman who underwent bilateral total knee arthroplasty 2 months ago. Following a recent fall onto the left side, she now reports anterior pain in the left knee. A CT scan shows that the femoral and tibial components are appropriately externally rotated and radiographs show acceptable axial alignment and no evidence of loosening. What is the most appropriate treatment option?

Explanation

DISCUSSION: Treatment of patellofemoral instability after total knee arthroplasty (TKA) is directed by its etiology. In instances of component malpositioning, revision of one or both components is indicated.
If the components are determined to be in satisfactory position, soft-tissue procedures can be pursued. Lateral retinacular release is usually the first soft-tissue procedure used to improve patellofemoral mechanics. In this patient, the patellar fracture fragment is so small that it can be excised. Distal realignment is not usually used as the first line of treatment for patellar maltracking following TKA.
REFERENCES: Fehring TK, Christie MJ, Lavemia C, et al: Revision total knee arthroplasty: Planning, management, and controversies. Instr Course Lect 2008;57:341-363.
Patel J, Ries MD, Bozic KJ: Extensor mechanism complications after total knee arthroplasty. Instr Course Lect 2008;57:283-294.

Question 40

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Explanation

DISCUSSION: The use of chemotherapy has dramatically improved survival rates of patients with Ewing’s sarcoma. Local disease is best handled with wide resection to decrease local recurrence and to avoid the complications of radiation therapy (ie, secondary sarcomas). Radiation therapy alone is reserved for unresectable lesions or poor surgical margins. Amputation generally is not necessary.
REFERENCES: Toni A, Neff JR, Sudanese A, et al: The role of surgical therapy in patients with non-metastatic Ewing’s sarcoma of the limbs. Clin Orthop 1991;286:225.
Picci P, Rougraff BT, Bacci G, et al: Prognostic significance of histopathologic response to chemotherapy in non-metastatic Ewing’s sarcoma of the extremities. J Clin Oncol 1993;11:1763.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant Bone Tumors. Instr Course Lect 2002;51:413-428.
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Question 41

A 78-year-old woman falls onto her nondominant left elbow and sustains the injury shown in Figure A. What treatment option allows her the shortest recovery time and highest likelihood of good function and range of motion? Review Topic

Explanation

Total elbow arthroplasty has become the treatment of choice for complex, comminuted distal humeral fractures in patients older than age 70 years. It yields a faster recovery with more predictable functional outcomes, although limitations of lifting weight of more than 5 pounds must be followed to avoid loosening.

Question 42

What would be the advantage of surgery for the patient described in this scenario?

Explanation

DISCUSSION
The MR image of the lumbar spine postgadolinium contrast shows a ring-enhancing fluid collection. Ring-enhancing lesions within the spinal canal on postgadolinium MR images are indicative of epidural abscess. It is important to obtain a culture-specific diagnosis to inform the choice of antibiotics and educate patients regarding the likelihood of failure for standalone antibiotic therapy. Infection with MSSA, age younger than 65 years, the absence of neurologic deficit, and lumbar abscess location are all factors that point toward a patient being a reasonable candidate for a trial of culture-specific IV antibiotics. In this case, nafcillin is a suitable treatment for MSSA. The antibiotic should be initiated and closely observed with serial labs (WBC, ESR, CRP, repeat blood cultures) to ensure that the patient responds appropriately to therapy and that neurologic deficits do not develop. In the setting of epidural abscess, surgery is performed to evacuate the abscess and reverse or prevent neurologic deterioration. In the current scenario in which sepsis is not an issue, scant high-quality evidence shows that surgical intervention influences risk for mortality or chronic pain following epidural abscess.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.View Abstract at PubMed
Adogwa O, Karikari IO, Carr KR, Krucoff M, Ajay D, Fatemi P, Perez EL, Cheng JS, Bagley CA, Isaacs RE. Spontaneous spinal epidural abscess in patients 50 years of age and older: a 15-year institutional perspective and review of the literature: clinical article. J Neurosurg Spine. 2014 Mar;20(3):344-9. doi: 10.3171/2013.11.SPINE13527. Epub 2013 Dec 20. Review.
PubMed PMID: 24359002.View Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014
Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 43

Which of the following illustrations shown in Figures 21a through 21e correctly shows the projection of the sacroiliac joint on the outer table of the ilium?

Explanation

DISCUSSION: The projection of the sacroiliac joint on the outer surface of the ilium should be well understood to avoid violation of the joint during bone graft harvesting and to help in insertion of the screw across the joint. The sacroiliac joint has superior and inferior limbs. The average lengths of the superior and inferior limbs are 4.4 cm and 5.6 cm, respectively. The average width of each limb is 2.0 cm. The average distance from the longitudinal axis of the superior limb to the posterior superior iliac spine is 5.5 cm. The average longitudinal axis of the inferior limb is 1.2 cm superior to the inferior margin of the posterior inferior iliac spine. The average angle between the two axes is 93 degrees. Figure 21c most closely shows the projection of the sacroiliac joint on the outer table of the ilium.
REFERENCES: Waldrop JT, Ebraheim NA, Yeasting RA, Jackson WT: The location of the sacroiliac joint on the outer table of the posterior ilium. J Orthop Trauma 1993;7:510-513.
Xu R, Ebraheim NA, Yeasting RA, Jackson WT: Anatomic considerations for posterior iliac bone harvesting. Spine 1996;21:1017-1020.

Question 44

A 15-year-old female field hockey player sustains a blow to the mouth from a hockey stick. Three front teeth are knocked out and shown in Figure 4. In addition to calling a dentist immediately, what is the next best step in management?

Explanation

DISCUSSION: Tooth avulsions can occur in contact or collision sports. An avulsed tooth is a medical emergency. The likelihood of survival of the tooth depends on the length of time that the tooth is out of the socket and the degree to which the periodontal ligament is damaged. The tooth should be handled only by the crown end and not the root end. It can be rinsed of debris with water or normal saline solution. The tooth should not be brushed or cleaned otherwise. During transport, the tooth must be kept moist. An avulsed tooth can be transported in whole milk, saliva, sterile saline solution, or commercially available kits with physiologic buffer solutions. The tooth and the athlete should be transported to the dentist for reinsertion as soon as possible and preferably within an hour.
REFERENCES: Krasner P: Management of sports-related tooth displacements and avulsions. Dent Clin North Am 2000;44:111-135.
Sullivan JA, Anderson SJ (eds): Care of the Young Athlete. Rosemont IL, American Academy of Orthopaedic Surgeons, Elk Grove Village, IL, American Academy of Pediatrics, 2000, p 190.
Galante A: Facial trauma, in Baker CL (ed): The Hughston Clinic Sports Medicine Book. Baltimore, MD, Williams & Wilkins, 1995, p 121.

Question 45

What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

Explanation

DISCUSSION: Cadaver and clinical studies have shown that the sural nerve is at the highest risk for injury with a percutaneous repair of the Achilles tendon.
REFERENCE: Hockenbury RT, Johns JC: A biomechanical in vitro comparison of open versus percutaneous repair of tendon Achilles. Foot Ankle 1990;11:67-72.

Question 46

Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of

Explanation

DISCUSSION: The problem with this reconstruction is the medial protrusion of the base plate. The use of a base plate with an offset stem can prevent the protrusion and thus the impingement and pain. Allograft bone or smoothing the outline with cement would be just as prominent and likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate would lead to less medial protrusion but at the expense of a smaller area for load carriage on the proximal tibia.
REFERENCE: Gustke K: Cemented tibial stems are not requisite in revision. Orthopedics 2004;27:991-992.

Question 47

Figure 11 shows the lateral radiograph of a 16-year-old boy who has been unable to participate in sports activities because of pain in the anterior aspect of the knee. He states that the pain is aching in nature and is located in the region of the tibial tuberosity. He denies having joint effusion or symptoms of instability. Management should consist of

Explanation

DISCUSSION: The prognosis for most patients with Osgood-Schlatter disease is good. When the secondary ossification center unites with the main body of the tibial tubercle, the patellar tendon has a more rigid anchor, and heterotopic ossification and its associated reaction often become quiescent. However, even after closure of the growth plates, some patients have persistent symptoms. Excision of the ossicle and prominence of the tibial tuberosity decompresses the patellar tendon and allows most patients to resume sports activities. Nonsurgical modalities are ineffective. Better results have been reported after excision than after drilling of the tubercle. Excision of the ossicle is not indicated prior to skeletal maturity because symptoms will resolve in most patients when the secondary ossification center unites.
REFERENCES: Flowers MJ, Bhadreshwar DR: Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995;15:292-297.
Greene WB: Osteochondrosis and tibia vara, in Canale ST, Beaty JH (eds): Operative Pediatric Orthopaedics, ed 2. Philadelphia, Pa, Mosby, 1995, pp 804-854.

Question 48

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

Explanation

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

Question 49

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

Explanation

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

Question 50

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

Explanation

DISCUSSION: The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2. Philadelphia, PA, WB Saunders, 1993, pp 492-503.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 51

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectional
instability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 52

78A B Figures 78a and 78b are the emergency department radiographs of an 83-year-old woman who tripped and braced herself against a wall; this was followed by shoulder pain. Which intervention would provide optimal treatment for this patient?

Explanation

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849. View Abstract
at PubMed
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430. View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 53

Figure 18 is the radiograph of a 52-year-old woman who has leg length inequality and chronic activity-related buttock discomfort. This has been a life-long problem, but it is getting worse and increasingly causing back pain. What is the best current technique for total hip arthroplasty?

Explanation

DISCUSSION
A high hip center is not recommended for Crowe IV hips because of the lack of acetabular bone and altered hip biomechanics. An anatomic center is a better option but necessitates a technique to address the tight soft-tissue envelope. A trochanteric osteotomy with progressive femoral shortening has been described but can be prone to trochanter nonunion. Iliofemoral lengthening prior to surgery has been described but may not be tolerated by all patients. A shortening subtrochanteric osteotomy avoids trochanter nonunion and allows adjustment of femoral anteversion. Fixation of the osteotomy can include a stem with distal rotational control, plate fixation, a step vs. oblique cut, or strut grafts.

Question 54

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Explanation

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 55

An otherwise healthy 76-year-old woman has pain 2 years after total hip arthroplasty. The clinical photograph in Figures below demonstrates her skin envelope, and associated radiograph. Her C-reactive protein level is normal, and her erythrocyte sedimentation rate is mildly elevated. The white blood cell count is normal. Hip aspiration attempted under fluoroscopy generates no fluid. What is the best definitive treatment?

Explanation

DISCUSSION:
This patient clearly has a chronically infected total hip arthroplasty, indicated by the open, draining sinus, as well as trochanteric bone resorption on radiographs, and two years of pain. Recently, specific guidelines have been published to better help the clinician define infection. Repeating the hip aspiration is unnecessary, because infection is already evident. Initiating a wound care consult would not address the underlying infection. The determination whether to retain the components or perform a two-stage exchange is based more on the acuity of infection. In this particular case, the patient is chronically infected. Irrigation and debridement with a liner exchange and retention of the components are reserved for the acute setting.

Question 56

A 43-year-old woman has a 2-week history of right shoulder pain. She denies any injury to initiate her symptoms but states that she has shoulder pain with range of motion and lifting objects. Examination reveals mild pain with abduction, empty can testing, and with the Neer and Hawkins impingement tests. Her range of motion with the right shoulder reveals passive forward flexion to 90 degrees, abduction to 90 degrees, external rotation at the side to 15 degrees, and internal rotation to her buttock. The uninvolved left shoulder has forward flexion to 160 degrees, abduction to 150 degrees, external rotation at the side to 60 degrees, and internal rotation to T6. Radiographs of the shoulder are normal. What is the next most appropriate step in management? Review Topic

Explanation

The patient has the recent onset of adhesive capsulitis, which is characterized by loss of both active and passive range of motion. A home exercise program is as helpful as organized therapy to improve her range of motion. While a sling might be appropriate for comfort, continuous use might increase her shoulder stiffness. Surgical treatments, such as a manipulation under anesthesia or arthroscopic capsular release, might be necessary if her motion cannot be restored with physical therapy and home exercises. However, the natural history of idiopathic adhesive capsulitis is self limited and does not usually require surgery. An arthroscopic rotator cuff repair is not indicated because she does not have a rotator cuff tear.

Question 57

What is the most specific physical examination finding? Review Topic

Explanation

Overhead athletes are prone to a number of problems involving the shoulder. Pitchers and volleyball players are susceptible to posterior superior labral tears and internal impingement. These patients will have posterior superior shoulder pain, a positive relocation sign, and a positive active compression test. Occasionally, these posterior superior labral tears are associated with a spinoglenoid cyst as seen in the MRI scan. These cysts cause compression of the suprascapular nerve which manifests primarily as weakness of the infraspinatus, resulting in weakness of external rotation.

Question 58

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 59

Examination of a 28-year-old woman reveals a moderate hallux valgus deformity and a prominence of the medial eminence. She reports that she can participate in all activities, wear 3-inch heels with minimal discomfort, and walk in a 1-inch heel with no pain. However, she is concerned that the deformity will get worse and requests recommendations regarding surgical correction. What is the best course of action?

Explanation

DISCUSSION: Because the patient is essentially asymptomatic, the most appropriate course of action is observation. Prophylactic hallux valgus surgery is not medically indicated. Steroid injection would only risk infection, as well as joint and capsule damage. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Special shoe wear or an extra-depth shoe is not necessary and is unlikely to be accepted by the patient.
REFERENCES: Donley BG, Tisdel CL, Sferra JJ, Hall JO: Diagnosing and treating hallux valgus: A conservative approach for a common problem. Cleve Clin J Med 1997;64:469-474.
Teitz CC, Hu SS, Arendt EA: The female athlete: Evaluation and treatment of sports-related problems. J Am Acad Orthop Surg 1997;5:87-96.

Question 60

Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?

Explanation

DISCUSSION: Several large clinical studies have shown that the most common problem after elastic nailing of a femoral shaft fracture is persistent pain and irritation at the nail insertion site. Unacceptable shortening and malunion are very rare in a 7-year-old patient. Rotational malalignment also is unusual. Osteonecrosis has been reported in solid antegrade nailing but not with elastic nailing of femoral shaft fractures in skeletally immature patients.
REFERENCES: Flynn JM, Luedtke LM, Ganley TJ, et al: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-777.
Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.

Question 61

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they want to “get the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared with nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 62

During the cocking and acceleration phases of the overhand throw (pitch), there are several static and dynamic restraints to provide medial elbow support and prevent valgus instability. The dynamic structures found to be most important during these phases of the overhand throw are the flexor digitorum Review Topic

Explanation

Biomechanical analysis has demonstrated that local dynamic stability of the elbow is provided by the flexor digitorum superficialis and the flexor carpi ulnaris, especially during the cocking and acceleration phases of the overhand throw. This provides dynamic joint compression across the elbow joint and may be protective to the static restraints such as the ulnar collateral ligament. It also emphasizes the need to strengthen distant muscles in the forearm to assist with elbow biomechanics and potentially prevent injury.

Question 63

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Explanation

DISCUSSION: SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.
REFERENCES: Cantu RC: Second-impact syndrome. Clin Sports Med 1998;17:37-44.
Saunders RL, Harbaugh RE: Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 64

An orthopaedic surgeon who is the developer of a knee arthroplasty system is discussing treatment options with a patient who has tricompartmental osteoarthritis. As a part of this discussion, the orthopaedic surgeon has an obligation to disclose

Explanation

This topic is listed in Appendix D of the Code of Ethics for Orthopaedic Surgeons/American Academy of Orthopaedic Surgeons under sections III B and C.
III. Conflicts of Interest
B. Where there are financial interests involved in the ownership of a pharmacy, rehabilitation center, imaging equipment, surgery center, or health care facility where the orthopaedic surgeon’s financial interest is not immediately obvious, the orthopaedic surgeon must disclose that financial interest to the patient and to colleagues.
C. When an orthopaedic surgeon receives anything of value, including royalties, from a manufacturer, the orthopaedic surgeon must disclose this fact to the patient and to colleagues. It is unethical for an orthopaedic surgeon to receive compensation (excluding royalties) from a manufacturer for using a particular device or medication. Reimbursement for administrative costs in conducting or participating in a scientifically sound research trial is acceptable.

Question 65

A 14-year-old girl has had progressive heel pain for the past several months. Based on the radiograph, MRI scan, and biopsy specimens shown in Figures 37a through 37d, treatment should include

Explanation

DISCUSSION: An aneurysmal bone cyst is a benign, locally destructive lesion of bone. Most are seen in patients in the second decade of life. The clinical presentation varies, but most patients have pain, tenderness, swelling, and/or pathologic fracture. Radiographs show a radiolucent lesion sometimes with expansile remodeling of the cortex. MRI best detects the commonly seen fluid-fluid levels associated with this lesion. Histologic findings include

blood-filled spaces with bland fibrous connective tissue septa. The stroma has histiocytes, fibroblasts, scattered giant cells, hemosiderin, and occasional inflammatory cells. Treatment of these lesions consists of extended curettage, plus or minus the use of adjuvants (liquid nitrogen, phenol, argon beam coagulation), and finally filling the bone void (allograft or other bone substitute).
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Ramirez AR, Stanton RP: Aneurysmal bone cyst in 29 children. J Pediatr Orthop 2002;22:533-539.

Question 66

The iliopectineal fascia runs between which of the following structures?

Explanation

DISCUSSION: The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis.
REFERENCES: Masquelet AC, McCullough CJ, Tubiana R: An Atlas of Surgical Exposures of the Lower Extremity. Philadelphia, PA, JB Lippincott, 1993.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 67

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

Explanation

DISCUSSION: Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options.
REFERENCES: Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584.
Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.
Pochatko DJ, Schlehr FJ, Murphey MD, Hamilton JJ: Distal chevron osteotomy with lateral release for treatment of hallux valgus deformity. Foot Ankle Int 1994;15:457-461.

Question 68

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

Explanation

DISCUSSION: Low-molecular-weight heparin is highly bioavailable with a half-life
to 18 hours. This is greater than the 1 hour half-life of unfractionated heparin.

Low-molecular-weight heparin offers an advantage over unfractionated heparin by selectively targeting Factor Xa while having a lesser effect on circulating thrombin (Factor IIa). Circulating thrombin Factor IIa is needed for local hemostasis at the site of the surgical wound. Clinical studies have shown a reduction by one third in the incidence of thrombocytopenia with the use of low-molecular-weight heparin. Low-molecular-weight heparin has been shown to demonstrate similar clinical results compared to warfarin with respect to preventing thromboembolic disease after total hip arthroplasty and complications such as bleeding.
REFERENCES: Zimlich RH, Fulbright BM, Friedman RJ: Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996;4:54-62.
Colwell CW Jr, Spiro TE, Trowbridge AA, et al: Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Torholm C, Broeng L, Jorgensen PS, et al: Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery: A placebo controlled study. J Bone Joint Surg Br 1991;73:434-438.

Question 69

A 30-year-old man sustains a head injury as well as a femur and pelvis fractures as the result of a rollover motor vehicle accident. He is initially comatosed, but recovers cognitive function after 10 days in the hospital. Soon after awakening he complains of wrist pain and an x-ray demonstrates a distal radius fracture. What is the most likely explanation for this delayed diagnosis?

Explanation

DISCUSSION: According to the cited article by Born et al, who prospectively studied the incidence of delayed recognition of skeletal injury at a Level I trauma center over an 18-month period, the majority of missed skeletal injuries result from failure to image the affected extremity. These authors identified 39 fractures in 26 of 1,006 consecutive blunt trauma patients that were not diagnosed in a timely fashion (delays ranging from 1-91 days). Although other factors contributed to the diagnostic failure (23% were visible on admission films and not recognized; 10% were not visible due to inadequate x-rays of appropriate limb; 13% had adequate x-rays but diagnosis could not be made from initial studies), 55% of the fractures that were delayed in diagnosis resulted from failure to image the affected extremity. They went on to conclude that, “although the delay of fracture identification was not felt to contribute to additional long-term cosmetic, functional, or neurologic problems,” continued radiographic surveillance is necessary to prevent diagnostic failure.

Question 70

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

Explanation

The ZPA is located on the posterior (ulnar) margin of the limb bud. It expresses Shh protein. When tissue from ZPA is added to the anterior (radial) margin of the limb bud, ulnar dimelia, or mirror hand duplication, occurs.
The ZPA controls AP (radioulnar) growth. The signaling molecule is Shh, which is dose dependent. Higher Shh doses lead to posterior (ulnar) digits ulnar sided polydactyly. The extent of duplication is dose dependent (higher dose = more replication). Reduced Shh leads to loss of digits. Posterior elements (little finger/ulna) are formed EARLY prior to anterior elements which are formed LATE (radius/thumb). Disruption of AP patterning will result in loss of later forming elements (radius/thumb).
Al-Qattan et al. reviewed embryology of the upper limb. They summarized that embryology of the upper limb can be viewed in 2 distinct ways: the steps of limb development and the way that the limb is patterned along its 3 spatial axes. Cell signaling plays a major role in regulating growth and patterning of the vertebrate limbs. Signaling cell dysfunction results in congenital differences according to the affected signaling axis.
Illustration A shows an experiment to create ulnar dimelia by adding ZPA tissue to the anterior limb bud. The video shows development of the limb.
Incorrect Answers:

Question 71

A cortisone injection in the subacromial space will most likely result in

Explanation

DISCUSSION: A cortisone injection in the subacromial space will most likely result in elevated blood glucose levels in patients with type I diabetes mellitus. Patients should be warned of this potential complication. Cortisone does not have an effect on instability or proprioception, and a single injection would not affect osteoporosis. Repetitive injections or injection into the tendon itself could accelerate rupture of the biceps tendon.
REFERENCES: Matsen FA III, Arntz CT: Subacromial impingement, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 623-646.
Koehler BE, Urowitz MB, Killinger DW: The systemic effects of intra-articular corticosteroid. J Rheumatol 1974;1:117-125.

Question 72

A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?

Explanation

DISCUSSION: The radiograph reveals a “bony mallet injury.” As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate.
REFERENCES: Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.
Bendre AA, Hartigan BJ, Kalainov DM: Mallet finger. J Am Acad Orthop Surg 2005;13:336-344.

Question 73

You are studying a single continuous variable after administration of a defined treatment intervention. Your statistician informs you the data are not normally distributed. What is the best test to analyze the data?

Explanation

The Mann-Whitney U test is used when data are nonparametric, meaning either not normally distributed or variances are not equal among groups. Both the Student t test and ANOVA are used with parametric, normally distributed data. A regression analysis is a statistical model that allows for control of potentially confounding variables. It is used to assess the relationship between a dependent variable and (usually) multiple independent variables.

Question 74

Which of the following rehabilitation methods should be used for the first 24 hours following a blunt injury to the quadriceps musculature to avoid short-term stiffness?

Explanation

A West Point study utilizing a three-phase protocol after quads contusion was cited. Phase I was to limit hemorrhage. Rest, ice, compression and elevation were used for 24 to 48 hours depending on the severity of the contusion. Rest involved ace wrap to entire leg and hip and knee flexed to tolerance. When the patient was pain free at rest and thigh girth had stabilized Phase II had begun. The purpose of this phase was to restore ROM. Ice and cool whirlpool were continued, gravity assisted motion and active flexion and extension exercises are started. Weightbearing to tolerance in continued and crutches are discontinued when 90 degrees of motion, no limp and good quad control is attained. Phase III starts when there is 120 degrees of pain free active motion and participation in noncontact sports is allowed, when full strength, motion and endurance is achieved contact sports can be resumed. A thigh pad is worn for 3-6 months.
In the past immobilization in full extension was recommended, but it was noticed that the lack of flexion prolonged disability. Flexion of the knee during the first 24 hours also aids in limiting the extent of intramuscular hematoma.
Myositis ossificans is higher in any patient presenting after a quad contusion and has active knee ROM of less than 120 degrees and delay in treatment greater than 3 days.

Question 75

The main arterial supply to the humeral head is provided by which of the following arteries?

Explanation

DISCUSSION: The main arterial supply to the humeral head is provided by the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There are significant intraosseous anastomoses between the arcuate artery, the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus, the metaphyseal vessels, and the vessels of the greater and lesser tuberosities. Four-part fractures and dissection during exposure affect perfusion of the humeral head.
REFERENCES: Brooks CH, Revell WJ, Heatley FW: Vascularity of the humeral head after proximal humeral fractures: An anatomical cadaver study. J Bone Joint Surg Br 1993;75:132-136.
Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head: An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494.

Question 76

A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle. In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved. A CT scan reveals a posterior sternoclavicular dislocation. Initial management should include

Explanation

DISCUSSION: Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway. Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available. A successful closed reduction is usually stable. Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures. If closed reduction is unsuccessful, open reduction is indicated. Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297.
Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, vol 2, pp 1010-1017.

Question 77

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Explanation

DISCUSSION: Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures.
REFERENCES: Goldman RT, Koval KJ, Cuomo F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and fourth-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.
Hawkins RJ, Switlyk P: Acute prosthetic replacement for severe fractures of the proximal humerus. Clin Orthop 1993;289:156-160.

Question 78

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Explanation

DISCUSSION: Increased levels of calcium are known to cause anorexia, nausea, vomiting, dehydration, muscle weakness, polyuria, and polydipsia. Treatment may include hydration, saline diuresis, and bisphosphonates.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 79

A tendon repair is thought to be weakest during which phase of tendon healing?

Explanation

Healing after a tendon repair or rupture has the following stages: inflammatory, cellular proliferation, and remodeling. During the inflammatory phase, neutrophils and macrophages migrate into the injury site and release chemotactic factors that recruit fibroblasts. A tendon is thought to be weakest 5 to 21 days after repair, which coincides with the inflammatory phase. During the proliferative phase, inflammatory cells secrete cytokines and growth factors (platelet-derived growth factor, insulin-like growth factor, bone morphogenetic protein (BMP)-12 and BMP 13, and transforming growth factor-beta) that promote differentiation of fibroblasts. Fibrosis and decreased cellularity are the hallmarks of the remodeling stage.

Question 80

Figures below show the clinical photograph and radiograph obtained from a 62-year-old man who has deformity and pain 1 year after primary total hip arthroplasty. What is the reason for the observed deformity?

Explanation

DISCUSSION:
Figure 1 reveals an external rotation deformity of the right lower extremity. This deformity can have numerous causes, including extra-articular deformity. Figure 2 reveals a loose, subsided femoral component. Femoral stems typically subside into retroversion due to proximal femoral biomechanics, which cause a compensatory external rotation deformity. The combined findings from both images suggest an external rotation deformity most likely related to subsidence into retroversion.

Question 81

A patient has had a locked posterior dislocation of the shoulder for the past 6 months. After undergoing total shoulder arthroplasty that includes adequate anterior releases and posterior capsulorrhaphy, the patient still exhibits posterior instability intraoperatively. The postoperative rehabilitation regimen should include

Explanation

DISCUSSION: Achieving stability in chronic locked posterior dislocations of the shoulder remains a difficult challenge. Intraoperative measures include decreased humeral retroversion, anterior releases, and posterior capsular tightening. Postoperative rehabilitation is of equal importance. Immobilization in an external rotation brace (10 degrees to 15 degrees) with the arm at the side for 4 to 6 weeks is recommended to decrease tension in the posterior capsule. When passive range-of-motion exercises are instituted, they should be performed in the plane of the scapula to avoid stress posteriorly. Internal rotation and supine elevation should be avoided for similar reasons.
REFERENCES: Hawkins RJ, Neer CS II, Pianta RM, Mendoza FX: Locked posterior dislocation of the shoulder. J Bone Joint Surg Am 1987;69:9-18.
Loebenberg MI, Cuomo F: The treatment of chronic anterior and posterior dislocations of the glenohumeral joint and associated articular surface defects. Orthop Clin North Am 2000;31:23-24.

Question 82

Examination of a 30-year-old professional singer who has persistent neck and shoulder pain reveals a positive Hoffman’s sign and clonus because of anterior C2-3 cord compression. The MRI scan shown in Figure 11a and the cervical CT scan shown in Figure 11b reveal focal anterior cord compression at the C2-3 level. Which of the following surgical approaches would least affect her professional career?

Explanation

DISCUSSION: Protection of the superior laryngeal nerve is critical in a professional singer. The nerve is easily injured with retraction when using vertical extension of common anterior surgical approaches to gain exposure to the C2-3 level. McAfee and associates reported on 17 patients with C1-2 and C2-3 pathology. They used a modified submandibular approach as an anterior retropharyngeal exposure with modification of the superior extension of the Smith-Robinson technique that allows visualization of the superior laryngeal nerve and surrounding structures. No incidences of superior laryngeal nerve injury were recorded. The transoral approach should be avoided because of the high rate of infection and limited exposure.
REFERENCES: McAfee PC, Bohlman HH, Reilly LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surgery Am 1987;69:1371-1383.
Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach to the cervical spine: Surgical anatomy. Orthopedics 2000;23:841-845.

Question 83

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

Explanation

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

Question 84

Figures 14a and 14b show the plain radiographs of an 85-year-old woman who has had severe pain in the right knee for the past 4 months. Management should consist of

Explanation

DISCUSSION: The patient has osteonecrosis of the lateral femoral condyle with collapse of the articular surface. Because there is already collapse of the articular surface, a total knee arthroplasty is the treatment of choice. The results of total knee arthroplasty in these patients are usually excellent. However, knee replacement is only a resurfacing procedure, and some patients with global osteonecrosis of the distal femur may have residual pain after knee replacement. High tibial osteotomy may be indicated in younger patients who have a varus deformity and localized osteonecrosis. Arthroscopic surgery would provide minimal relief for this patient because there is already collapse of the articular surface. A hinged knee brace will not adequately unload the joint. An osteochondral allograft should be considered only for younger patients with localized osteonecrosis.
REFERENCES: Bergman NR, Rand JA: Total knee arthroplasty in osteonecrosis. Clin Orthop 1991;273:77-82.
Lotke PA, Abend JA, Ecker ML: The treatment of osteonecrosis of the medial femoral condyle. Clin Orthop 1982;171:109-116.

Question 85

Which of the following best characterizes the injury shown in Figure 53? Review Topic

Explanation

The injury shown is a flexion compression injury also known as "tear drop" fracture. It is characterized by the large anteroinferior fragment off the vertebral body and the retrolisthesis seen in this image. It is considered an unstable injury and should be distinguished from the more stable and minor extension tear drop avulsion where there is no vertebral malalignment and the anteroinferior fracture is a small avulsion of the annulus attachment. Other axial load injuries can be stable but have more of a compression or even burst pattern with loss of body height rather than the anteroinferior fragment. The radiograph does not demonstrate facet malalignment that would be seen with a facet dislocation.

Question 86

An 11-year-old boy has had a fever and pain and swelling over the lateral aspect of his right ankle for the past 3 days. Examination reveals warmth, swelling, and tenderness over the lateral malleolus, and he has a temperature of 103.2 degrees F (39.5 degrees C). Laboratory studies show a WBC count of 13,200/mm 3 with 61% neutrophils, an erythocyte sedimentation rate of 112 mm/h, and a C-reactive protein of 15.7. Radiographs and a T 2 -weighted MRI scan are shown in Figures 13a through 13c. Aspiration yields 1 mL of purulent fluid. Management should now consist of

Explanation

DISCUSSION: The initial signs and symptoms of acute hematogenous osteomyelitis vary widely but usually include fever, bone pain, and impaired use of the involved extremity. In lower extremity infections, the child may limp or refuse to walk. Examination often reveals bone tenderness. In more advanced cases, erythema, warmth, and swelling may be present. The WBC and neutrophil counts are not always elevated, but the erythocyte sedimentation rate will be abnormal in more than 90% of patients. When the infection is diagnosed early, before a subperiosteal abscess has formed, antibiotics alone may be adequate to treat the infection. This patient has a more advanced infection, however, with the MRI scan revealing a subperiosteal abscess that was confirmed by aspiration. When an abscess is present, surgical drainage is generally indicated to remove devitalized tissue and to enhance the efficacy of the antibiotics. Further studies, such as bone or indium scans, are not necessary and will delay

definitive treatment.
REFERENCES: Scott RJ, Christofersen MR, Robertson WW Jr, et al: Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-652.
Vaughan PA, Newman NM, Rosman MA: Acute hematogenous osteomyelitis. J Pediatr Orthop 1987;7:652-655.

Question 87

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 88

To prevent injury to the posterior interosseous nerve during the approach for reduction and fixation of a fracture of the radial head, anterior retraction should be performed with the forearm

Explanation

Position of the patient-Place supine on the operating table, with the affected arm positioned over the chest. Pronate the forearm.
Deep surgical dissection-Fully pronate the forearm to move the posterior interosseous nerve away from the operative field. Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament. Do not incise the capsule too far anteriorly; the radial nerve runs over the front of the anterolateral portion of the elbow capsule. Do not continue their dissection below the annular ligament or retract vigorously, distally, or anteriorly, because the posterior interosseous nerve lies within the substance of the supinator muscle and is vunerable to injury.
Dangers: Nerves-The posterior interosseous nerve is in no danger as long as the dissection remains proximal to the annular ligament. Pronation of the forearm keeps the nerve as far from the operative field as it possible can be. To ensure the safety of the nerve, take great care to place the retractors directly on the bone and be careful in their placement. Because the posterior interosseous nerve actually may touch the bone of the radial neck, directly opposite the bicipital tuberosity, placing retractors behind it poses a risk.

Question 89

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 90

An otherwise healthy year-old woman has pain 2 years after total hip arthroplasty. The clinical photograph in below demonstrates her skin envelope, and associated radiograph. Her C-reactive protein level is normal, and her erythrocyte sedimentation rate is mildly elevated. The white blood cell count is normal. Hip aspiration attempted under fluoroscopy generates no fluid. What is the best definitive treatment?

Explanation

Question 91

No fractures were identified and the patient was treated nonsurgically in a range-of-motion brace. Two months later, he continued to experience elbow pain and was unable to return to sports. He regained motion and strength with physical therapy, there was no gross instability with varus or valgus testing, and he had a negative moving-valgus stress test. The orthopaedic surgeon performed an examination under anesthesia in the operating room (Video 54). Which anatomic structure is injured?

Explanation

DISCUSSION
Ninety percent of elbow dislocations occur in a posterolateral direction. O’Driscoll and associates described the mechanism of injury in posterolateral elbow dislocations in 1992, reporting that they occur most typically after a fall onto an outstretched arm. As the arm hits the ground it causes axial compression, forearm supination, and valgus load across the elbow. The triceps fires, pulling the olecranon posterior; the forearm supinates while simultaneous shoulder internal rotators fire; and the elbow falls into valgus. These 3 mechanisms cause the elbow to subluxate and dislocate posterolaterally. The elbow is most stable following posterolateral dislocation in a flexed and pronated position. The elbow is least stable in extension and supination. Simple dislocation often can be treated nonsurgically, while fracture dislocation will usually necessitate surgical intervention. The video shows the elbow pivot-shift test, which evaluates for posterolateral rotatory instability. A positive test finding elicits apprehension and, in this case, radial head subluxation and confirms an insufficient lateral UCL.

Question 92

In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?

Explanation

DISCUSSION:
When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

Question 93

A 27-year-old man has recurrent anterior shoulder instability following an arthroscopic Bankart repair 4 years ago. Current CT scans are shown in Figures 19a and 19b. Deficiency of what mechanism is most likely to contribute to the current joint instability? Review Topic

Explanation

Loss of the anterior glenoid rim can commonly occur as a result of acute fracture or progressive wear following multiple dislocations. This decreases the effective depth of the glenoid. The ability of the rotator cuff to stabilize the joint through production of a joint reactive force is markedly decreased. Synovial fluid adhesion-cohesion and negative intra-articular pressure are maintained in the closed capsular space. The Hill-Sachs lesion in this case is not large enough to be a significant factor in failed Bankart repair. Poor scapulothoracic rhythm can increase the risk of instability but is not typically the primary factor.

Question 94

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

Explanation

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

Question 95

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Explanation

Whereas ipsilateral fractures of the femoral neck and shaft are uncommon, it is critical to recognize a femoral neck fracture that may occur in conjunction with a femoral shaft fracture. The combined injury is seen in 2% to 9% of femoral shaft fractures and may initially be missed in as many as one third of the cases. Preoperative examination of a thin cut CT scan and dedicated AP internal rotation views of the femoral neck can help identify this injury. In addition, the intraoperative AP and lateral hip fluoroscopic view should be examined, and a dedicated radiograph of the hip obtained at the conclusion of the surgery. At follow-up, Tornetta and associates has recommended
obtaining a dedicated AP radiograph of the hip with the leg internally rotated 15 to 20 degrees. Because the femoral neck is anteverted, 15 to 20 degrees of internal rotation of the hip offers the best view of the femoral neck. Whereas associated lumbar spine pathology may cause groin pain, the presence of a missed femoral neck fracture must first be ruled out prior to investigating other sources of pain.

Question 96

A 54-year-old woman underwent prophylactic intramedullary fixation for an impending fracture of her right femur secondary to metastatic breast cancer. A bone scan revealed a second lesion in her inferior pubic ramus. Her oncologist has recommended that she receive the intravenous bisphosphonate, zoledronic acid, because the medication would

Explanation

DISCUSSION: Bisphosphonates have been reported to reduce the incidence of new osseous lesions and prevent an increase in size of existing lesions. Zoledronic acid has been reported in clinical trials to decrease the skeletal complications of patients with multiple myeloma and with bone metastases from solid tumors. Results also have demonstrated that zoledronic acid delays the initial onset of bone complications by more than 2 months in patients with non-small-cell lung cancer and other solid tumors. In two placebo-controlled clinical studies of zoledronic acid conducted in patients with bone metastases from prostate cancer or other solid tumors, there was a decrease in the number of patients with skeletal-related events compared to placebo, and the time to the first skeletal-related event was delayed.
REFERENCES: Mundy GR, Yoneda T: Bisphosphonates as anticancer drugs. N Engl J Med 1998;339:398-400.
Rosen LS, Gordon D, Kaminski M, et al: Zoledronic acid versus pamidronate in the treatment of skeletal metastases in patients with breast cancer or osteolytic lesions of multiple myeloma: A phase III, double-blind, comparative trial. Cancer J 2001;7:377-387.

Question 97

Which of the following tumors have characteristic chromosomal translocations?

Explanation

DISCUSSION: Ewing’s sarcoma has an 11;22 translocation that creates the EWS/FLI1 fusion gene, and synovial sarcoma has an X;18 translocation that creates the STT/SSX fusion gene. The other tumors do not have consistent translocations.
REFERENCES: Sandberg AA: Cytogenetics and molecular genetics of bone and soft-tissue tumors. Am J Med Genet 2002;115:189-193.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 11-20.

Question 98

A 28-year-old man sustained numerous injuries in an accident including a dislocation of the elbow and a severe closed head injury that resulted in unconsciousness. The elbow was reduced in the emergency department. After 1 month of rehabilitation, the patient reports pain and stiffness. A radiograph is shown in Figure 23. Management should now consist of

Explanation

DISCUSSION: In a young individual with a chronic dislocation of the elbow and heterotopic bone formation, the treatment of choice is open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a dynamic hinged fixator to begin protected early postoperative range of motion. It is important to understand that the fixator protects the reconstruction and allows early range of motion, but it does not maintain the reduction and should not be expected to do so. Pin fixation across the elbow delays early motion and is not recommended. Total elbow arthroplasty is not indicated, and ulnohumeral arthroplasty is for a primary arthritic condition.
REFERENCES: Garland DE, Hanscom DA, Keenan MA, et al: Resection of heterotopic ossification in the adult with head trauma. J Bone Joint Surg Am 1985;67:1261-1269.
Moor TJ: Functional outcome following surgical excision of heterotopic ossification in patients with traumatic brain injury. J Orthop Trauma 1993;7:11-14.

Question 99

Figure 1 is the radiograph of an 18-year-old right-hand-dominant man who has pain and stiffness 3 months after sustaining an injury to his dominant ring finger while playing basketball. An examination reveals significant proximal interphalangeal (PIP) joint swelling with active and passive PIP joint motion of 15/40 degrees of flexion. What is the best next step?

Explanation

EXPLANATION:
This patient has a subacute PIP joint dorsal fracture dislocation with involvement of 50% to 60% of the palmar articular surface of the base of P2. A "V sign" (Figure 2) is evident, indicating dorsal subluxation of the joint. In some cases, an ORIF is possible, but substantial comminution often precludes proper restoration of the critical volar buttress. Therapy is not the answer because the joint is dorsally subluxated and must be corrected. Dynamic external fixation on its own would not result in a reduced joint. The hemi-hamate autograft has proven useful in this type of scenario and serves to restore the volar buttress of P2 using an osteochondral autograft harvested from the distal articular aspect of the hamate at its articulation with the fourth/fifth metacarpal bases. Intraoperative clinical photographs and a postsurgical radiograph are shown in Figures 3 through 5.

Question 100

A 14-year-old boy has an anteromedial distal thigh mass. A radiograph and MRI scan are shown in Figures 39a and 39b. An open biopsy of the mass should include

Explanation

DISCUSSION: Biopsy of the soft-tissue component is often diagnostic. Alternatively, in centers with pathologists familiar with bone tumors, needle biopsy is usually successful. The principles of biopsy of bone tumors include avoiding contamination of uninvolved structures and compartments, taking the most direct path to the tumors, making an excisable biopsy tract, and obtaining diagnostic tissue. Transverse biopsy incisions should be avoided because they hinder the definitive surgical procedure.
REFERENCES: Peabody TD, Simon MA: Making the diagnosis: Keys to a successful biopsy in children with bone and soft-tissue tumors. Orthop Clin North Am 1996;27:453-459.
Mankin HJ, Mankin CJ, Simon MA: The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am 1996;78:656-663.
Skrzynski MC, Biermann JS, Montag A, Simon MA: Diagnostic accuracy and charge-savings of outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors. J Bone Joint Surg Am 1996;78:644-649.

Full Question & Answer Text (for Search Engines)

Question 1:

In children with moderate to severe osteogenesis imperfecta (OI), intravenous pamidronate therapy has been shown to increase the thickness of cortical bone. This occurs primarily as a consequence of

Options:

increased bone turnover in the cortical area.
inhibition of osteoclast-mediated bone resorption.
improved mineralization of cortical bone.
improved osteoblast organic matrix production.
improved organization of collagen matrix.

Correct Answer: inhibition of osteoclast-mediated bone resorption.

Explanation:

DISCUSSION: Histologic studies have shown that increased bone turnover is the rule in OI. Pamidronate (and all bisphosphonates) reduce osteoclast-mediated bone resorption. Osteoblastic new bone formation on the periosteal surface of long bones is minimally impaired. With inhibition of osteoclastic bone resorption on the endosteal surface, the cortex of the bone can begin to thicken as it does with normal growth in individuals unaffected by OI. Mineralization and collagen matrix organization are not directly affected by pamidronate.
REFERENCES: Zeitlin L, Fassier F, Glorieux FH: Modern approach to children with osteogenesis imperfecta. J Pediatr Orthop B 2003;12:77-87.
Falk MJ, Heeger S, Lynch KA, et al: Intravenous bisphosphonate therapy in children with osteogenesis imperfecta. Pediatrics 2003;111:573-578.
Glorieux FH, Bishop NJ, Plotkin H, et al: Cyclic administration of pamidronate in children with severe osteogenesis imperfecta. N Engl J Med 1998;339:947-952.

Question 2:

Options:

Pain during sitting; flexion abduction and external rotation of the hip
Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°
Clicking; abductor lurch
Buttock pain; pain with hip extension, adduction, and external rotation while prone

Correct Answer: Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°

Explanation:

Question 3:

Figures 31a and 31b show the T1- and T2-weighted MRI scans of a patient’s knee joint. What is the most likely diagnosis?

Options:

Torn anterior cruciate ligament
Torn medial meniscus
Staphylococcus infection
Rheumatoid arthritis
Tibial plateau fracture

Correct Answer: Tibial plateau fracture

Explanation:

Question 4:

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 5:

Options:

external fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
external fixation of both fractures.
open reduction and internal fixation of both fractures.
open reduction and the internal fixation of the forearm fracture and functional bracing of the humeral shaft fracture.
application of a long arm cast.

Correct Answer: open reduction and internal fixation of both fractures.

Explanation:

Question 6:

What role does quorum sensing play in the development of a bacterial biofilm?

Options:

Activates genes that produce virulence factors
Creates planktonic bacteria
Facilitates bacterial adhesion to a substrate
Lowers antimicrobial resistance

Correct Answer: Activates genes that produce virulence factors

Explanation:

Question 7:

Options:

Use a constrained acetabular liner
Revise the femoral component to provide greater femoral offset
Revise the femoral head from a 28-mm head size to a 36-mm head size
Revise the acetabular component to 15 degrees of anteversion and 45 degrees of abduction
Perform a greater trochanteric osteotomy to improve soft-tissue tension

Correct Answer: Revise the acetabular component to 15 degrees of anteversion and 45 degrees of abduction

Explanation:

DISCUSSION: The most common cause of recurrent dislocation following total hip arthroplasty continues to be component malposition. Component malposition should be addressed prior to any other treatment options, such as increasing soft-tissue tension with increased femoral offset or greater trochanteric advancement. A larger femoral head size may help, but correcting the component malposition should give more predictable results. A retroverted acetabular component should be revised to 15 degrees to 20 degrees of anteversion, matching the patient’s anatomy with an abduction angle close to 45 degrees.
REFERENCES: Daly PJ, Morrey BF: Operative correction of an unstable total hip arthroplasty. J Bone Joint Surg Am 1992;74:1334-1343.
Jolles BM, Zangger P, Leyvraz PF: Factors predisposing to dislocation after primary total hip arthroplasty: A multivariate analysis. J Arthroplasty 2002;17-282-288.
Hamilton W, McAuley JP: Evaluation of the unstable total hip arthroplasty. Inst Course Lect 2004;53:87-92.

Question 8:

- A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include

Options:

an onlay bone graft
electrical stimulation
resection of the distal clavicle
plate fixation and a bone graft
smooth Kirschner wire fixation and a bone graft

Correct Answer: smooth Kirschner wire fixation and a bone graft

Explanation:

Question 9:

Options:

open reduction and internal fixation of the fragment along with the rectus femoris.
open reduction and internal fixation of the fragment along with the sartorius.
open reduction and internal fixation of the fragment along with the iliopsoas.
rest and protected weight bearing with crutches.
excision of the fragment.

Correct Answer: rest and protected weight bearing with crutches.

Explanation:

Question 10:

- What is the primary immediate source of energy for muscle?

Options:

Glycolytic pathway
Oxidative phosphorylation
Breakdown of fat
Breakdown of protein
Breakdown of adenosine triphosphate

Correct Answer: Breakdown of adenosine triphosphate

Explanation:

Question 11:

Flow cytometry of tumors measures the

Options:

Size of cells
Amount of DNA in cells
Nucleus-cytoplasm ratio
Specific DNA sequences
Specific messenger RNA sequences

Correct Answer: Amount of DNA in cells

Explanation:

Question 12:

Options:

posterior C1-2 fusion.
anterior C2-3 fusion.
Gardner-Wells traction for 6 weeks, followed by 6 weeks of halo vest immobilization.
halo vest immobilization.
a hard collar.

Correct Answer: halo vest immobilization.

Explanation:

Question 13:

Options:

Total shoulder arthroplasty
Hemiarthroplasty with glenoid interposition
Surface replacement hemiarthroplasty
Arthroscopic debridement
Anti-inflammatory drugs and a range-of-motion stretching program

Correct Answer: Anti-inflammatory drugs and a range-of-motion stretching program

Explanation:

Question 14:

Options:

Bone scan
Curettage and bone grafting of the cyst
Cast immobilization
Observation with reduced activity
Skeletal survey

Correct Answer: Observation with reduced activity

Explanation:

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture. It is common in athletic children and is associated with a tight Achilles tendon. Cast immobilization may be necessary if activity reduction fails. Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.
REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis. J Ped Orthop 2004;24:488-492.
Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients. Clin Orthop Relat Res 2004;424:202-210.

Question 15:

Based on the MR arthrogram of the elbow shown in Figure 8, which of the following structures is torn?

Options:

Common flexor tendon
Anconeus
Radial collateral ligament
Ulnar collateral ligament
Lateral ulnar collateral ligament

Correct Answer: Ulnar collateral ligament

Explanation:

Question 16:

Options:

Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy
Total shoulder arthroplasty
Shoulder fusion
Arthroscopic debridement and capsular release
Humeral head resurface arthroplasty

Correct Answer: Nonsteroidal anti-inflammatory drugs, cortisone injection, and physical therapy

Explanation:

DISCUSSION: The patient is a young laborer with osteoarthritis. Initial treatment should begin with nonsurgical management that may include anti-inflammatory drugs, cortisone injections, and physical therapy to diminish pain and improve motion. The other choices may eventually be necessary but should only follow a course of nonsurgical management.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 257-266.
Skedros JG, O’Rourke PJ, Zimmerman JM, et al: Alternatives to replacement arthroplasty for glenohumeral arthritis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 485-499.

Question 17:

Options:

intramedullary rod fixation.
arterial embolization.
skeletal traction and radiation therapy for 2 weeks.
CT of the chest, abdomen, and pelvis, and serum protein electrophoresis.
a skeletal survey and serum protein electrophoresis.

Correct Answer: CT of the chest, abdomen, and pelvis, and serum protein electrophoresis.

Explanation:

Question 18:

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Options:

Medial sided tenderness
Medial sided swelling
Positive cotton test
Medial clear space widening with gravity stress radiographs
Positive squeeze test

Correct Answer: Medial sided tenderness

Explanation:

Question 19:

Options:

Hypoesthesia
Elevated white blood cell count
Elevated C-reactive protein level
Pain disproportionate to the inciting event

Correct Answer: Pain disproportionate to the inciting event

Explanation:

Question 20:

Options:

Complete release of the proximal annular pulley of the flexor sheath
Removal of the nodule in the flexor pollicis longus
Fractional lengthening of the flexor pollicis longus tendon at the musculotendinous junction
Steroid injection into the palpable nodule
No treatment because this condition normally spontaneously resolves

Correct Answer: Complete release of the proximal annular pulley of the flexor sheath

Explanation:

DISCUSSION: The child has a trigger thumb deformity. A trigger thumb is a developmental mechanical problem rather than a congenital deformity. The anomaly generally is not noted at birth. A fixed flexion deformity of the IP joint of the thumb most commonly occurs in children in the first 2 years of life. A stretching and splinting program may correct the deformity in the first year of life, but nonsurgical management after age 3 years results in a success rate of only 50%. Release of the proximal annular pulley of the flexor sheath is recommended at this age.
REFERENCES: Tan AH, Lam KS, Lee EH: The treatment outcome of trigger thumb in children. J Pediatric Orthop B 2002;11:256-259.
Slakey JB, Hennrikus WL: Acquired thumb flexion contracture in children: Congenital trigger thumb. J Bone Joint Surg Br 1996;78:481-483.
Herring JA: Disorders of the upper extremity: Thumb dysplasia, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, p 445.

Question 21:

Options:

Hip arthroscopy and labral debridement
Femoroacetabular osteoplasty and labral repair
Femoral osteotomy
Hemiarthroplasty
Total hip arthroplasty

Correct Answer: Femoroacetabular osteoplasty and labral repair

Explanation:

Question 22:

Options:

Hornblower's Test
Jobe's Test
Apprehension Sign with shoulder abducted and externally rotated
Speed's Test
Kim's Test

Correct Answer: Hornblower's Test

Explanation:

Question 23:

Options:

Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.
Place blocking screws lateral and posterior to the nail. Use a nail with a Herzog curve distal to the fracture site.
Place blocking screws lateral and anterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Correct Answer: Place blocking screws medial and posterior to the nail. Use a nail with a Herzog curve proximal to the fracture site.

Explanation:

Question 24:

Options:

Biceps tear
Bankart lesion
Teres minor avulsion
Suprascapular nerve injury
Superior labrum anterior and posterior tear

Correct Answer: Suprascapular nerve injury

Explanation:

Question 25:

Options:

5 mm
10 mm
15 mm
20 mm
25 mm

Correct Answer: 20 mm

Explanation:

Question 26:

98 degrees (range, 0 degrees to 9 degrees). In knees with varus joint lines

Options:

>4 degrees (normal = neutral), the posterior condylar angle was more internally rotated relative to the transepicondylar axis. Therefore, to prevent internal malalignment using standard components, the femoral component should be more externally rotated relative to the posterior condylar axis in this scenario.
Incorrect Answers:

Correct Answer: >4 degrees (normal = neutral), the posterior condylar angle was more internally rotated relative to the transepicondylar axis. Therefore, to prevent internal malalignment using standard components, the femoral component should be more externally rotated relative to the posterior condylar axis in this scenario.

Question 27:

Options:

Anesthesia in the first dorsal web space
Inability to extend the fingers
Inability to abduct the fingers
Inability to flex the thumb interphalangeal (IP) joint

Correct Answer: Inability to flex the thumb interphalangeal (IP) joint

Explanation:

Question 28:

A 12-year-old boy falls from a bicycle. A radiograph of his injured shoulder is shown in Figure 41. What is the optimal method of treatment?

Options:

Suture of the coracoclavicular ligament
Temporary plate fixation across the acromioclavicular joint
Immobilization in a shoulder spica cast
Sling immobilization
Reduction and temporary intramedullary fixation across the acromioclavicular joint

Correct Answer: Sling immobilization

Explanation:

DISCUSSION: The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.
REFERENCES: Bishop JY, Flatow EL: Pediatric shoulder trauma. Clin Orthop Relat Res 2005;432:41-48.

Question 29:

Options:

Postoperative indomethacin for 3 weeks
Postoperative indomethacin for 6 weeks
No treatment indicated; can treat later if heterotopic bone forms
800 centigrey of radiation given to the periprosthetic soft tissues preoperatively on the morning of surgery
400 centigrey of radiation given to the periprosthetic soft tissues day 2 postoperatively

Correct Answer: 800 centigrey of radiation given to the periprosthetic soft tissues preoperatively on the morning of surgery

Explanation:

Question 30:

Options:

observation.
varus prevention orthoses.
physeal bar resection.
proximal tibial osteotomy that produces a neutral mechanical axis.
proximal tibial osteotomy that produces 10 degrees of valgus.

Correct Answer: proximal tibial osteotomy that produces 10 degrees of valgus.

Explanation:

Question 31:

Reverse total shoulder arthroplasty improves kinematics in the rotator cuff deficient joint by what directional change to the center of rotation? Review Topic

Options:

Medial
Lateral
Posterior
Proximal

Correct Answer: Medial

Explanation:

Question 32:

- Which of the following conditions is associated é the highest mortality in patients é a pelvic fracture?

Options:

Shock from hypovolemia
Associated rupture of the bladder
Arterial bleeding on pelvic angiogram
Presence of a hematoma in the perineum and scrotum
Fractures of both the anterior and posterior pelvic ring

Correct Answer: Shock from hypovolemia

Explanation:

The highest rate of mortality rate after a pelvic fracture is associated with hypovolemic shock. Most of which is secondary to extensive intrapelvic arterial injuries.

Question 33:

Options:

Obtain a menstrual history.
Advise the athlete never to compete in high level endurance sports again.
Obtain serum calcium levels.
Obtain a psychiatric consultation.
Recommend changes in training intensity.

Correct Answer: Obtain a menstrual history.

Explanation:

Question 34:

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Options:

Observation
External beam radiation therapy
Intra-articular radiation therapy
Resection of nodule only
Open complete synovectomy

Correct Answer: Resection of nodule only

Explanation:

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.
J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 35:

What is the main benefit of using metal-backed tibial components in total knee arthroplasty?

Options:

Improve the conformity of the articular surfaces
Reduce the maximum compressive stresses on the underlying cancellous bone
Increase the tensile forces on the other condyle when one is loaded
Decrease the thickness of the polyethylene tray
Decrease the compressive forces on the polyethylene tray

Correct Answer: Reduce the maximum compressive stresses on the underlying cancellous bone

Explanation:

Question 36:

Options:

immobilization for 3 weeks, followed by rehabilitation.
open biceps tenodesis.
arthroscopy with revision stabilization.
arthroscopy with repair of the superior labrum.
subscapularis repair.

Correct Answer: subscapularis repair.

Explanation:

Question 37:

Options:

C5 and C6 spinal roots
Superior trunk
Anterior division of the inferior trunk
Posterior cord
Lateral and posterior cords

Correct Answer: Posterior cord

Explanation:

Question 38:

Options:

needle biopsy of the distal femur.
open reduction and internal fixation with a locking plate.
closed reduction and fixation with a reamed antegrade locking intramedullary nail.
referral to an orthopaedic oncologist for staging studies, biopsy, and definitive management.
IV antibiotics for 6 weeks.

Correct Answer: referral to an orthopaedic oncologist for staging studies, biopsy, and definitive management.

Explanation:

DISCUSSION: The radiograph shows a pathologic fracture through a destructive lesion of the distal femur metaphysis with osteolytic and osteoblastic features. The lateral cortex is destroyed, and there is periosteal new bone formation. These findings are consistent with malignancy, most likely an osteogenic sarcoma. Patients with suspected malignant tumors are best managed by surgeons with specific expertise in orthopaedic oncology. The biopsy of a malignant lesion should be deferred to the surgeon who is capable of definitive management of the patient.
REFERENCES: Enneking W: Principles of musculoskeletal oncologic surgery, in Evarts C (ed): Surgery of the Musculoskeletal System. New York, NY, Churchill Livingston, 1990.
Herring JA: General principles of tumor management, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, from the Texas Scottish Rite Hospital for Children, ed 3. Philadelphia, PA, WB Saunders, 2002, pp 1897-1900.

Question 39:

Options:

Fracture fixation and bracing
Lateral retinacular release with proximal realignment
Tibial component revision
Distal realignment by medialization of the tibial tubercle
Revision of the patellar component

Correct Answer: Lateral retinacular release with proximal realignment

Explanation:

Question 40:

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Options:

chemotherapy and radiation therapy to the femur.
chemotherapy and wide resection.
chemotherapy and above-knee amputation.
hip disarticulation.
wide resection.

Correct Answer: chemotherapy and wide resection.

Explanation:

Question 41:

Options:

Total elbow arthroplasty
Open reduction and internal fixation
Radial head arthroplasty
Sling and swathe
Bone stimulator

Correct Answer: Total elbow arthroplasty

Explanation:

Question 42:

What would be the advantage of surgery for the patient described in this scenario?

Options:

Shorter length of antibiotic therapy
Reduced mortality risk
Reduced risk for neurologic deterioration
Reduced risk for chronic pain

Correct Answer: Reduced risk for neurologic deterioration

Explanation:

DISCUSSION
The MR image of the lumbar spine postgadolinium contrast shows a ring-enhancing fluid collection. Ring-enhancing lesions within the spinal canal on postgadolinium MR images are indicative of epidural abscess. It is important to obtain a culture-specific diagnosis to inform the choice of antibiotics and educate patients regarding the likelihood of failure for standalone antibiotic therapy. Infection with MSSA, age younger than 65 years, the absence of neurologic deficit, and lumbar abscess location are all factors that point toward a patient being a reasonable candidate for a trial of culture-specific IV antibiotics. In this case, nafcillin is a suitable treatment for MSSA. The antibiotic should be initiated and closely observed with serial labs (WBC, ESR, CRP, repeat blood cultures) to ensure that the patient responds appropriately to therapy and that neurologic deficits do not develop. In the setting of epidural abscess, surgery is performed to evacuate the abscess and reverse or prevent neurologic deterioration. In the current scenario in which sepsis is not an issue, scant high-quality evidence shows that surgical intervention influences risk for mortality or chronic pain following epidural abscess.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.
View
Abstract at PubMed
Adogwa O, Karikari IO, Carr KR, Krucoff M, Ajay D, Fatemi P, Perez EL, Cheng JS, Bagley CA, Isaacs RE. Spontaneous spinal epidural abscess in patients 50 years of age and older: a 15-year institutional perspective and review of the literature: clinical article. J Neurosurg Spine. 2014 Mar;20(3):344-9. doi: 10.3171/2013.11.SPINE13527. Epub 2013 Dec 20. Review.
PubMed PMID: 24359002.
View Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014
Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 43:

Which of the following illustrations shown in Figures 21a through 21e correctly shows the projection of the sacroiliac joint on the outer table of the ilium?

Options:

Correct Answer: 21c

Explanation:

Question 44:

Options:

Place the teeth in an ice water bath.
Pour normal saline solution on the teeth and then place them in milk.
Have the player gargle with mouthwash and place the teeth in water.
Clean the teeth with a toothbrush and then reimplant them.
Clean the teeth with a toothbrush and place them on ice.

Correct Answer: Pour normal saline solution on the teeth and then place them in milk.

Explanation:

Question 45:

What nerve is at the highest risk for injury with a percutaneous repair of an Achilles tendon injury?

Options:

Posterior tibial
Calcaneal
Intermediate branch of the superficial peroneal
Lateral plantar
Sural

Correct Answer: Sural

Explanation:

Question 46:

Options:

a base plate with an offset tibial stem attachment.
a bone ingrowth surface on the augment.
a nonstemmed tibial base plate.
allograft bone instead of metal augments.
bone cement to smooth the outline of the proximal medial tibia.

Correct Answer: a base plate with an offset tibial stem attachment.

Explanation:

DISCUSSION: The problem with this reconstruction is the medial protrusion of the base plate. The use of a base plate with an offset stem can prevent the protrusion and thus the impingement and pain. Allograft bone or smoothing the outline with cement would be just as prominent and likely to cause pain. An ingrowth surface may improve soft-tissue attachment but would still leave the implant protruding medially and likely to cause pain. A nonstemmed tibial base plate would lead to less medial protrusion but at the expense of a smaller area for load carriage on the proximal tibia.
REFERENCE: Gustke K: Cemented tibial stems are not requisite in revision. Orthopedics 2004;27:991-992.

Question 47:

Options:

phonophoresis treatment and a program of quadriceps stretching.
application of a hinge, post, and shell design functional knee brace.
application of a hinge, post, and strap design functional knee brace.
an MRI scan of the knee, a CT scan of the chest, a technetium Tc 99m bone scan, liver function tests, and a biopsy of the proximal tibia.
excision of the ossicle and prominence of the tibial tuberosity.

Correct Answer: excision of the ossicle and prominence of the tibial tuberosity.

Explanation:

Question 48:

Options:

Conventional osteosarcoma
Myositis ossificans
Osteochondroma
Parosteal osteosarcoma
Dedifferentiated parosteal osteosarcoma

Correct Answer: Dedifferentiated parosteal osteosarcoma

Explanation:

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

Question 49:

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

Options:

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

Correct Answer: Preservation of external rotation

Explanation:

Question 50:

Options:

Inadequate physical therapy
Exposure of the periosteum of the lateral ulna during surgery
Inappropriate location of the suture anchor
Fixation of the tendon with the forearm fully pronated
Subluxation of the radial head

Correct Answer: Exposure of the periosteum of the lateral ulna during surgery

Explanation:

Question 51:

Options:

Abrasion arthroplasty of the anterior glenoid rim
Posterior capsular advancement into a Hill-Sachs defect
Repair of an inferior glenohumeral ligament detachment
Repair of an unstable SLAP tear
Closure of the rotator interval

Correct Answer: Closure of the rotator interval

Explanation:

Question 52:

Options:

- Nonsurgical treatment with closed reduction and immobilization
- Early mobilization with physical therapy initiated within 2 weeks
- Open reduction and internal fixation (ORIF) with locked implants
- Use of supplemental bone graft or substitutes
- Arthroplasty
- Workup for osteoporosis and counseling

Correct Answer: - Early mobilization with physical therapy initiated within 2 weeks

Explanation:

DISCUSSION
Low-energy fractures in elderly patients typically are treated with nonsurgical care that involves early immobilization followed by early rehabilitation/therapy, especially when proximal humerus and distal humerus fractures are involved. Physical therapy should be initiated within the first 2 weeks. If surgery is needed ORIF is preferred for most fractures, but replacement may improve outcomes for unreconstructable fractures. The use of hemiarthroplasty vs reverse shoulder replacement is currently being debated.
For treatment of distal radius fractures in elderly patients, cast immobilization for about 6 weeks will allow for optimal fracture healing. This should be followed by aggressive therapy to improve range of motion and function. Moderately displaced fractures in elderly patients will result in satisfactory outcomes even though reduction may not be "anatomic."
RECOMMENDED READINGS
Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011 Dec 7;93(23):2146-53. doi: 10.2106/JBJS.J.01597. PubMed PMID: 22159849.
View
Abstract
at PubMed
Tejwani NC, Liporace F, Walsh M, France MA, Zuckerman JD, Egol KA. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):216-9. doi: 10.1016/j.jse.2007.07.016. Epub 2008 Jan 22. PubMed
PMID: 18207430.
View Abstract at PubMed
Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: the effect of initial fracture pattern on outcome. J Orthop Trauma. 2009 Feb;23(2):113-9. doi: 10.1097/BOT.0b013e31819344bf. PubMed PMID:

Question 53:

Options:

High hip center
Anatomic hip center with trochanteric osteotomy and progressive femoral shortening
Anatomic hip center with subtrochanteric shortening osteotomy
Iliofemoral lengthening followed by an anatomic hip center

Correct Answer: Anatomic hip center with subtrochanteric shortening osteotomy

Explanation:

Question 54:

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Options:

AP canal diameter of less than 20 mm
AP canal diameter of less than 50 mm
Cross-sectional area of less than 100 mm2
Cross-sectional area of less than 50 mm2
Circumferential area of less than 25 mm

Correct Answer: Cross-sectional area of less than 100 mm2

Explanation:

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 55:

Options:

Repeat left hip aspiration
Initiation of a wound care consult and oral antibiotics
Irrigation and debridement with closure of the dehisced wound, performance of a liner exchange, and administration of intravenous antibiotics
Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Correct Answer: Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Explanation:

Question 56:

Options:

Home exercise program
Sling at all times until her pain decreases
Closed manipulation under anesthesia
Arthroscopic rotator cuff repair
Arthroscopic anterior and posterior capsular release

Correct Answer: Home exercise program

Explanation:

Question 57:

What is the most specific physical examination finding? Review Topic

Options:

Positive impingement sign
Positive apprehension
Positive active compression
Weakness of external rotation
Weakness of abduction

Correct Answer: Weakness of external rotation

Explanation:

Question 58:

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 59:

Options:

Hallux valgus correction
Custom orthosis to prevent further deformity
Observation only
Steroid injection to decrease inflammation
Extra-depth shoes

Correct Answer: Observation only

Explanation:

Question 60:

Figure 22 shows the radiograph of a 7-year-old boy who underwent retrograde elastic nailing of a femoral shaft fracture. What is the most common problem following this procedure?

Options:

Unacceptable shortening
Osteonecrosis of the femoral head
Malunion
Persistent pain and irritation at the nail insertion site
Rotational malalignment

Correct Answer: Persistent pain and irritation at the nail insertion site

Explanation:

DISCUSSION: Several large clinical studies have shown that the most common problem after elastic nailing of a femoral shaft fracture is persistent pain and irritation at the nail insertion site. Unacceptable shortening and malunion are very rare in a 7-year-old patient. Rotational malalignment also is unusual. Osteonecrosis has been reported in solid antegrade nailing but not with elastic nailing of femoral shaft fractures in skeletally immature patients.
REFERENCES: Flynn JM, Luedtke LM, Ganley TJ, et al: Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86:770-777.
Flynn JM, Hresko T, Reynolds RA, et al: Titanium elastic nails for pediatric femur fractures: A multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4-8.
Ligier JN, Metaizeau JP, Prevot J, et al: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.

Question 61:

Options:

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

Correct Answer: no differences in long-term results.

Explanation:

Question 62:

Options:

profundus and extensor carpi radialis longus.
profundus and extensor carpi radialis brevis.
superficialis and extensor carpi radialis longus.
superficialis and flexor carpi ulnaris.
superficialis and flexor carpi radialis.

Correct Answer: superficialis and flexor carpi ulnaris.

Explanation:

Question 63:

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Options:

Gradual progression of neurologic symptoms
Preventable by restricting return to play until symptom-free
Excellent prognosis for full recovery
Rarely involves brain stem compromise
CT rarely shows brain edema

Correct Answer: Preventable by restricting return to play until symptom-free

Explanation:

Question 64:

- An orthopaedic surgeon who is the developer of a knee arthroplasty system is discussing treatment options with a patient who has tricompartmental osteoarthritis. As a part of this discussion, the orthopaedic surgeon has an obligation to disclose

Options:

The name of the manufacturer
The manufacturer’s potential liability
The physician’s clinical performance
The physician’s materials testing data
Any royalties the physician receives from the manufacturer

Correct Answer: Any royalties the physician receives from the manufacturer

Explanation:

Question 65:

A 14-year-old girl has had progressive heel pain for the past several months. Based on the radiograph, MRI scan, and biopsy specimens shown in Figures 37a through 37d, treatment should include

Options:

observation.
wide resection.
radiation therapy.
extended curettage.
chemotherapy.

Correct Answer: extended curettage.

Explanation:

DISCUSSION: An aneurysmal bone cyst is a benign, locally destructive lesion of bone. Most are seen in patients in the second decade of life. The clinical presentation varies, but most patients have pain, tenderness, swelling, and/or pathologic fracture. Radiographs show a radiolucent lesion sometimes with expansile remodeling of the cortex. MRI best detects the commonly seen fluid-fluid levels associated with this lesion. Histologic findings include
blood-filled spaces with bland fibrous connective tissue septa. The stroma has histiocytes, fibroblasts, scattered giant cells, hemosiderin, and occasional inflammatory cells. Treatment of these lesions consists of extended curettage, plus or minus the use of adjuvants (liquid nitrogen, phenol, argon beam coagulation), and finally filling the bone void (allograft or other bone substitute).
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Ramirez AR, Stanton RP: Aneurysmal bone cyst in 29 children. J Pediatr Orthop 2002;22:533-539.

Question 66:

The iliopectineal fascia runs between which of the following structures?

Options:

Iliopsoas muscle and the iliac vessels/femoral nerve
Lateral femoral cutaneous nerve and the iliac vessels
Iliopsoas muscle/femoral nerve and the iliac vessels
Iliac wing and the iliopsoas muscle
Pubic symphysis and the iliac vessels

Correct Answer: Iliopsoas muscle/femoral nerve and the iliac vessels

Explanation:

DISCUSSION: The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis.
REFERENCES: Masquelet AC, McCullough CJ, Tubiana R: An Atlas of Surgical Exposures of the Lower Extremity. Philadelphia, PA, JB Lippincott, 1993.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 67:

Options:

Chevron osteotomy to correct hallux valgus
Custom orthosis to prevent further deformity
Observation only
Steroid injection to decrease inflammation
Extra-depth shoes

Correct Answer: Chevron osteotomy to correct hallux valgus

Explanation:

Question 68:

Which of the following is accurate regarding low-molecular-weight heparin used for deep venous thrombosis (DVT) prophylaxis in total joint arthroplasty?

Options:

The incidence of thrombocytopenia is lower with low-molecular-weight heparin than with unfractionated heparin.
The half-life of low-molecular-weight heparin is less than that of unfractionated heparin.
Low-molecular-weight heparin affects circulating thrombin (Factor IIa) to a greater extent than unfractionated heparin.
The mechanism of action of low-molecular-weight heparin is primarily by targeting Factor Xa.
There is a significant decrease in postoperative bleeding with the use of low-molecular-weight heparin compared to warfarin.

Correct Answer: The mechanism of action of low-molecular-weight heparin is primarily by targeting Factor Xa.

Explanation:

DISCUSSION: Low-molecular-weight heparin is highly bioavailable with a half-life
to 18 hours. This is greater than the 1 hour half-life of unfractionated heparin.
Low-molecular-weight heparin offers an advantage over unfractionated heparin by selectively targeting Factor Xa while having a lesser effect on circulating thrombin (Factor IIa). Circulating thrombin Factor IIa is needed for local hemostasis at the site of the surgical wound. Clinical studies have shown a reduction by one third in the incidence of thrombocytopenia with the use of low-molecular-weight heparin. Low-molecular-weight heparin has been shown to demonstrate similar clinical results compared to warfarin with respect to preventing thromboembolic disease after total hip arthroplasty and complications such as bleeding.
REFERENCES: Zimlich RH, Fulbright BM, Friedman RJ: Current status of anticoagulation therapy after total hip and total knee arthroplasty. J Am Acad Orthop Surg 1996;4:54-62.
Colwell CW Jr, Spiro TE, Trowbridge AA, et al: Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: A clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994;76:3-14.
Torholm C, Broeng L, Jorgensen PS, et al: Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery: A placebo controlled study. J Bone Joint Surg Br 1991;73:434-438.

Question 69:

Options:

wrist x-ray not initially obtained
x-ray obtained, but MRI necessary for diagnosis not obtained
forearm x-ray initially obtained did not show fracture
CT initially performed, but no 3-D images reconstructed
wrist x-ray initially obtained did not show fracture

Correct Answer: wrist x-ray not initially obtained

Explanation:

Question 70:

Options:

Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.
Site A is the AER. Site A tissue expresses FGF8.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses Shh protein.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses FGF8 protein.
Site A is non-AER ectoderm. Site A tissue expresses WNT7a.

Correct Answer: Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.

Explanation:

Question 71:

A cortisone injection in the subacromial space will most likely result in

Options:

elevated blood glucose levels in patients with diabetes.
increased instability in multidirectional patients.
accelerated rupture of the long head of the biceps.
accelerated osteoporosis of the tuberosity.
altered proprioception of the glenohumeral joint.

Correct Answer: elevated blood glucose levels in patients with diabetes.

Explanation:

Question 72:

Options:

Extension splinting of the proximal interphalangeal and distal interphalangeal joints
Extension splinting of the distal interphalangeal joint
Transarticular pinning of the distal interphalangeal joint
Extension block pinning of the distal interphalangeal joint
Open reduction and internal fixation of the distal phalanx

Correct Answer: Extension splinting of the distal interphalangeal joint

Explanation:

DISCUSSION: The radiograph reveals a “bony mallet injury.” As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate.
REFERENCES: Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.
Bendre AA, Hartigan BJ, Kalainov DM: Mallet finger. J Am Acad Orthop Surg 2005;13:336-344.

Question 73:

Options:

Analysis of variance (ANOVA)
Regression analysis
Student t test
Mann-Whitney U test

Correct Answer: Mann-Whitney U test

Explanation:

Question 74:

- Which of the following rehabilitation methods should be used for the first 24 hours following a blunt injury to the quadriceps musculature to avoid short-term stiffness?

Options:

Heat
Gentle active flexion-extension exercises
Isokinetic strengthening
Electrical muscle stimulation
Immobilization of the limb with the knee in full flexion

Correct Answer: Immobilization of the limb with the knee in full flexion

Explanation:

Question 75:

The main arterial supply to the humeral head is provided by which of the following arteries?

Options:

Anterior humeral circumflex
Posterior humeral circumflex
Thoracoacromial
Subscapular
Deep (profunda) brachial

Correct Answer: Anterior humeral circumflex

Explanation:

Question 76:

Options:

a snug figure-of-8 splint and observation for spontaneous reduction.
closed reduction under general anesthesia.
closed reduction under general anesthesia and percutaneous pinning.
open reduction and capsuloligamentous repair.
open reduction and wire stabilization of the joint.

Correct Answer: closed reduction under general anesthesia.

Explanation:

Question 77:

After humeral head replacement for four-part fractures, what is the most commonly reported difficulty?

Options:

Pain
Inability to carry 10 lb at the side
Inability to wash the opposite axilla
Reaching to the back pocket
Working at shoulder level or above

Correct Answer: Working at shoulder level or above

Explanation:

Question 78:

What is a common clinical finding in patients with severe hypercalcemia secondary to bony metastasis?

Options:

Atrial fibrillation
Seizures
Urinary retention
Muscle weakness
Hyperreflexia

Correct Answer: Muscle weakness

Explanation:

Question 79:

A tendon repair is thought to be weakest during which phase of tendon healing?

Options:

Inflammatory
Proliferation
Maturation
Remodeling

Correct Answer: Inflammatory

Explanation:

Question 80:

Options:

A Vancouver type B1 fracture
Residual leg-length discrepancy
Loosening and subsidence of the femoral stem into anteversion
Loosening and subsidence of the femoral stem into retroversion

Correct Answer: Loosening and subsidence of the femoral stem into retroversion

Explanation:

Question 81:

Options:

use of a sling with no range-of-motion exercises until the condition is stable.
use of a sling and passive range-of-motion exercises within the limits of the repair.
no sling and supine passive range-of-motion exercises.
an internal rotation brace holding the arm at the side.
an external rotation brace holding the arm at the side.

Correct Answer: an external rotation brace holding the arm at the side.

Explanation:

Question 82:

Options:

Transoral, transmucosal direct anterior approach to C2-3
Left-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided posterior retropharyngeal approach to C2-3 (Whitesides)
Right-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Correct Answer: Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Explanation:

Question 83:

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

Options:

Anterior
Anterior and superior
Posterior
Percutaneous pinning
Closed reduction

Correct Answer: Posterior

Explanation:

Question 84:

Figures 14a and 14b show the plain radiographs of an 85-year-old woman who has had severe pain in the right knee for the past 4 months. Management should consist of

Options:

a hinged knee brace.
arthroscopic debridement.
high tibial osteotomy.
total knee arthroplasty.
osteochondral grafts.

Correct Answer: total knee arthroplasty.

Explanation:

Question 85:

Which of the following best characterizes the injury shown in Figure 53? Review Topic

Options:

Stable tear drop extension injury
Facet dislocation
Unstable flexion compression injury
Stable axial load injury
Burst fracture

Correct Answer: Unstable flexion compression injury

Explanation:

Question 86:

Options:

oral antibiotics and a follow-up office appointment the next day.
incision and drainage of the distal fibular metaphysis.
indium-labeled WBC scan.
antituberculous medication for 6 months.
three-phase technetium Tc 99m bone scan.

Correct Answer: incision and drainage of the distal fibular metaphysis.

Explanation:

DISCUSSION: The initial signs and symptoms of acute hematogenous osteomyelitis vary widely but usually include fever, bone pain, and impaired use of the involved extremity. In lower extremity infections, the child may limp or refuse to walk. Examination often reveals bone tenderness. In more advanced cases, erythema, warmth, and swelling may be present. The WBC and neutrophil counts are not always elevated, but the erythocyte sedimentation rate will be abnormal in more than 90% of patients. When the infection is diagnosed early, before a subperiosteal abscess has formed, antibiotics alone may be adequate to treat the infection. This patient has a more advanced infection, however, with the MRI scan revealing a subperiosteal abscess that was confirmed by aspiration. When an abscess is present, surgical drainage is generally indicated to remove devitalized tissue and to enhance the efficacy of the antibiotics. Further studies, such as bone or indium scans, are not necessary and will delay
definitive treatment.
REFERENCES: Scott RJ, Christofersen MR, Robertson WW Jr, et al: Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-652.
Vaughan PA, Newman NM, Rosman MA: Acute hematogenous osteomyelitis. J Pediatr Orthop 1987;7:652-655.

Question 87:

Options:

Gradual return to play
Physical therapy program
Custom orthosis
Non-weight-bearing cast
Weight-bearing AP radiograph

Correct Answer: Weight-bearing AP radiograph

Explanation:

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return
to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 88:

To prevent injury to the posterior interosseous nerve during the approach for reduction and fixation of a fracture of the radial head, anterior retraction should be performed with the forearm

Options:

Maximally pronated and elbow extended
Maximally pronated and the elbow flexed
Maximally supinated and the elbow flexed
Maximally supinated and the elbow extended
In neutral rotation, with the elbow extended

Correct Answer: Maximally pronated and the elbow flexed

Explanation:

Question 89:

Which group experiences the highest rate of anterior cruciate ligament (ACL) tears?

Options:

Female athletes with valgus knee alignment and small femoral notch width
Female athletes with valgus knee alignment and large ACL width
Male athletes with valgus knee alignment and small ACL width
Male athletes with varus knee alignment and small femoral notch width

Correct Answer: Female athletes with valgus knee alignment and small femoral notch width

Explanation:

DISCUSSION
ACL tears are several times more common among women than men. Women who land from jumps in increased valgus and external rotation are at particularly increased risk for ACL tears. Women have smaller notch widths and a smaller ACL cross-sectional area than men, but these factors have not been proven to increase risk for ACL tears.
CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 67
Figure 64 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain.

Question 90:

Options:

Repeat left hip aspiration
Initiation of a wound care consult and oral antibiotics
Irrigation and debridement with closure of the dehisced wound, performance of a liner exchange, and administration of intravenous antibiotics
Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Correct Answer: Debridement of the wound, explant of the total hip, placement of a spacer, and administration of intravenous antibiotics

Explanation:

Question 91:

Options:

Medial ulnar collateral ligament (UCL) (anterior bundle)
Medial UCL (posterior bundle)
Lateral UCL
Annular ligament

Correct Answer: Lateral UCL

Explanation:

Question 92:

Options:

Subtrochanteric osteotomy with femoral shortening
An offset femoral component
A lateralized liner
Extended trochanteric osteotomy

Correct Answer: Subtrochanteric osteotomy with femoral shortening

Explanation:

Question 93:

Options:

Synovial fluid adhesion-cohesion
Negative intra-articular pressure
Concavity-compression of the humeral head in the glenoid
Decreased functional arc of motion as a result of a Hill-Sachs lesion
Poor rehabilitation of scapulothoracic rhythm

Correct Answer: Concavity-compression of the humeral head in the glenoid

Explanation:

Question 94:

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

Options:

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

Correct Answer: No differences in motion and strength

Explanation:

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

Question 95:

A patient who underwent intramedullary nailing of a femoral shaft fracture 2 weeks ago now reports groin pain. What is the next most appropriate step in management?

Options:

Obtain a radiograph of the hip
Obtain radiographs of the lumbar spine
Obtain an MRI scan of the lumbar spine
Review the radiographic report from the time of injury
Reassure the patient that the pain will improve and order physical therapy

Correct Answer: Obtain a radiograph of the hip

Explanation:

Question 96:

Options:

result in increased bone density.
accelerate healing of the femoral fracture.
lower the serum phosphate level.
reduce processing of future bone metastases.
heal other impending fractures.

Correct Answer: reduce processing of future bone metastases.

Explanation:

Question 97:

Which of the following tumors have characteristic chromosomal translocations?

Options:

Ewing’s sarcoma and osteosarcoma
Ewing’s sarcoma and conventional chondrosarcoma
Ewing’s sarcoma and synovial sarcoma
Osteosarcoma and conventional chondrosarcoma
Myeloma and malignant fibrous histiocytoma

Correct Answer: Ewing’s sarcoma and synovial sarcoma

Explanation:

Question 98:

Options:

semiconstrained total elbow arthroplasty.
ulnohumeral arthroplasty and anterior and posterior capsular releases.
closed reduction and external fixation.
open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.
open reduction, heterotopic excision, anterior and posterior capsular releases, and pin fixation across the joint for 3 weeks.

Correct Answer: open reduction, heterotopic bone excision, anterior and posterior capsular releases, and a hinged elbow fixator.

Explanation:

Question 99:

Options:

Supervised hand therapy
Hemi-hamate autograft
Dynamic external fixation
Open reduction and internal fixation (ORIF)

Correct Answer: Hemi-hamate autograft

Explanation:

Question 100:

A 14-year-old boy has an anteromedial distal thigh mass. A radiograph and MRI scan are shown in Figures 39a and 39b. An open biopsy of the mass should include

Options:

bone obtained through a knee arthrotomy with creation of a portal that will be used for retrograde femoral nailing.
bone obtained by going through the mass.
bone obtained through a posterior approach, dissecting out and protecting the sciatic nerve and popliteal artery.
soft tissue obtained through a longitudinal incision centered over the mass.
soft tissue obtained through a transverse incision on the medial thigh.

Correct Answer: soft tissue obtained through a longitudinal incision centered over the mass.

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

OITE & ABOS Orthopedic Board Prep: Fracture, Hip, Knee, Nerve MCQs Part 12

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 12

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index