Orthopedic Board Review MCQs: Upper Extremity & Trauma

About This Board Review Set

This is Part 120 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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Two distinct learning modes are available:

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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 120

This module focuses heavily on: Elbow, Fracture, Shoulder, Wrist.

Sample Questions from This Set

Sample Question 1: Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 de...

Sample Question 2: Which of the following structures may help maintain radial length after a radial head fracture?...

Sample Question 3: Which of the following anatomic structures is labeled 6 in Figure 27?...

Sample Question 4: A 45-year-old woman has had right wrist pain for the past 2 months. A radiograph, bone scan, and MRI scan are shown in Figures 66a through 66c, and a photomicrograph is shown in Figure 66d. What is the most likely diagnosis?...

Sample Question 5: A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nons...

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

Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 degrees of pronation. The interosseous space and distal radioulnar joint are stable. Management should consist of

Explanation

DISCUSSION: The radial head is an important secondary stabilizer of the elbow, helping to resist valgus forces. There has been a movement toward open reduction and internal fixation of the radial head when technically feasible, especially in a relatively high-demand athlete or laborer. The examination and radiograph suggest that displacement of the fragment is great enough to create a mechanical block. Extended splinting would only serve to encourage arthrofibrosis. Early range of motion is appropriate if there is minimal displacement of the radial head fragement, it is stable, and there is no mechanical block to motion. Fragments larger than one third of the joint surface should be excised only if it is not possible to reduce and repair the fragment. Primary excision of the radial head should be avoided if possible. Complications after excision of the radial head include muscle weakness, wrist pain, valgus elbow instability, heterotopic ossification, and arthritis.
REFERENCES: Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.
Esser RD, Davis S, Taavao T: Fractures of the radial head treated by internal fixation: Late results in 26 cases. J Orthop Trauma 1995;9:318-323.

Question 2

Which of the following structures may help maintain radial length after a radial head fracture?

Explanation

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius.
REFERENCES: Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.
Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Question 3

Which of the following anatomic structures is labeled 6 in Figure 27?

Explanation

DISCUSSION: The line labeled 6 points to the A2 pulley. This structure is the condensation of the digital flexor tendon sheath corresponding to the proximal aspect of the proximal phalanx. Grayson’s ligament is volar to the digital nerve and artery. Cleland’s ligament is dorsal to the digital nerve and artery. The sagittal band anchors the extensor tendons over the metacarpophalangeal joints. The triangular ligament connects the lateral bands just proximal to the terminal tendon inserting onto the base of the distal phalanx.
REFERENCES: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, p 467.
Tubiana R, McCullough CJ, Masquelet AC: An Atlas of Surgical Exposures of the Upper Extremity. Philadelphia, PA, JB Lippincott, 1990, p 309.

Question 4

A 45-year-old woman has had right wrist pain for the past 2 months. A radiograph, bone scan, and MRI scan are shown in Figures 66a through 66c, and a photomicrograph is shown in Figure 66d. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph shows a purely radiolucent lesion without matrix mineralization in the epiphysis of the distal radius. The lesion is “hot” on bone scan, and the MRI scan reveals cortical destruction with a soft-tissue mass. These findings are most consistent with giant cell tumor. The distal radius is a common location for giant cell tumors. The other options would be very uncommon in this location in a 45-year-old patient. The photomicrograph demonstrates multinucleated giant cells in a sea of mononuclear cells. The nuclei of the giant cells and the nuclei of the mononuclear stromal cells are identical. This feature helps distinguish giant cell tumor from other lesions that might contain giant cells.
REFERENCES: Cheng CY, Shih HN, Hsu KY, et al: Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221-228.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 263-284.

Question 5

A 59-year-old construction worker who is right-hand dominant has had right shoulder pain for the past 9 months with no history of injury. Nonsurgical management consisting of two cortisone injections, physical therapy for 3 months, and nonsteroidal anti-inflammatory drugs has failed to provide lasting relief. Examination reveals tenderness over the acromioclavicular (AC) joint and over the subacromial bursa. He has positive Neer and Hawkins impingement signs and AC joint pain with adduction of the shoulder. Radiographs are shown in Figures 36a and 36b. An MRI scan reveals an intact rotator cuff. Management should now consist of

Explanation

DISCUSSION: Because the patient has clinical and radiographic signs of AC arthritis and subacromial impingement, the treatment of choice is anterior acromioplasty and distal clavicle excision. Arthroscopic acromioplasty alone would not address the AC arthritis. The rotator cuff is intact; therefore, rotator cuff repair is not indicated. An open Mumford procedure would address the AC arthritis only and not the impingement symptoms. Immobilization might lead to stiffness of the shoulder and is not recommended for treating impingement.
REFERENCE: Peterson CA, Altchek DW, Warren RF: Shoulder arthroscopy, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 290-335.

Question 6

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 7

Figures 22a and 22b show the radiographs of a patient who reports stiffness of the hip and associated pain. Management should consist of

Explanation

DISCUSSION: The patient has grade IV heterotopic ossification with the limb in an abnormal nonfunctional position. Treatment should consist of excision of the bone to restore hip motion and prophylaxis to prevent recurrent formation. The best time to excise the bone is controversial, with no conclusive evidence supporting early or late excision.
REFERENCES: Pellegrini VD Jr, Koniski AA, Gastel JA, Rubin P, Evarts CM: Prevention of heterotopic ossification with irradiation after total hip arthroplasty: Radiation therapy with a single dose of eight hundred centigray administered to a limited field. J Bone Joint Surg Am 1992;74:186-200.
Warren SB, Brooker AF Jr: Excision of heterotopic bone followed by irradiation after total hip arthroplasty. J Bone Joint Surg Am 1992;74:201-210.

Question 8

Figures 9a and 9b show the spinal radiographs of a 3-year-old child with short limb dwarfism. The lateral radiograph is obtained with maximal lumbar extension. Management should consist of

Explanation

DISCUSSION: The patient has kyphosis in association with achondroplasia. The AP radiograph shows decreased interpedicular distance at the lower lumbar vertebrae, a feature considered to be a distinctive sign of achondroplasia. Most patients with achondroplasia have kyphosis, and this usually resolves spontaneously. When the fixed component is greater than 30°, however, brace treatment is recommended. Spinal fusion is seldom required.
REFERENCE: Pauli RM, Breed A, Horton VK, Glinski LP, Reiser CA: Prevention of fixed angular kyphosis in achondroplasia. J Pediatr Orthop 1997;17:726-733.

Question 9

A 63-year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coated titanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 years but has now had two dislocations and reports pain and weakness around the left hip. She denies any fevers, chills, or constitutional symptoms. On examination, the patient walks well without any signs of an antalgic or Trendelenburg gait. Her abductor mechanism demonstrates good strength. Her erythrocyte sedimentation rate and C-reactive protein level are normal. On radiographs, all components appear well fixed and in good alignment. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Trunnionosis is a recently recognized complication following total hip arthroplasty and can occur when a cobalt alloy femoral head is used on a titanium alloy or cobalt alloy femoral stem. Patients often present with pain or swelling around the hip but at times can present with instability. Certain femoral stem designs have been associated with increased reports of trunnionosis. In a patient with a cobalt alloy femoral head who presents with instability, swelling, and weakness around the hip, the potential for trunnionosis and
an adverse local tissue reaction should be considered.

Question 10

Analysis of which of the following proteins is used to establish the diagnosis of Becker muscular dystrophy?

Explanation

Becker muscular dystrophy is an X-linked inherited disorder present in approximately 1 in 30,000 live male births. The responsible gene is located on the xp21 region of the X chromosome including sixty-five exons that encode for the protein dystrophin. Duchenne muscular dystrophy is also related to a mutation of the dystrophin gene. Muscle biopsies for dystrophin have been extremely successful for identifying these dystrophies and distinguishing them from other clinically similar autosomal recessive myopathies. (Ref: Shapiro, Hoffman) Question 18 -
A 25-year-old woman with spastic diplegia has a painful progressive bunion deformity that has failed to respond to nonsurgical treatment. Examination reveals tenderness and erythema over the bunion prominence; however, the hallux metatarsophalangeal joint has full range of motion. A standing AP radiograph shows a hallux valgus angle of 30 degrees and a 1-2 intermetatarsal angle of 13 degrees. Treatment should now consist of
arthrodesis of the hallux metatarsophalangeal joint.
arthrodesis of the first tarsometatarsal joint.
excision of the medial eminence and medial capsular reefing of the metatarsophalangeal joint.
osteotomy of the distal first metatarsal.
proximal metatarsal osteotomy with distal soft-tissue realignment.
Treatment of hallux valgus in a patient with cerebral palsy is largely dependent on the degree of spasticity and the pattern of gait. The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.
The optimal arthrodesis angle is 25-30 degrees, and the metatarsal inclination angle should be 25-30 degrees also. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated WB

Question 11

..The optimal method to treat a recurrent presentation of pigmented villonodular synovitis (PVNS) with diffuse joint involvement in a 24-year-old woman with pain and symptomatic effusions is

Explanation

Question 12

Which of the following is considered a major characteristic of hyaluronate?

Explanation

DISCUSSION: Hyaluronate is a naturally occurring compound that is the backbone of the central core of the proteoglycan aggregate. Cartilage is made of two principal tissue structures. The connective tissue component includes collagen, which forms the framework for structural strength and elasticity. The proteoglycan aggregate provides a unique property of water incorporation and friction reduction capabilities. Hyaluronate forms the base or central core of the aggregate on which a link protein binds a protein core. Chondroitin sulfate and keratin sulfate are then bound to this protein core, forming the terminal extension of the aggregate.
REFERENCES: Callaghan JJ, Dennis DA, Paprosky WA, Rosenberg AG (eds): Orthopedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 69-78.
Felson DT: Osteoarthritis. Rheum Dis Clin North Am 1990;16:499-512.
Hurd ER: Extraarticular manifestations of rheumatoid arthritis. Semin Arthritis Rheum 1979;8:151-176.

Question 13

A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve?

Explanation

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstay of treatment for medial scapular winging.

Question 14

A 32-year-old construction worker reports a persistent burning, tingling sensation on the dorsum of his right foot and significant sensitivity on the plantar surface after a 500-lb steel beam dropped on it 8 weeks ago. Initial radiographs revealed no fractures, and the skin remained intact at the time of injury. Physical therapy, anti-inflammatory drugs, and a serotonin reuptake inhibitor have failed to provide relief. What is the next most appropriate step in management?

Explanation

DISCUSSION: Following failure of physical therapy and pharmacologic management in a patient with complex regional pain syndrome, the management of choice is sympathetic blocks. While continued physical therapy would be assistive, sympathetic blocks allow a more rapid relief of symptoms. Neurostimulation is not appropriate at this stage because of its invasive nature.
REFERENCES: Cepeda MS, Lau J, Carr DB: Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: A narrative and systematic review. Clin J Pain 2002;18:216-233.
Perez RS, Kwakkel G, Zuurmond WW, et al: Treatment of reflex sympathetic dystrophy (CRPS type 1): A research synthesis of 21 randomized clinical trials. J Pain Symptom Manage 2001;21:511-526.
Tran KM, Frank SM, Raja SN, et al: Lumbar sympathetic block for sympathetically maintained pain changes in cutaneous temperatures and pain perception. Anesth Analg 2000;90:1396-1401.
Stanton-Hicks M, Baron R, Boas R, et al: Complex regional pain syndromes: Guidelines for therapy. Clin J Pain 1998;14:155-166.

Question 15

A 6-year-old boy has had increasing pain and a mass in the suprapatellar region of the right femur for the past week. Examination of the mass reveals it may be firm, immobile, and tender to palpitation. The patient has no systemic symptoms. Laboratory studies show a WBC of 7000 per cubic millimeter, a hematocrit of 40%, and an erythrocyte sedimentation rate of 10 mm/hr. radiographs are normal. Figures 64a and 64b show saggital and axial T1-weighted MRI scans. Figure 64c shows frozen section pathology of the biopsy specimen. What is the most likely diagnosis?

Explanation

Multiple hints in this history, MRI and pathology section leads to the diagnosis of soft tissue abscess. The sarcomas are slow growing and mostly are asymptomatic. The mass is tender and enlarging over the past week. PVNS would give the patient a painful boggy joint and this mass is supracondyler. Esinophilic granuloma would give a punched-out lesion in the long bones on the plain radiographs. The best clue is the slide given which shows inflammatory cells. PVNS would show hemosiderin stained giant cells, synovial sarcoma would reveal a biphasic pattern of spindle cells, E.G. would show eosinophils and histiocytes, and rhabdomyosarcoma would have cross striation within the tumor cells.

Question 16

Which of the following best characterizes bone mineralization?

Explanation

DISCUSSION: Mineralization occurs at the site of hole zones between the collagen fibrils. Crystals begin from the necessary ions of the lattice that come together with the correct orientation to form the first stable crystal. Formation of this critical nucleus is the most energy-demanding step of crystallization. Enzymes within the extracellular matrix vesicles degrade inhibitors such as adenosine triphosphate, pyrophosphate, and proteoglycans found in the surrounding extracellular matrix. Bone mineral consists of numerous impurities (carbonate, magnesium) that are more soluble, allowing the bone to act as a reservoir for calcium, phosphate, and magnesium ions. Crystals may form by addition of ions or ion clusters to the critical nucleus in many directions, with ‘kink’ sites forming to branch and exponentially proliferate the crystals. Macromolecules facilitate formation of the critical nucleus and increasing local concentrations of necessary ions. Once the crystals are formed and proliferating, macromolecules bind to the surface and block the growth of the crystal, regulating size, shape, and number of crystals.
REFERENCES: Lian JB, Stein GS, Canalis E, et al: Bone formation: Osteoblast lineage cells, growth factors, matrix proteins, and the mineralization process, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 14-29.
Gehron RP, Boskey AL: The biochemistry of bone, in Marcus R, Feldman D, Kelsey J (eds): Osteoporosis. San Diego, CA, Academic Press, 1996, pp 95-184.

Question 17

Figure 1 is the radiograph of an 18-year-old, right hand-dominant man who has right side thumb pain after a tackle during a rugby game. Examination shows ecchymosis and swelling of the right thumb along with tenderness to palpation about the thumb CMC joint and metacarpal base. What ligament is holding the small fracture fragment in anatomical location to the trapezium?

Explanation

EXPLANATION:
Bennett fractures are defined as intra-articular thumb metacarpal base fractures. The fracture is often caused by axial loading, and concomitant injuries to the thumb MCP joint and trapezium are common. The palmar ulnar aspect of the base of the metacarpal stays in place through its attachment to the trapezium by way of the anterior oblique ligament. The metacarpal shaft is displaced dorsally, proximally, and radially by the pull of the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and adductor pollicis brevis. These fractures are often considered unstable and are treated surgically.

Question 18

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

Explanation

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation; this must be avoided by careful attention to initial resting position and station of the knee.

Question 19

Two major pharmacologic classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The nitrogen-containing compounds work by which of the following actions?

Explanation

Bisphosphonates represent the most clinically important class of antiresorptive agents available to treat diseases characterized by osteoclast-mediated bone resorption. Two classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The non-nitrogen-containing bisphosphonates work by metabolizing into cytotoxic ATP analogs. The nitrogen-containing bisphosphonates work via the mevalonate pathway by inhibiting GTPase formation, leading to loss of GTP prenylation and eventual induction of osteoclast apoptosis.

Question 20

A 21-year-old basketball player inverts his foot during practice. Examination reveals obvious deformity of the hindfoot with a prominence of the talar head dorsolaterally and medial displacement of the forefoot. A radiograph is shown in Figure 17. What is the most likely obstacle to closed reduction?

Explanation

DISCUSSION: The patient has a medial subtalar dislocation. These injuries should be reduced as soon as possible to minimize risk to the skin. Most often, this can be done easily, and further radiographic evaluation then can be performed as necessary. On rare occasions, closed reduction is not possible because of fractures of the articular surface of the talus, navicular, interposed extensor digitorum brevis, or transverse fibers of the cruciate crural ligament. The posterior tibial tendon is the most common obstruction to closed reduction in lateral subtalar dislocations, which are less common than medial dislocations. The majority of both injuries can be managed by closed reduction and immobilization.
REFERENCES: Mulroy RD: The tibialis posterior tendon as an obstacle to reduction of a lateral anterior subtalar dislocation. J Bone Joint Surg Am 1953;37:859-863.
Heckman JD: Fractures and dislocations of the foot, in Rockwood CA, Green DP, Bucholz RW (eds): Fractures in Adults. Philadelphia, PA, JB Lippincott, 1991, pp 2093-2100.
Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.

Question 21

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

Explanation

Herpes simplex virus (HSV) can cause serious outbreaks on athletic teams, especially wrestling. HSV is highly contagious; it is secreted from active blisters, saliva, and mucous membranes. For wrestlers, the NCAA states that the athlete must be free from systemic symptoms and any new blisters for 72 hours before being allowed to participate. Also, all lesions must be dry and crusted and at least 120 hours of antiviral therapy should have been instituted.

Question 22

Figures 1 and 2 demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. Which bearing surface is contraindicated for this patient?

Explanation

DISCUSSION:
THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cell counts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Question 23

Figures 19a through 19c show radiographs of the cervical spine of an asymptomatic patient with Down syndrome who wants to participate in a Special Olympics running event. The neurologic examination is normal. Management should consist of

Explanation

DISCUSSION: An atlanto-dens interval (ADI) of up to 4 mm in children is considered normal. Children with Down syndrome have increased ligamentous laxity, with atlantoaxial instability occurring in as many as 15% to 20% of patients. These patients are at risk for catastrophic injury following minor trauma and should be routinely screened for instability, generally beginning when the patient starts to walk. Patients with an ADI of greater than 5 mm should avoid contact sports and high-risk activities such as gymnastics, diving, the high jump, and the butterfly stroke. The American Academy of Pediatrics Committee of Sports Medicine and Fitness guidelines recommend that lateral views of the cervical spine in neutral, flexion, and extension should be obtained in all children with Down syndrome who wish to participate in sports. Patients with normal radiographs and examinations do not need repeat radiographs, although some authors suggest that instability increases with age, and therefore recommend repeat radiographs every 5 years. Cervical spine fusion in patients with Down syndrome has a high rate of complications and should be performed only on patients with symptoms and evidence of myelopathy.
REFERENCES: American Academy of Pediatrics Committee of Sports Medicine and Fitness: Atlantoaxial instability in Down syndrome. Pediatrics 1995;96:151-154.
Copley LA, Dormans JP: Cervical spine disorders in infants and children. J Am Acad Orthop Surg 1998;6:204-214.
Tredwell SJ, Newman DE, Lockitch G: Instability of the upper cervical spine in Down syndrome. J Pediatr Orthop 1990;10:602-606.

Question 24

A 79-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing right shoulder pain for the past year, and nonsurgical management has failed to provide relief. Her neurologic examination is entirely normal, but she is unable to elevate her arm against gravity. An AP radiograph is shown in Figure 13. Treatment should consist of

Explanation

DISCUSSION: Because the patient has end-stage rheumatoid arthritis with glenoid and rotator cuff deficiency, humeral arthroplasty is the treatment of choice. When a patient has an intact rotator cuff and there is sufficient glenoid bone stock to implant a glenoid component, total shoulder arthroplasty is the preferred method because it appears to provide more predictable pain relief. Glenohumeral arthrodesis is generally avoided when there is a functional deltoid or rotator cuff. Open synovectomy is appropriate in early rheumatoid disease before articular changes are present. Anterior acromioplasty with coracoacromial ligament resection is avoided in patients with rheumatoid arthritis because this procedure compromises the coracoacromial arch and may result in anterosuperior instability.
REFERENCES: Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-337.
Neer CS II: Glenohumeral arthroplasty, in Neer CS II (ed): Shoulder Reconstruction. Philadelphia, PA, WB Saunders, 1990, pp 143-271.
Pollock RG, Deliz ED, McIlveen ST, et al: Prosthetic replacement in rotator cuff deficient shoulders. J Shoulder Elbow Surg 1992;1:173-186.
Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Anderson NH: Total shoulder replacement in rheumatoid arthritis: Proximal migration and loosening. J Shoulder Elbow Surg 1996;5:47-52.

Question 25

Figures 1a and 1b are the recent radiographs of an 82-year-old man with rheumatoid arthritis who underwent total knee arthroplasty (TKA) 18 years ago. These radiographs reveal osteolysis with loosening of the tibial component. Aspiration and laboratory study findings for infection are negative. During the revision TKA, treatment of tibial bone loss should consist of

Explanation

DISCUSSION

Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 26

A B C D E Figures 45a through 45c are the MR images of a 22-year-old woman who has had 6 months of ankle pain related to activities of daily living. She recently completed a course of cast immobilization and protected weight bearing without symptom resolution. Figures 45d and 45e are the intraoperative arthroscopy images after minimal probing. What is the most appropriate treatment?

Explanation

DISCUSSION
The MR images reveal a large cystic medial talar dome osteochondral lesion (OCL) in a patient who has failed nonsurgical treatment. Ankle fusion is inappropriate because the patient has an otherwise normal ankle. Arthroscopic debridement and drilling are appropriate for smaller (< 1.5 cm sq) noncystic lesions. Retrograde drilling and bone grafting is an option in the treatment of cystic OCL if the cartilage surface is intact; however, intraoperative arthroscopy images show that this patient's cartilage surface is unstable. Osteochondral allografts and autografts are effective in the treatment of large cystic talar dome OCLs but are not appropriate for the initial surgical treatment of smaller lesions like this one.
RECOMMENDED READINGS
Hannon CP, Smyth NA, Murawski CD, Savage-Elliott I, Deyer TW, Calder JD, Kennedy JG. Osteochondral lesions of the talus: aspects of current management. Bone Joint J. 2014 Feb;96-B(2):164-71. doi: 10.1302/0301-620X.96B2.31637. Review. PubMed PMID:

Question 27

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient?

Explanation

/
Figure 55a Question 55
A 22-year-old male basketball player has had knee pain for the past 3 months. He denies any history of trauma. He has symptoms of catching but no locking. He has rested for 2 weeks but symptoms returned when he resumed sporting activities. Tr and T2-weighted MRI scans are shown in Figures 55a and 55b. What is the most likely diagnosis?
Locked lateral meniscus tear
Anterior cruciate ligament tear
Ganglion cyst of the anterior cruciate ligament
Synovial osteochondromatosis
Pigmented villonodular synovitis PREFERRED RESPONSE: 3
DISCUSSION: The MRI scans show a cystic structure within the anterior cruciate ligament. It is fluid filled as seen on the T2 sequence. Ganglion cysts of the cruciate ligaments are rare. The most common presentation is pain with occasional loss of motion. Instability is not a chief complaint and often there is no evidence of laxity on examination. If nonsurgical management fails, arthroscopic debridement of the cyst is the accepted method of treatment.
REFERENCES: Liu SH, Osti L, Mirzayan R: Ganglion cysts of the anterior cruciate ligament: A case report and review of the literature. Arthroscopy 1994; 10:110-112.
Parish EN, Dixon P, Cross MJ: Ganglion cysts of the anterior cruciate ligament: A series of 15 cases. Arthroscopy 2005;21:445-447.

Question 28

During cemented total hip arthroplasty, peak pulmonary embolization of marrow contents occurs when the

Explanation

DISCUSSION: Peak embolization is observed during femoral stem insertion. Embolization is also observed during acetabular preparation and hip reduction.
REFERENCES: Lewallen DG, Parvizi J, Ereth MH: Perioperative mortality associated with hip and knee arthroplasty, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 119-127.
Ereth MH, Weber JG, Abel MD, et al: Cemented versus noncemented total hip arthroplasty: Embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992;67:1066-1074.

Question 29

What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint? Review Topic

Explanation

Concavity compression is a stabilizing mechanism by which muscular compression of the humeral head into the glenoid fossa stabilizes the glenohumeral joint against shear forces. This is dependent on the depth of the concavity and the magnitude of the compressive force.

Question 30

A 40-year-old woman who is an avid tennis player reports the insidious onset of progressive left shoulder pain for the past 2 months. Examination reveals full range of motion with a positive impingement sign. Strength in the supraspinatus and infraspinatus muscles is normal, although stress testing is painful. An earlier subacromial cortisone injection provided good, but only temporary relief. An AP radiograph of the left shoulder is shown in Figure 10. Management should now consist of

Explanation

DISCUSSION: The radiograph shows calcific deposits within the substance of the supraspinatus tendon. Patients with this condition are prone to recurrent bouts of acute inflammation in the shoulder. While the response to cortisone injection is often dramatic, repeated injections are not recommended because of injury to the collagen fibers. Good results have been obtained with arthroscopic evacuation of the calcium deposits. In one study, the addition of a subacromial decompression did not improve the results.
REFERENCES: Jerosch J, Strauss JM, Schmiel S: Arthroscopic treatment of calcific tendinitis of the shoulder. J Shoulder Elbow Surg 1998;7:30-37.
Ark JW, Flock TJ, Flatow EL, Bigliani LU: Arthroscopic treatment of calcific tendinitis of the shoulder. Arthroscopy 1992;8:183-188.

Question 31

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true? Review Topic

Explanation

Bundle A is the anteromedial (AM) bundle, which is longer, and is tight in flexion. Bundle B is the posterolateral (PL) bundle, which is shorter, and is loose in flexion. The AM bundle is attached anterior to the PL bundle on the tibia.
The ACL is comprised of 2 bundles. The AM bundle is longer than the PL bundle.
Their names reflect their relative anatomic positions on the tibial insertion site. On the femur, the AM bundle begins at the proximal-anterior aspect of the femoral insertion site, while the PL bundle begins at the posterior-inferior part. In flexion, the AM bundle is tight and the PL bundle is loose. In extension, the AM bundle is loose and the PL bundle is tight.
Bicer et al. reviewed the anatomy of the ACL. They found that the AM bundle was longer (32mm) compared with the PL bundle (18mm). PL bundle carries greater force near full extension, and the AM bundle carries greater force after 15-45° of flexion. Under combined rotatory loads (valgus and internal tibial torque at knee flexion
>30°), the AM bundle bore more force than the PL bundle.
Figure A shows the 2 bundles of the ACL. The AM bundle is longer than the PL bundle. The oft referred to length of ACL refers mainly to the length of the AM bundle. Illustrations A and B show the spatial relationships of the AM and PL bundles in a cadaveric knee. Illustration C shows the relative positions of the attachments of each bundle.
Incorrect

Question 32

A 43-year-old man has had right groin pain for the past 3 months. A radiograph, CT scan, and biopsy specimen are shown in Figures 18a through 18c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographic appearance of the lesion is lytic with calcifications in the supra-acetabular region. The CT scan shows bone destruction and periosteal reaction, which rules out an enchondroma. The histologic appearance is that of cellular cartilage, with a high cytoplasmic:nuclear ratio and basophilic appearance to the cytoplasm; these findings rule out chordoma and metastatic renal cell carcinoma. In addition, chordomas are most frequently found in the sacrum and base of the skull. Because there is no high-grade spindle cell component to suggest dedifferentiation, the most likely diagnosis is chondrosarcoma.
REFERENCES: Pring M, Weber KL, Unni K, Sim FH: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 71-92.

Question 33

One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?

Explanation

DISCUSSION
Dysphagia after anterior cervical diskectomy and fusion is a common, usually transient finding after anterior cervical approaches to the spine. While it has been reported to occur in up to 70% of patients 2 weeks following surgery, in most cases the symptoms quickly resolve. There is, however, a small subset of patients for whom symptoms of dysphagia will persist. Lee and associates prospectively studied the rate of dysphagia after anterior cervical diskectomy and fusion, reporting a 15% rate of dysphagia at 12 months, and 12% at 24 months. Phillips and associates analyzed the 2-year data from the PCM FDE clinical trial and found a 12.1% incidence of dysphagia in the ACDF arm.
RECOMMENDED READINGS
Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Spine J. 2007 Mar-Apr;7(2):141-7. Epub 2007 Jan 22. PubMed PMID: 17321961. View Abstract at PubMed
Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936. View Abstract at PubMed
Edwards CC 2nd, Karpitskaya Y, Cha C, Heller JG, Lauryssen C, Yoon ST, Riew KD. Accurate identification of adverse outcomes after cervical spine surgery. J Bone Joint Surg Am. 2004 Feb;86-A(2):251-6. PubMed PMID: 14960668. View Abstract at PubMed
Phillips FM, Lee JY, Geisler FH, Cappuccino A, Chaput CD, DeVine JG, Reah C, Gilder KM, Howell KM, McAfee PC. A prospective, randomized, controlled clinical investigation comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. 2-year results from the US FDA IDE clinical trial. Spine (Phila Pa 1976). 2013 Jul 1;38(15):E907-18. doi: 10.1097/BRS.0b013e318296232f.
Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011 Mar;469(3):658-65. PMID: 21140251.View Abstract at PubMed

Question 34

An otherwise healthy adolescent girl was treated for left slipped capital femoral epiphysis. The contralateral hip had not slipped, but was stabilized prophylactically with a single cannulated screw. The implants were removed after 1 year. The pelvic radiographs (Figures 215a and 215b) and the MRI scans of the hip that had not originally slipped (Figures 215c through 215e) were obtained 10 months after screw removal (22 months after the original fixation). Which findings are shown in these studies?

Explanation

Question 35

A 3-year-old child sustains a T2/T3 fracture-dislocation with complete paraplegia secondary to a car accident in which the child was an unrestrained passenger. What is the likelihood that this child will develop subsequent spinal deformity in the future? Review Topic

Explanation

More than than 90% of preadolescent children who sustain a significant spinal cord injury subsequently develop scoliosis. Conversely, progressive paralytic spinal deformity is uncommon in the postadolescent patient. Bracing has not been shown to be effective in the prevention of scoliosis in the preadolescent patient with spinal cord injury.

Question 36

The lesion seen in Figure 4 is most likely the result of metastases from what solid organ?

Explanation

DISCUSSION: The primary carcinoma most likely to metastasize distal to the elbow and knees is lung carcinoma. Renal cell carcinoma can also metastasize to distal sites. Most metastatic bone disease occurs in the vertebral bodies, pelvis, and proximal long bones.
REFERENCES: Simon MA, Bartucci EJ: The search for the primary tumor in patients with skeletal metastases of unknown origin. Cancer 1986;58:1088-1095.
Leeson MC, Makley JT, Carter JR: Metastatic skeletal disease distal to the elbow and knee. Clin Orthop 1986;206:94-99.

Question 37

What is the most common complication following surgical fixation of a distal humeral fracture?

Explanation

DISCUSSION: In most series, elbow stiffness is the most common complication and can be overcome by achieving stable fixation and initiating early motion after surgery. All of the other complications are seen but to a lesser degree than elbow stiffness.
REFERENCES: Sanders RA, Raney EM, Pipkin S: Operative treatment of bicondylar intra-articular fractures of the distal humerus. Orthopedics 1992;15:159-163.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 397-404.

Question 38

Figures 9a and 9b show the radiographs of a 12-year-old girl who has had right hip pain for the past 4 months. She reports that the pain is so severe that she is unable to walk and is now using a wheelchair. Examination reveals pain with any attempted range of motion. Management should include

Explanation

DISCUSSION: In addition to mild hip dysplasia, the radiograph shows an osteoblastic lesion of the right ilium. The patient’s symptoms are much more severe than is typical for late hip dysplasia. MRI can determine the extent of the lesion in the bone and soft tissues. Following work-up and biopsy, the patient was diagnosed with Ewing’s sarcoma.
REFERENCES: Springfield DS, Gebhardt MC: Bone and soft tissue tumors, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 507-518, 542-544.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

p 2030.

Question 39

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Explanation

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462. View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381. View Abstract t PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303. View Abstract at PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803. View Abstract at PubMed Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228. View Abstract at PubMed

Question 40

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

Explanation

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

Question 41

Intermittent daily administration of recombinant parathyroid hormone (rhPTH) is an FDA-approved treatment for osteoporosis. Intermittent rhPTH treatment targets which of the following cells in osteoporotic patients?

Explanation

PTH is an anabolic agent that enhances osteoblastic bone formation on both cortical and cancellous surfaces. It is synthesized in the parathyroid glands as a 115 amino acid precursor and is cleaved into the active 84 amino acid form. The biological activity in the clinically used recombinant PTH is in the 1-34 amino acid sequence at the N-terminus of the molecule. There are PTH receptors expressed by osteoblasts that mediate the anabolic bone response to intermittent PTH administration. Chronic elevation of PTH leads to stimulation of osteoclasts, producing bone loss.

Question 42

Figure 17 shows the radiograph of an 82-year-old right-hand dominant woman who fell while weeding her garden. She has severe right shoulder pain. She is neurovascularly intact. What is the most appropriate treatment? Review Topic

Explanation

The patient has a displaced four-part proximal humerus fracture. The humeral head is displaced and if allowed to heal in this position, the patient will likely have a stiff and painful shoulder. The humerus is at risk for osteonecrosis given the displacement of the fracture. Given a patient age of 82 years, replacement options of either hemiarthroplasty or reverse total shoulder arthoplasty, allow maximal restoration of function. Physical therapy is not indicated in this acute fracture. Closed reduction techniques will not be successful in this displaced fracture.

Question 43

A 17-year-old high school football player reports wrist pain 5 months after the conclusion of the football season. A radiograph and MRI scan are shown in Figures 29a and 29b. What is the recommended intervention?

Explanation

DISCUSSION: The patient has a nonunion of the proximal pole of the scaphoid. Acutely, this can be repaired with a screw alone, but as a nonunion the proximal pole has very poor healing potential. Vacularized bone grafts have been successful for these challenging nonunions, particularly in adolescents. A cast can be used for nondisplaced acute waist fractures, and corticocancellous grafts can be used for nonunions of the waist.
REFERENCES: Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920.
Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002;27:391-401.

Question 44

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Explanation

DISCUSSION: Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.
Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of compartment syndrome."
Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

Question 45

Which of the following conditions is most likely inherited as an autosomal dominant trait?

Explanation

Postaxial polydactyly involves polydactyly of the little finger, preaxial polydactyly usually involves the thumb or the index finger. Postaxial polydactyly is further divided into Type A, in which the well formed extra digit artier with the fifth or an extra metacarpal and Type B, a small extra digit that is poorly formed and often is little more than a skin tag. Postaxial polydactyly is inherited as an autosomal dominant trait with marked penetrance.

Question 46

A 17-year-old high school football player is seen for follow-up after sustaining an injury 3 days ago. He reports that he tackled a player, felt numbness throughout his body, and could not move for approximately 15 seconds. A spinal cord injury protocol was initiated on the field. Evaluation in the emergency department revealed a normal neurologic examination and full painless neck motion. He states that he has no history of a similar injury. An MRI scan of the cervical spine is normal. During counseling, the patient and his family should be informed that he has sustained

Explanation

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro AR, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 47

A 30 year-old male is involved in a motor vehicle collision and sustains a scapular fracture. In patients with scapular fractures, what other fracture is MOST commonly observed?

Explanation

Intramedullary nail
Hemiarthroplasty
Closed reduction percutaneous pinning
Total hip arthroplasty
Sliding hip screw
At baseline, with minimal ambulatory status and dependence on a 24-hour home health aide, the best treatment choice is hemiarthroplasty.
Arthroplasty is the gold standard for displaced femoral neck fractures in the elderly. In community ambulators with relative independent lives, total hip arthroplasty (THA) is recommended. For minimal ambulator, hemiarthroplasty is recommended.
van den Bekerom et al. randomized 252 patients over 70-years-old to either THA or hemiarthroplasty for displaced femoral neck fractures. With increased blood loss, operative time and dislocation risk, they did not recommend THA unless there was good preoperative ambulatory status, and/or pre-existing osteoarthritis or rheumatoid arthritis.
Figure A exhibits a displaced femoral neck fracture Incorrect answers:

Question 48

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

Explanation

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

Question 49

Figures 1 through 6 reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures. What is the most appropriate treatment?

Explanation

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation. The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter collagen fibrils, oriented perpendicular to the joint surface, and the highest concentration of proteoglycans.

Question 50

Figure 4a shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 4b shows an arthroscopic view (posterior portal). The arrow points to a

Explanation

DISCUSSION: The radiograph shows an anterior dislocation of the shoulder. A frequently encountered sequela of this is a compression fracture of the posterolateral humeral head, commonly referred to as a Hill-Sachs defect. The arthroscopic view of the glenohumeral joint visualizes the posterior aspect of the humeral head. In the image, the area devoid of cartilage to the right is the bare area. The indentation seen to the left is a Hill-Sachs defect.
REFERENCES: Matsen FA, Thomas SC, Rockwood CA, et al: Glenohumeral instability, in Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998,

pp 611-754.
Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principals of techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.

Question 51

In the evaluation of somatosensory-evoked potential waveforms for intraoperative neuromonitoring for spinal surgery, the minimum criteria for determining potentially significant changes include Review Topic

Explanation

The established criteria for interpreting a significant change are 50% decrease in signal amplitude, 10% latency increase, and/or a complete loss of potential. Intraoperative spinal cord monitoring during spinal surgery generally consists of a combination of monitoring modalities. Somatosensory-evoked potentials in combination with intraoperative electromyography can provide adequate coverage of sensory and motor components of spinal cord and nerve root function. Significant changes in evoked potential waveform characteristics can reflect dysfunction of the ascending somatosensory system.

Question 52

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

Explanation

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

Question 53

Which of the following methods is effective in correcting recurrent dislocation following total hip arthroplasty?

Explanation

DISCUSSION: Recurrent dislocation following total hip arthroplasty is a difficult problem to correct. Studies conducted by the Mayo Clinic show a failure rate of close to 40% with surgical treatment. A variety of methods have been successful, but no specific approach has been reported to be the most predictably successful. To select and institute the proper treatment option, the cause of the dislocation must be identified. Surgical options fall into several broad categories that include increasing soft-tissue tension (trochanteric advancement or longer neck lengths) or more stable articulation (larger diameter head component, bipolar prosthesis, or a constrained component). In a series of total hip arthroplasties done with a constrained cup, the loosening rates of the cup and the stem were reported to be 6% each, comparable to a reported series of complex revision total hip arthroplasties at a similar follow-up interval.
REFERENCES: Woo RY, Morrey BF: Dislocations after total hip arthroplasty. J Bone Joint Surg Am 1982;64:1295-1306.
Goetz DD, Capello WN, Callaghan JJ, Brown TD, Johnston RC: Salvage of a recurrently dislocating total hip prosthesis with use of a constrained acetabular component: A retrospective analysis of fifty-six cases. J Bone Joint Surg Am 1998;80:502-509.

Question 54

In performing an opening wedge high tibial osteotomy at the tibial tubercle, the osteotome extends 5 mm posteriorly and centrally out of the bone as shown in Figures 17a and 17b. What is the first structure it enters?

Explanation

DISCUSSION: The major risk of performing a high tibial osteotomy is neurovascular injury. The new version of the high tibial osteotomy makes a transverse osteotomy at the level of the tibial tubercle. The osteotome is protected by the oblique belly of the popliteus muscle. The popliteal artery and vein and tibial nerve all lie posterior to the muscle. The soleus muscle originates below this level.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 422.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 480.

Question 55

A 54-year man has left shoulder pain and weakness after falling while skiing 4 months ago. Examination reveals full range of motion passively, but he has a positive abdominal compression test and weakness with the lift-off test. External rotation strength with the arm at the side and strength with the arm abducted and internally rotated are normal. MRI scans are shown in Figures 1a and 1b. Treatment should consist of

Explanation

DISCUSSION: The examination findings are consistent with subscapularis muscle weakness but normal supraspinatus and infraspinatus strength. The lift-off test and abdominal compression test are specific for subscapularis function. The MRI scan reveals a chronic avulsion and retraction of the subscapularis. The transverse image reveals a normal infraspinatus muscle, and the sagittal image reveals an atrophic subscapularis. Surgical repair of the isolated subscapularis tendon is indicated.
REFERENCES: Iannotti JP, Williams GR: Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 31-56.
Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon: Results of operative treatment. J Bone Joint Surg Am 1996;78:1015-1023.

Question 56

Six weeks after open reduction internal fixation of a closed tibial pilon fracture, a patient has a draining wound with surrounding erythema and swelling. Radiographs show lucency around screws. What is the most appropriate treatment sequence?

Explanation

Discussion: Management of acutely infected wounds is primarily surgical. Osteomyelitis frequently involves Orthopaedic hardware, which would ideally be removed or replaced given biofilm involvement. Multiple operative cultures of fluid collections, soft tissues and bone should routinely be obtained. Culture yield is highest if cultures are obtained before empiric antibiotic treatment is started. Tissue samples are greatly preferred to swabs, which are notoriously inaccurate.

Question 57

A 77-year-old woman who underwent total knee arthroplasty 16 years ago now reports pain, swelling, and notable crepitation with range of motion. AP, lateral, and Merchant radiographs are shown in Figures 54a through 54c. What is the most likely diagnosis?

Explanation

DISCUSSION: The Merchant radiograph shows a lateral patellar shift with total polyethylene failure, resulting in a metal-on-metal bearing. This problem is associated with metal-backed patellar components. Component fixation appears solid, and no osteolysis is evident.
REFERENCES: Poss R (ed): Orthopaedic Knowledge Update 3. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 590-593.
Leopold SS, Berger RA, Patterson L, et al: Serum titanium level for diagnosis of a failed metal-backed patellar component. J Arthroplasty 2000;15:938-943.
Frymoyer JW (ed): Orthopaedic Knowledge Update 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1993, pp 613-614.

Question 58

A 66-year-old patient with type 1 diabetes mellitus has a deep, nonhealing ulcer under the first metatarsal head and a necrotic tip of the great toe. He has been under the direction of a wound care clinic for 4 months, and has had orthotics and shoe wear changes. What objective findings are indicative of the patient’s ability to heal the wound postoperatively?

Explanation

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.

A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 59

A 48-year-old woman with a history of a spinal cord injury as a teenager, has unilateral weakness in the left lower extremity. She has used an ankle-foot orthosis for many years without difficulty but recently has had a recurrent painful callus beneath the great toe that has been recalcitrant to nonsurgical management. Examination reveals intact sensation with an intractable plantar keratosis (IPK) beneath the first metatarsal head. Motor examination reveals no active ankle or great toe dorsiflexion, and 4/5 plantar flexion strength at the ankle and great toe. Passive ankle dorsiflexion is 10 degrees, whereas passive plantar flexion is 40 degrees. Passive great toe dorsiflexion is 30 degrees and plantar flexion is 10 degrees. Foot alignment on standing is normal. Radiographs are shown in Figures 47a and 47b with a marker beneath the IPK. Based on her request for surgical treatment, what is the most appropriate procedure?

Explanation

DISCUSSION: Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure.
REFERENCES: Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627.
Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.
Richardson EG: Hallucal sesamoid pain: Causes and surgical treatment. J Am Acad Orthop Surg 1999;7:270-278.

Question 60

Which of the following agents increases the risk for a nonunion following a posterior spinal fusion?

Explanation

DISCUSSION: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to increase the risk of pseudarthrosis. In a controlled rabbit study, nonunions were reported with the use of toradol and indomethacin. NSAIDs are commonly used medications with the potential to diminish osteogenesis. Studies clearly have demonstrated inhibition of spinal fusion following the postoperative administration of several NSAIDs, including ibuprofen. Cigarette smoking is another potent inhibitor of spinal fusion.
REFERENCES: Glassman SD, Rose SM, Dimar JR, et al: The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine 1998;23:834-838.
Martin GJ Jr, Boden SD, Titus L: Recombinant human bone morphogenetic protein-2 overcomes the inhibitory effect of ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), on posterolateral lumbar intertransverse process spine fusion. Spine 1999;24:2188-2193.

Question 61

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

Explanation

Question 62

With increasing abduction in the scapular plane, maintaining neutral rotation, contact area, and contact pressure per unit area between the humeral head and glenoid follows what pattern if the total load across the joint is held constant?

Explanation

DISCUSSION: The glenohumeral joint becomes more congruent at higher levels of abduction. As a consequence, contact area increases. As the load is spread more evenly across the joint, contact pressure per unit area decreases as long as the total load across the joint is held constant.
REFERENCES: Warner JJP, Bowen MK, Deng XH, et al: Articular contact patterns of the normal glenohumeral joint. J Shoulder Elbow Surg 1998;7:381-388.
Greis PE, Scuderi MG, Mohr A, et al: Glenohumeral articular contact areas and pressures following labral and osseous injury to the anteroinferior quadrant of the glenoid. J Shoulder Elbow Surg 2002;11:442-451.

Question 63

A 21-year-old football player who sustained a direct blow to the posterior hindfoot while making a cut is unable to bear weight on the injured foot. Examination reveals tenderness and swelling of the great toe metatarsophalangeal (MTP) joint. Radiographs are shown in Figures 9a and 9b. What is the most likely diagnosis?

Explanation

DISCUSSION: Turf toe occurs in collision and contact sports in which the athlete pushes off to accelerate or change direction and there is hyperextension of the great toe MTP joint. Typically, there is also axial loading of the posterior hindfoot, which increases the hyperextension of the MTP joint. The most common presentation is pain and swelling of the MTP joint and inability to hyperextend the joint without significant symptoms. With significant force, fractures of the sesmoids and plantar soft tissues can occur. The radiographs do not show a dislocation of the great toe MTP joint because it is concentrically located on both radiographs. However, the radiographs show a fracture of the lateral sesamoid or a diastasis of a bipartite lateral sesamoid. The medial sesamoid is also proximal indicating a rupture of the plantar (volar) plate. Therefore, the most likely diagnosis is a fracture of the lateral sesamoid with rupture of the plantar plate leading to proximal migration of the proximal fragment of the lateral sesamoid and the medial sesamoid.
REFERENCES: Rodeo SA, et al: Diastasis of bipartite sesamoids of the first metatarsophalangeal joint. Foot Ankle 1993;l4:425-434.
Rodeo SA, O’Brien S, Warren RF, et al: Turf toe: An analysis of metatarsal joint sprains in professional football players. Am J Sports Med 1990;18:280-285.

Question 64

EXT1

Explanation

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following would be the most appropriate treatment:

Question 65

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

Explanation

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

Question 66

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 67

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete’s shoulder?

Explanation

DISCUSSION: The goal in the initial phase of shoulder rehabilitation is to improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. In the advanced strengthening and final phase, the goals are to initiate aggressive strengthening drills, enhance power and endurance, perform functional drills, and to gradually initiate throwing activities.
REFERENCES: Wilk KE, Meister K, Andrews JR: Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med 2002;30:136-151.
Wilk KE, Arrigo C: Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports Phys Ther 1993;18:365-378.

Question 68

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Explanation

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common non-anesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery. Pedicle screw malpositioning, spinal cord ischemia, and retractor placement are all less common causes. Hypotension, not hypertension, can be a cause of intraoperative neurophysiologic changes.

Question 69

Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best next treatment step?

Explanation

Question 70

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

Explanation

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.

J Arthroplasty 2003;18:792-798.

Question 71

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

Explanation

DISCUSSION
Cauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.
RECOMMENDED READINGS
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744. View Abstract at PubMed
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636. View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80
Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.

A B

Question 72

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Explanation

What is the most common organism implicated in periprosthetic infection of the shoulder?
A. Methicillin-resistant Staphylococcus aureus (MRSA)
B. Cutibacterium acnes
C. Enterococcus species
D. Staphylococcus epidermidis
C acnes is the most common organism recovered in prosthetic shoulder infections (33%), Coagulase-negative Staphylococcus is second (21%), Methicillin-sensitive S aureus (13%), and S epidermidis (10%). MRSA accounts for 5% and Enterococcus species, 1.5%.

Question 73

The nucleus pulposus of the intervertebral disk consists of chondrocyte-like cells that have a limited vascular supply and generate energy through which of the following?

Explanation

The intervertebral disk is an avascular structure in the adult. Nucleus pulposus cells have a critical need for glucose because they obtain their energy primarily by glycolysis, even in the absence of oxygen. Disk cells do not require oxygen to remain alive but they die at low glucose levels or acidic pH. Nutrients are supplied from the blood vessels at the margins of the disk and have to traverse the cartilaginous end plate to reach the disk cells. The loss of the nutrient supply through the vertebral body will starve the cells in the disk center and may be a major factor in disk degeneration.

Question 74

Anterior subluxation in a throwing athlete is most commonly the result of

Explanation

DISCUSSION: Subtle anterior subluxation in the throwing athlete most frequently results from excessive capsular laxity because of repetitive microtrauma. Avulsion of the inferior glenohumeral ligament from the glenoid, or more rarely from the humerus, occurs with macrotrauma. A large Hill-Sachs lesion and a glenoid rim fracture also may result from a traumatic anterior dislocation.
REFERENCES: Kvitne RS, Jobe FW: The diagnosis and treatment of anterior instability in the throwing athlete. Clin Orthop 1993;291:107-123.
Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1999, pp 961-990.

Question 75

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 76

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Explanation

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,

ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 77

Figure 35 shows a postoperative radiograph of a femur fracture proximal to a total knee prosthesis that was treated by open reduction and blade plate fixation 9 months ago. What is the most likely reason the previously well seated screw has backed out of the central portion of the plate?

Explanation

[Radiograph: An A-P view of the distal femur. There is patchy increased radiodensity in the mid-plate region at the level of the fracture, which was just distal to the middle-distal third junction. The screw in the middle hole of the plate has backed out approximately 1 cm. There is no obvious fracture line at this time. The lateral cortex is not intact.]
The referenced article clearly states that the major cause of failure of fractures to heal is nonunion. From the radiograph it appears the screw at one time was long enough. While the distal fragment perhaps has some disuse osteopenia there is no focal area of what could be considered osteonecrosis. We are not given any history of possible infection even though this could be the case.

Question 78

A 15-year-old girl with a midshaft fibular lesion has histologic findings consistent with Ewing’s sarcoma. Following induction chemotherapy, local control typically consists of

Explanation

DISCUSSION: The current treatment regimen for Ewing’s sarcoma typically involves induction chemotherapy followed by local control and further chemotherapy. Local control consists of surgery only, radiation therapy only, or a combination of the two. In bones that are easily resectable (expendable) with wide margins, surgery is usually recommended. For areas that cannot be resected (ie, large bulky pelvic tumors), radiation therapy alone is sometimes the preferred method of local control. If surgery is chosen and the margins are close, radiation therapy can be used as an adjuvant treatment. Amputation is rarely required for an isolated fibular lesion. Observation without adequate local control results in local recurrence.
REFERENCES: Nesbit ME Jr, Gehan EA, Burgert EO Jr, et al: Multimodality therapy for the treatment of primary, non-metastatic Ewing’s sarcoma of the bone: A long-term follow-up of the first intergroup study. J Clin Oncol 1990;8:1664-1674.
Simon M, Springfield D, et al: Ewing’s Sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 296.

Question 79

A 24-year-old man sustains the injury shown in Figures 19a through 19e in a paragliding accident. He is neurologically intact. He also sustained fractures of his left femur and right distal radius. Which of the following represents the best option for management of the spinal injury?

Explanation

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.

J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 80

Figures 20a and 20b show the AP and lateral radiographs of a 62-year-old man who has had hip pain for the past 3 weeks. Figure 20c shows a CT scan of the abdomen and pelvis. A needle biopsy specimen is shown in Figure 20d. Preoperative management should include which of the following?

Explanation

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 81

A Spanish speaking child sustained the injury seen in Figure A after a fall at school. He was casted in the emergency department without the assistance of an interpreter and advised to return to see an orthopaedic surgeon in 1 week. However, the family returns to the emergency department with the child 3 months later, still in the cast. What is the most likely reason the child did not attend the recommended orthopaedic follow-up visit.?

Explanation

The most likely reason the child did not attend the recommended orthopaedic followup visit was a language barrier preventing effective communication of the intended follow-up instructions.
Communication skills and cultural competence is a key element in good orthopaedic care. Poor communication can often lead to devastating outcomes. In this example, poor communication resulted in this patient being lost to follow-up. Language barriers must be accommodated and alternative methods of communication must be utilized.
Levinson et al. examined how patients present their medical issues in clinical encounters and how physicians respond to these clues in routine primary care and surgical settings. They showed that good communication relies mostly on the physicians ability to identify patient clues within the clinical encounter. Poor communication between the physician tended to delay clinical visits, poor follow-up and unsatisfactory outcomes.
Figure A is an AP radiograph of the elbow in a skeletally immature patient. Figure B is a lateral radiograph of the elbow with a posterior fat pad sign, suggestive of an occult fracture.
Incorrect Answers:

Question 82

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Explanation

Question 83

What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?

Explanation

DISCUSSION: Traditional surgeries for anterior cruciate ligament-deficient knees carry the potential risk of premature physeal closure in young athletes. Therefore, most surgeons are reluctant to recommend intra-articular reconstruction using bone tunnels with bone-patellar tendon-bone autografts or hamstring tendons. The current recommendation for young athletes is activity modification, rehabilitation, and functional bracing until the patient is near skeletal maturity. At that time, for the very symptomatic patient, the treatment of choice is intra-articular repair of the anterior cruciate ligament. If a skeletally immature patient continues to have instability despite rehabilitation and bracing, a modification of the femoral tunnel to the over-the-top position will not place the lateral femoral physis at risk for premature closure and deformity. A centrally placed tibial tunnel will minimize the risk of angular deformity and minimize limb-length discrepancy if physeal arrest occurs.
REFERENCES: Barry P: Anterior cruciate ligament injuries, in Andrews JR, Timmerman LA (eds): Diagnostic and Operative Arthroscopy. Philadelphia, Pa, WB Saunders, 1997, p 358.
McCarroll JR, Shelbourne KD, Porter DA, Rettig AC, Murray S: Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes: An algorithm for management. Am J Sports Med 1994;22:478-484.
Nottage WM, Matsuura PA: Management of complete traumatic anterior cruciate ligament tears in the skeletally immature patient: Current concepts and review of the literature. Arthroscopy 1994;10:569-573.
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158.

Question 84

Figure 1 shows the radiograph obtained from a 67-year-old man recently diagnosed with osteoarthritis, 8 years after receiving a left metal-on-metal total hip arthroplasty (THA). The acetabular component has a modular cobalt alloy acetabular liner. The patient states that he did very well postoperatively, but for the last 6 months has noted worsening pain and swelling in his left hip. Serum metal ion testing reveals a chromium level of 12.4 ng/mL, compared with a normal level of less than 0.3 ng/mL, and a cobalt level of 11.8 ng/mL, compared with a normal level less than 0.7 ng/mL. An MRI with metal artefact reduction sequence (MARS) was performed and is shown in Figure 2. What is the most appropriate management at this time?

Explanation

DISCUSSION:
Metal-on-metal THA was initially introduced in the 1990s, with the proposed advantages of decreased wear and improved stability. However, catastrophic adverse local tissue reactions associated with their use has raised numerous concerns. The work-up of a patient with a prior metal-on-metal total hip arthroplasty involves a thorough history and physical examination; blood analysis, including the erythrocyte sedimentation rate, C-reactive protein, and metal ion levels; and secondary imaging, including ultrasonography, CT, and MRI. In a patient with clinical symptoms, elevated metal ion levels, and a large fluid collection seen on MRI, the most appropriate treatment would be removal of the metal-on-metal bearing. Given the presence of an adverse reaction involving cobalt and chromium, a revision ceramic head may be most appropriate to avoid the potential of trunnion-associated corrosion.

Question 85

A patient with a history of chronic low back pain for several years reports decreased pain visual analog scores with the home use of a transcutaneous electrical neuromuscular stimulation (TENS) unit. This pain relief is most likely due to which of the following?

Explanation

TENS units deliver superficial electrical stimulation. This electrical stimulation induces analgesia via inhibitory effects at the spinal cord level. The stimulation of small myelinated afferent fibers produces a presynaptic inhibition of the nociceptive transmission via unmyelinated C fibers, thus decreasing the transmission of pain stimuli. Additional benefit may come from the endogenous release of endorphins in the stimulated tissues.

Question 86

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

Explanation

DISCUSSION: Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature.
REFERENCES: Bibbo C, Anderson RB, Davis WH, et al: The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: Analysis of 725 procedures in 104 patients. Foot Ankle Int 2003;24:40-44.
Bibbo C, Goldberg JW: Infections and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int

2004;25:331-335.
Sorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg 2003;238:1-5.

Question 87

A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. During resisted extension exercises, she felt a "pop" in her elbow, accompanied with pain and inability to extend her elbow against resistance. What is the most likely cause of her symptoms? Review Topic

Explanation

During a Bryan-Morrey approach for total elbow arthroplasty, the triceps is dissected free from its ulnar insertion and reflected laterally. At the conclusion of the procedure, the triceps tendon is reattached to the ulna through drill holes. Whereas motion can be initiated postoperatively, 6 to 8 weeks of protection are recommended before initiation of resistance exercises to protect the triceps repair. A periprosthetic fracture or component failure is rare in the absence of more significant trauma, and they are usually late complications.

Question 88

A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Explanation

DISCUSSION: Nonsurgical management of OCD of the talus in skeletally immature individuals frequently results in a fairly rapid decrease in symptoms, but radiographic abnormalities can frequently be found even 6 months after treatment. Spontaneous resolution of this condition is rare. Hyperbaric oxygen treatment has not been shown to be beneficial for this condition. Progression of the condition to the point of requiring ankle fusion is rare.
REFERENCES: Perumal V, Wall E, Babekir N: Juvenile osteochondritis dissecans of the talus. J Pediat Orthop 2007;27:821-825.
Letts M, Davidson D, Ahmer A: Osteochondritis dissecans of the talus in children. J Pediatr Orthop 2003;23:617-625.

Question 89

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Explanation

DISCUSSION: Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2 vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks, p=0.001). However, 15% had hardware and wound complications. At one year, the operative group was more likely to be satisfied with the shoulder in general (p=0.002) and the appearance of the shoulder in particular (p=0.001) in comparison to the nonoperative group.
Prior studies have shown that greater than 2cm of shortening treated non-operatively results in increased fatigueability and poor outcome, but not necessarily nonunion. The Lazarides article concluded that “Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result.”
Studies have shown no difference in outcome when treated with a Figure-of-8 harness compared to a simple sling

Question 90

Figures 44a through 44c show the radiographs of an 18-year-old female soccer player who fell on her outstretched hand 1 day ago. She denies any history of wrist pain. Examination reveals tenderness at the anatomic snuffbox. Management should consist of

Explanation

DISCUSSION: The treatment of choice for proximal pole scaphoid fractures is open reduction and internal fixation with a differential pitch screw via a dorsal approach. Healing rates of 100% have been reported for these acute fractures. Casting results in slow healing, with recommendations including 16 weeks or more in a cast. Vascularized bone grafts are not indicated for acute fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 91

What is the most common complication following total disk arthroplasty in the lumbar spine?

Explanation

DISCUSSION: In a midterm (7 to 11 years) follow-up study of lumbar total disk arthroplasty, 5 of 55 patients had transient radicular leg pain without evidence of nerve root compression. Implant migration is rare. Deep venous thrombosis, incisional hernia, and retrograde ejaculation are less common complications of disk arthroplasty.
REFERENCE: Tropiano P, Huang RC, Girardi FP, et al: Lumbar total disc replacement: Seven to eleven-year follow-up. J Bone Joint Surg Am 2005;87:490-496.

Question 92

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

Explanation

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

Question 93

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

Explanation

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

A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 94

A patient sustains a transection of the posterior cord of the brachial plexus from a knife injury. This injury would affect all of the following muscles EXCEPT?

Explanation

DISCUSSION: The posterior cord of the brachial plexus gives rise to the 1) upper subscapular nerve 2) lower subscapular nerve 3) thoracodorsal nerve 4) axillary nerves 5) radial nerve. The upper subscapular nerve innervates the subscapularis. The lower subscapular nerve innervates teres major and also subscapularis. The thoracodorsal nerve innervates latissimus dorsi. The axillary nerves innervates deltoid and teres minor. The radial nerve innervates the triceps, brachioradialis, wrist extensors, and finger extensors. The supraspinatus is innervated by the suprascapular nerve off the upper trunk and therefore would not be affected by an injury to the posterior cord. The anatomy of the brachial plexus is shown in Illustration A.

Question 95

A 21-year-old college student fell from a balcony and landed on his outstretched right hand. He is seen in the emergency department 4 hours later and reports wrist pain and diffuse hand numbness. The volar forearm compartment is soft and there is no pain with passive finger extension. Radiographs are shown in Figures 25a and 25b. Definitive treatment should consist of

Explanation

DISCUSSION: A spectrum of perilunate injury patterns exists, with the dorsal trans-scaphoid perilunate fracture-dislocation being the most common. Perilunate injuries are highly unstable complex carpal disruptions that are not amenable to closed treatment. Open reduction and internal fixation is necessary to accurately restore carpal alignment via fracture reduction and fixation and intercarpal ligament repair. Controversy exists regarding the need for dorsal or combined dorsal and volar approaches. Based on the radiographic findings of a volar dislocation of the lunate and the associated median nerve injury, the patient requires open reduction and internal fixation via combined dorsal and volar approaches with a concomitant carpal tunnel release.
REFERENCES: Herzberg G, Forissier D: Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502.
Melone CP Jr, Murphy MS, Raskin KB: Perilunate injuries: Repair by dual dorsal and volar approaches. Hand Clin 2000;16:439-448.
Herzberg G, Comtet JJ, Linscheid RL, et al: Perilunate dislocations and fracture-dislocations:

A multicenter study. J Hand Surg Am 1993;18:768-779.

Question 96

A 48-year-old man is brought in by emergency services after falling down a flight of stairs. He complains of weakness in both hands. Examination reveals weak grip bilaterally. Injury CT scans are shown in Figure A. What is the most appropriate treatment option? Review Topic

Explanation

This patient has ankylosing spondylitis (AS) and has suffered a shear fracture through C5-6. Due to the presence of neurological deficits, posterior decompression and fusion with a long construct (such as from C3-T2) is indicated.
The C-spine is the most common site of fracture in AS and is most susceptible to hyperextension injuries. When surgical intervention is required, multiple points of fixation both above and below the fracture are necessary. This is due to co-existing osteoporosis and abnormally increased forces from long lever arms of the ankylosed spine, both of which make the construct susceptible to failure and screw pullout.
Kubiak et al. reviewed the orthopaedic management of AS. They report bone scan, MRI or fine-cut CT is necessary because fractures are often missed on plain x-rays because of distortion of anatomy or difficulty with positioning.
Whang et al. reviewed spinal injuries in 12 patients with AS and 18 patients with DISH. Most injuries involved C5-C7. Patients with AS were more likley to have severe neurologic injury (41% ASIA A) than DISH (44% ASIA E). There was 81% good-excellent outcome and 4 deaths related to halo vest use.
Figure A is a sagittal CT reconstructed image showing a nondisplaced shear fracture through the C6 vertebral body and C5 posterior elements. Illustrations A and B are postop AP and lateral radiographs showing posterior decompression and C3-T2 fusion with lateral mass fixation in the cervical spine and pedicle screw fixation in the upper thoracic spine.
Incorrect Answers:
performed through a posterior approach. If there is significant osteoporosis and the risk of construct failure is high, a 360-approach may be necessary.

Question 97

What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

Explanation

DISCUSSION: Prepubescent athletes gain strength through neurogenic adaptations, including recruitment of motor units, reduced inhibition, and learned motor skills. Myogenic adaptations (muscle hypertrophy) occur after puberty and include increased contractile proteins, thickening of the connective tissue, and increased short-term energy sources such as creatine phosphate.
REFERENCES: Grana WA: Strength training, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 520-526.
Micheli LJ: Strength training, in Sullivan JA, Grana WA (eds): The Pediatric Athlete. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 17-20.

Question 98

A 16-year-old right-hand dominant pitcher has had pain with throwing for the past 6 months but denies any history of trauma. Figures 9a and 9b show noncontrast MRI scans of the involved shoulder. What is the most likely diagnosis? Review Topic

Explanation

Internal impingement differs from standard, or outlet, impingement because instability of the glenohumeral joint is commonly the primary etiology. Sports with repetitive stress of the glenohumeral joint, such as swimming, volleyball, and baseball, are most often associated with this problem. Pathology identified with diagnostic imaging and arthroscopy include: posterolateral humeral head edema, undersurface partial tearing of the rotator cuff, and increased anterior capsular volume. In throwing athletes, prevention and treatment centers on directed posterior capsular stretching and dynamic strengthening of the rotator cuff musculature.

Question 99

A 78-year-old patient undergoing revision total knee arthroplasty has bone loss throughout the knee at the time of revision. A distal femoral augment is used to restore the joint line. One month after surgery, the patient reports pain and is unable to ambulate. A lateral radiograph is shown in Figure 34. What is the most likely etiology of this problem?

Explanation

DISCUSSION: Instability is a leading cause of failure following total knee arthroplasty. Instability can present as global instability, extension gap (varus/valgus) instability, or flexion gap (anterior/posterior) instability. Treatment options are numerous based on the exact pathology. The radiograph reveals anterior/posterior instability with dislocation consistent with flexion gap instability. A loose flexion gap can allow the femoral component to ride above the tibial cam post mechanism, resulting in dislocation. Distal femoral augments treat extension gap instability, whereas tibial augments can treat both flexion and extension gap instability. Posterior condyle augments at the distal femur can also be used to treat flexion gap instability. Flexion gap instability is further aggravated by extension mechanism incompetence. Note the excessively thin patella on the lateral radiograph.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
McAuley J, Engh GA, Ammeen DJ: Treatment of the unstable total knee arthroplasty. Inst Course Lect 2004;53:237-241.
Naudie DD, Rorabeck CH: Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 2004;53:207-215.

Question 100

-Figures a and b are the posteroanterior and lateral radiographs of a 13-year-old girl with a progressive curve despite bracing with a thoracolumbosacral orthosis. Examination reveals no pain or neurologic findings. The lumbar curve measures 59 degrees and the thoracic curve measures 52 degrees.The most appropriate treatment is

Explanation

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

splinting for 3 weeks, followed by range-of-motion exercises.
aspiration of the hemarthrosis, followed by range-of-motion exercises the following day.
fragment excision.
open reduction and internal fixation.
radial head excision.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 2:

Which of the following structures may help maintain radial length after a radial head fracture?

Options:

Triangular fibrocartilage complex
Medial ulnar collateral ligament
Lateral ulnar collateral ligament
Annular ligament
Coronoid

Correct Answer: Triangular fibrocartilage complex

Explanation:

DISCUSSION: Essex-Lopresti injuries affect axial stability of the forearm. Injury to the interosseous membrane or the triangular fibrocartilage complex can result in proximal migration of the radius.
REFERENCES: Morrey BF, Chao EY, Hui FC: Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg Am 1979;61:63-68.
Coleman DA, Blair WF, Shurr D: Resection of the radial head for fracture of the radial head: Long-term follow-up of seventeen cases. J Bone Joint Surg Am 1987;69:385-392.

Question 3:

Which of the following anatomic structures is labeled 6 in Figure 27?

Options:

A2 pulley
Grayson’s ligament
Cleland’s ligament
Triangular ligament
Sagittal band

Correct Answer: A2 pulley

Explanation:

Question 4:

Options:

Osteomyelitis
Giant cell tumor
Osteosarcoma
Chondroblastoma
Histiocytosis

Correct Answer: Giant cell tumor

Explanation:

DISCUSSION: The radiograph shows a purely radiolucent lesion without matrix mineralization in the epiphysis of the distal radius. The lesion is “hot” on bone scan, and the MRI scan reveals cortical destruction with a soft-tissue mass. These findings are most consistent with giant cell tumor. The distal radius is a common location for giant cell tumors. The other options would be very uncommon in this location in a 45-year-old patient. The photomicrograph demonstrates multinucleated giant cells in a sea of mononuclear cells. The nuclei of the giant cells and the nuclei of the mononuclear stromal cells are identical. This feature helps distinguish giant cell tumor from other lesions that might contain giant cells.
REFERENCES: Cheng CY, Shih HN, Hsu KY, et al: Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221-228.
Unni KK: Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases, ed 5. Philadelphia, PA, Lippincott-Raven, 1996, pp 263-284.

Question 5:

Options:

open anterior acromioplasty and rotator cuff repair.
arthroscopic acromioplasty.
anterior acromioplasty and distal clavicle excision.
an open Mumford procedure.
immobilization in a sling for 4 weeks followed by additional physical therapy.

Correct Answer: anterior acromioplasty and distal clavicle excision.

Explanation:

Question 6:

Options:

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

Correct Answer: Total elbow arthroplasty

Explanation:

Question 7:

Figures 22a and 22b show the radiographs of a patient who reports stiffness of the hip and associated pain. Management should consist of

Options:

use of a cane for ambulation.
diphosphonate therapy.
physical therapy and indomethacin.
surgical excision and radiation therapy.
revision arthroplasty.

Correct Answer: surgical excision and radiation therapy.

Explanation:

Question 8:

Figures 9a and 9b show the spinal radiographs of a 3-year-old child with short limb dwarfism. The lateral radiograph is obtained with maximal lumbar extension. Management should consist of

Options:

close clinical follow-up.
a thoracolumbosacral orthosis.
anterior spinal fusion.
posterior spinal fusion.
fibroblast growth factor replacement.

Correct Answer: a thoracolumbosacral orthosis.

Explanation:

Question 9:

Options:

Physical therapy to improve hip stability
Use of an abduction brace to limit the patient’s range of motion
Conversion to a constrained acetabular liner
Cobalt and chromium serum metal ion level testing

Correct Answer: Cobalt and chromium serum metal ion level testing

Explanation:

Question 10:

- Analysis of which of the following proteins is used to establish the diagnosis of Becker muscular dystrophy?

Options:

Myosin
Troponin
Tropomyosin
Fibrillin
Dystrophin

Correct Answer: Myosin

Explanation:

Becker muscular dystrophy is an X-linked inherited disorder present in approximately 1 in 30,000 live male births. The responsible gene is located on the xp21 region of the X chromosome including sixty-five exons that encode for the protein dystrophin. Duchenne muscular dystrophy is also related to a mutation of the dystrophin gene. Muscle biopsies for dystrophin have been extremely successful for identifying these dystrophies and distinguishing them from other clinically similar autosomal recessive myopathies. (Ref: Shapiro, Hoffman)
Question 18 -
A 25-year-old woman with spastic diplegia has a painful progressive bunion deformity that has failed to respond to nonsurgical treatment. Examination reveals tenderness and erythema over the bunion prominence; however, the hallux metatarsophalangeal joint has full range of motion. A standing AP radiograph shows a hallux valgus angle of 30 degrees and a 1-2 intermetatarsal angle of 13 degrees. Treatment should now consist of
arthrodesis of the hallux metatarsophalangeal joint.
arthrodesis of the first tarsometatarsal joint.
excision of the medial eminence and medial capsular reefing of the metatarsophalangeal joint.
osteotomy of the distal first metatarsal.
proximal metatarsal osteotomy with distal soft-tissue realignment.
Treatment of hallux valgus in a patient with cerebral palsy is largely dependent on the degree of spasticity and the pattern of gait. The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.
The optimal arthrodesis angle is 25-30 degrees, and the metatarsal inclination angle should be 25-30 degrees also. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated WB

Question 11:

..The optimal method to treat a recurrent presentation of pigmented villonodular synovitis (PVNS) with diffuse joint involvement in a 24-year-old woman with pain and symptomatic effusions is

Options:

700 cGy of radiation therapy.
open arthrotomy with synovectomy.
imatinib therapy.
observation. DISCUSSION.. Local control of recurrent diffuse PVNS is best accomplished with open arthrotomy and complete synovectomy. Arthroscopic methods in the setting of persistent diffuse PVNS are associated with an unacceptably high rate of recurrence. Radiation therapy (700 cGy) is the typical dose administered for heterotopic ossification prophylaxis, but this dose is not high enough to achieve local control in PVNS. Imatinib, a colony-stimulating factor inhibitor, has been described for recurrent/refractory disease, but is not considered as effective as open surgical treatment.

Correct Answer: open arthrotomy with synovectomy.

Question 12:

Which of the following is considered a major characteristic of hyaluronate?

Options:

Artificial compound used in improving joint reactive force friction
Backbone of the proteoglycan aggregate
Made up of chondroitin sulfate and glucosamine
Primarily made up of water molecules in its protein matrix
Key building block of collagen

Correct Answer: Backbone of the proteoglycan aggregate

Explanation:

Question 13:

Options:

Long thoracic nerve
Cranial nerve XI (spinal accessory nerve)
Suprascapular nerve
Axillary nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 14:

Options:

Continued physical therapy
Alteration of medication to include an anti-epileptic
Tarsal tunnel release
Sympathetic blocks
Neurostimulation

Correct Answer: Sympathetic blocks

Explanation:

Question 15:

Options:

Synovial sarcoma
Soft-tissue abcess
Rhabdomyosarcoma
Eosinophilic granuloma
Nodular pigmented villonodular synovitis

Correct Answer: Soft-tissue abcess

Explanation:

Question 16:

Which of the following best characterizes bone mineralization?

Options:

Initial sites of mineralization occurring at hole zones between the collagen fibrils
High levels of adenosine triphosphate and proteoglycans at the site of nucleation
Highly pure and perfect crystals of hydroxyapatite increasing in dimension by adding ions in a linear fashion
An energy-limiting step of individual hydroxyapatite crystals combining in aggregate in one or more directions
Macromolecules binding to the crystal surface to promote further growth in that particular direction

Correct Answer: Initial sites of mineralization occurring at hole zones between the collagen fibrils

Explanation:

Question 17:

Options:

Posterior oblique
Dorsal radial
Anterior oblique
Dorsal trapeziometacarpal

Correct Answer: Anterior oblique

Explanation:

Question 18:

Options:

positive Lachman test, normal posterior drawer, positive pivot shift.
positive Lachman test, positive posterior drawer, negative pivot shift.
normal Lachman test, positive posterior drawer, positive pivot shift.
normal Lachman test, positive posterior drawer, negative pivot shift.

Correct Answer: normal Lachman test, positive posterior drawer, negative pivot shift.

Explanation:

The images provided reveal a posterior cruciate ligament (PCL) disruption with an intact anterior cruciate ligament (ACL). Common diagnostic findings for a PCL tear include a positive posterior drawer test, positive reverse pivot shift, positive quadriceps active test, and positive posterior sag. A positive Lachman test, which would indicate a torn ACL, would not be expected to be positive. A false-positive result for a Lachman test can arise with a torn PCL because of the overall increased anterior-posterior translation;
this must be avoided by careful attention to initial resting position and station of the knee.

Question 19:

Two major pharmacologic classes of bisphosphonates exist: nitrogen-containing and non-nitrogen-containing compounds. The nitrogen-containing compounds work by which of the following actions?

Options:

COX inhibition
ATPase formation
GTPase inhibition
DNA gyrase inhibition
RNA polymerase inhibition

Correct Answer: GTPase inhibition

Explanation:

Question 20:

Options:

Posterior tibial tendon
Impaction fracture of the head of the talus
Posterior tibial neurovascular bundle
Achilles tendon
Calcaneus fracture

Correct Answer: Impaction fracture of the head of the talus

Explanation:

Question 21:

Options:

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

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

Explanation:

Question 22:

Options:

Ceramic-on-ceramic
Ceramic-on-highly cross-linked polyethylene (HXPE)
Metal-on-HXPE
Metal-on-metal

Correct Answer: Metal-on-metal

Explanation:

Question 23:

Options:

an MRI scan.
fusion from the occiput to C2.
fusion of C1-C2.
application of a cervical collar and no participation in any sports.
periodic follow-up examinations and no contact sports.

Correct Answer: periodic follow-up examinations and no contact sports.

Explanation:

Question 24:

Options:

glenohumeral arthrodesis.
total shoulder arthroplasty.
humeral arthroplasty.
open synovectomy and rotator cuff repair.
anterior acromioplasty and rotator cuff repair.

Correct Answer: humeral arthroplasty.

Explanation:

Question 25:

Options:

filling the tibial defect with methylmethacrylate.
revision of the tibial component with porous metal augmentation.
reconstruction with iliac crest bone graft.
reconstruction with structural allograft.

Correct Answer: revision of the tibial component with porous metal augmentation.

Explanation:

DISCUSSION
Video 1 for reference
For severe tibial defects (Anderson Orthopaedic Research Institute [AORI] types 2 and 3), metaphyseal fixation is necessary to achieve construct fixation during revision TKA. Metaphyseal fixation may be achieved with cement, structural allograft, or conical metallic implants. The major concerns regarding structural allograft are graft resorption and mechanical failure and technical issues related to fashioning the graft and obtaining a good host-allograft interface. In a systematic review, porous metal cones were associated with a decreased loosening rate in AORI 2 and 3 defects compared to structural allografts. Metallic trabecular metal cones and metaphyseal porous coated sleeves provide a stable construct with which to support the tibial component during revision TKA. Clinical results with these devices include good metaphyseal fixation for severe tibial bone defects.

Question 26:

Options:

Ankle fusion
Arthroscopic debridement and drilling
Retrograde drilling and bone grafting
Malleolar osteotomy and osteochondral grafting

Correct Answer: Malleolar osteotomy and osteochondral grafting

Explanation:

Question 27:

Options:

Radial collateral ligament
Posterior bundle of the ulnar collateral ligament
Anterior bundle of the ulnar collateral ligament
Flexor carpi ulnaris
Pronation teres

Correct Answer: Anterior bundle of the ulnar collateral ligament

Explanation:

DISCUSSION: The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Cain EL, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.
Rettig AC, Sherrill C, Snead DS, et al: Nonoperative treatment of ulnar collateral ligament injuries in
throwing athletes. Am J Sports Med 2001 ;29:15-17.
/
Figure 55a Question 55
A 22-year-old male basketball player has had knee pain for the past 3 months. He denies any history of trauma. He has symptoms of catching but no locking. He has rested for 2 weeks but symptoms returned when he resumed sporting activities. T
r
and T
2
-weighted MRI scans are shown in Figures 55a and 55b. What is the most likely diagnosis?
Locked lateral meniscus tear
Anterior cruciate ligament tear
Ganglion cyst of the anterior cruciate ligament
Synovial osteochondromatosis
Pigmented villonodular synovitis PREFERRED RESPONSE: 3
DISCUSSION: The MRI scans show a cystic structure within the anterior cruciate ligament. It is fluid filled as seen on the T
2
sequence. Ganglion cysts of the cruciate ligaments are rare. The most common presentation is pain with occasional loss of motion. Instability is not a chief complaint and often there is no evidence of laxity on examination. If nonsurgical management fails, arthroscopic debridement of the cyst is the accepted method of treatment.
REFERENCES: Liu SH, Osti L, Mirzayan R: Ganglion cysts of the anterior cruciate ligament: A case report and review of the literature. Arthroscopy 1994; 10:110-112.
Parish EN, Dixon P, Cross MJ: Ganglion cysts of the anterior cruciate ligament: A series of 15 cases. Arthroscopy 2005;21:445-447.

Question 28:

During cemented total hip arthroplasty, peak pulmonary embolization of marrow contents occurs when the

Options:

hip is dislocated.
femoral neck is osteotomized.
acetabulum is prepared.
acetabular component is inserted.
femoral stem is inserted.

Correct Answer: femoral stem is inserted.

Explanation:

DISCUSSION: Peak embolization is observed during femoral stem insertion. Embolization is also observed during acetabular preparation and hip reduction.
REFERENCES: Lewallen DG, Parvizi J, Ereth MH: Perioperative mortality associated with hip and knee arthroplasty, in Morrey BF (ed): Joint Replacement Arthroplasty, ed 3. Philadelphia, PA, Churchill-Livingstone, 2003, pp 119-127.
Ereth MH, Weber JG, Abel MD, et al: Cemented versus noncemented total hip arthroplasty: Embolism, hemodynamics, and intrapulmonary shunting. Mayo Clin Proc 1992;67:1066-1074.

Question 29:

What is the most important stabilizing mechanism in the midrange of motion of the glenohumeral joint? Review Topic

Options:

Concavity compression
Isometric articular ligaments
Increased tensile force of the capsule
Biceps tendon
Deltoid contraction

Correct Answer: Concavity compression

Explanation:

Question 30:

Options:

a rotator cuff exercise program and anti-inflammatory drugs.
repeat subacromial cortisone injections as necessary.
open subacromial decompression.
arthroscopic evacuation of calcium deposits.
open rotator cuff repair.

Correct Answer: arthroscopic evacuation of calcium deposits.

Explanation:

Question 31:

Figure A shows the 2 bundles of the ACL dissected from a cadaveric knee off their bony attachments. They are labeled Bundle A and Bundle B, respectively. Which of the following is true? Review Topic

Options:

The tibial attachment of Bundle A is anterior to Bundle B. In extension, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle A is anterior to Bundle B. In flexion, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle B is loose and Bundle A is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In flexion, Bundle A is loose and Bundle B is tight.
The tibial attachment of Bundle B is anterior to Bundle A. In extension, Bundle A is loose and Bundle B is tight.

Correct Answer: The tibial attachment of Bundle A is anterior to Bundle B. In extension, Bundle B is loose and Bundle A is tight.

Explanation:

Question 32:

A 43-year-old man has had right groin pain for the past 3 months. A radiograph, CT scan, and biopsy specimen are shown in Figures 18a through 18c. What is the most likely diagnosis?

Options:

Chordoma
Enchondroma
Dedifferentiated chondrosarcoma
Chondrosarcoma
Metastatic renal cell carcinoma

Correct Answer: Chondrosarcoma

Explanation:

Question 33:

One year after undergoing anterior cervical decompression and fusion, what percentage of patients still have dysphagia?

Options:

10% to 15%
30% to 35%
50% to 55%
70% to 75%

Correct Answer: 10% to 15%

Explanation:

DISCUSSION
Dysphagia after anterior cervical diskectomy and fusion is a common, usually transient finding after anterior cervical approaches to the spine. While it has been reported to occur in up to 70% of patients 2 weeks following surgery, in most cases the symptoms quickly resolve. There is, however, a small subset of patients for whom symptoms of dysphagia will persist. Lee and associates prospectively studied the rate of dysphagia after anterior cervical diskectomy and fusion, reporting a 15% rate of dysphagia at 12 months, and 12% at 24 months. Phillips and associates analyzed the 2-year data from the PCM FDE clinical trial and found a 12.1% incidence of dysphagia in the ACDF arm.
RECOMMENDED READINGS
Lee MJ, Bazaz R, Furey CG, Yoo J. Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study. Spine J. 2007 Mar-Apr;7(2):141-7. Epub 2007 Jan 22. PubMed PMID: 17321961.
View Abstract at PubMed
Smith-Hammond CA, New KC, Pietrobon R, Curtis DJ, Scharver CH, Turner DA. Prospective analysis of incidence and risk factors of dysphagia in spine surgery patients: comparison of anterior cervical, posterior cervical, and lumbar procedures. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1441-6. PubMed PMID: 15223936.
View
Abstract at PubMed
Edwards CC 2nd, Karpitskaya Y, Cha C, Heller JG, Lauryssen C, Yoon ST, Riew KD. Accurate identification of adverse outcomes after cervical spine surgery. J Bone Joint Surg Am. 2004 Feb;86-A(2):251-6. PubMed PMID: 14960668.
View Abstract at PubMed
Phillips FM, Lee JY, Geisler FH, Cappuccino A, Chaput CD, DeVine JG, Reah C, Gilder KM, Howell KM, McAfee PC. A prospective, randomized, controlled clinical investigation comparing PCM cervical disc arthroplasty with anterior cervical discectomy and fusion. 2-year results from the US FDA IDE clinical trial. Spine (Phila Pa 1976). 2013 Jul 1;38(15):E907-18. doi: 10.1097/BRS.0b013e318296232f.
Rihn JA, Kane J, Albert TJ, Vaccaro AR, Hilibrand AS. What is the incidence and severity of dysphagia after anterior cervical surgery? Clin Orthop Relat Res. 2011 Mar;469(3):658-65. PMID: 21140251.
View Abstract at PubMed

Question 34:

Options:

Both hips are normal and no further assessments will be needed.
A neoplasm has developed in the femoral head on the unslipped side.
There is now increased risk for a slip in the hip and a new screw should be inserted.
Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.
The screw track in the bone has not filled spontaneously as expected and grafting should beconsidered.

Correct Answer: Osteonecrosis has developed in the unslipped hip adjacent to the previous screw position.

Question 35:

Options:

0% if bracing is used
25%
50%
75%
90% or greater

Correct Answer: 90% or greater

Explanation:

Question 36:

The lesion seen in Figure 4 is most likely the result of metastases from what solid organ?

Options:

Breast
Lung
Thyroid
Prostate
Liver

Correct Answer: Lung

Explanation:

Question 37:

What is the most common complication following surgical fixation of a distal humeral fracture?

Options:

Wound infection
Ulnar nerve injury
Failure of fixation
Nonunion
Elbow stiffness

Correct Answer: Elbow stiffness

Explanation:

Question 38:

Options:

right innominate osteotomy.
right varus upper femoral osteotomy.
open reduction of the right hip.
crutches, physical therapy, and an abduction brace.
MRI of the pelvis.

Correct Answer: MRI of the pelvis.

Explanation:

Question 39:

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Options:

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

Correct Answer: Ankle fusion

Explanation:

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462.
View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381.
View Abstract t
PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303.
View Abstract at
PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803.
View Abstract at PubMed
Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228.
View Abstract at
PubMed

Question 40:

Options:

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

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 41:

Options:

Osteoclasts
Macrophages
Chondrocytes
Osteoblasts
Endothelial cells

Correct Answer: Osteoblasts

Explanation:

Question 42:

Options:

Rest, ice, nonsteroidal anti-inflammatory drugs, activity as tolerated, and follow-up in 4 weeks
Coaptation splinting and follow-up in 4 weeks
Surgical replacement with hemiarthroplasty or reverse total shoulder arthroplasty
Physical therapy for range-of-motion exercises
Closed reduction, splinting, and follow-up in 4 weeks

Correct Answer: Surgical replacement with hemiarthroplasty or reverse total shoulder arthroplasty

Explanation:

Question 43:

Options:

Pedicled vascularized bone graft
Long arm thumb spica cast
Percutaneous screw fixation
Corticocancellous bone grating via a volar approach (Matti-Russe)
Open reduction and differential pitch screw placement via a dorsal approach

Correct Answer: Pedicled vascularized bone graft

Explanation:

DISCUSSION: The patient has a nonunion of the proximal pole of the scaphoid. Acutely, this can be repaired with a screw alone, but as a nonunion the proximal pole has very poor healing potential. Vacularized bone grafts have been successful for these challenging nonunions, particularly in adolescents. A cast can be used for nondisplaced acute waist fractures, and corticocancellous grafts can be used for nonunions of the waist.
REFERENCES: Waters PM, Stewart SL: Surgical treatment of nonunion and avascular necrosis of the proximal part of the scaphoid in adolescents. J Bone Joint Surg Am 2002;84:915-920.
Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002;27:391-401.

Question 44:

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Options:

pulselessness
palor
paresthesia
paralysis
increasing analgesia requirement

Correct Answer: pulselessness

Explanation:

Question 45:

- Which of the following conditions is most likely inherited as an autosomal dominant trait?

Options:

Syndactyly
Macrodactyly
Camptodactyly
Preaxial polydactyly
Postaxial polydactyly

Correct Answer: Postaxial polydactyly

Explanation:

Question 46:

Options:

a spinal cord injury and he cannot participate in contact sports.
no obvious injury and can return to all sports without risk of recurrence.
no obvious injury, but he is at a high risk for breaking his neck in athletic competition.
transient quadriplegia only, but this places him at greater risk for future spinal cord injury and he should refrain from all contact sports.
transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Correct Answer: transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Explanation:

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro
AR
, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 47:

A 30 year-old male is involved in a motor vehicle collision and sustains a scapular fracture. In patients with scapular fractures, what other fracture is MOST commonly observed?

Options:

Spine fracture
Rib fracture
Clavicle fracture
Humerus fracture
Pelvic fracture

Correct Answer: Humerus fracture

Explanation:

Rib fractures are the most commonly observed fractures associated with scapular fractures.
Scapular fractures are associated with high-energy trauma, with motor vehicle collisions being a common mechanism of injury. These fractures are also associated with increased Injury Severity Scores and therefore clinicians need to be cognizant of concomitant injuries. In addition to associated orthopaedic injuries, pulmonary injuries (contusions, hemothorax, and pneumothorax) and head injuries are associated with scapular fractures. A CT chest should be considered in patients with scapula
fractures, to best visualize associated rib fractures and pulmonary injuries.
Baldwin et al. conducted a retrospective case control analysis using the US National Trauma Database that included 9,453 scapular fractures. In their study, the most commonly associated fractures were rib fractures (52.9%), followed by fractures of the spine (29.2%), clavicle (25.2%), and pelvis (15.3%). Lung and head injuries occurred in 47.1% and 39.1% of the cases, respectively.
Incorrect Answers:
(SBQ12TR.107) An 87-year-old female sustains the injury shown in Figure A after a fall from standing. At baseline, she ambulates with a walker in her home and lives with a 24-hour home health aide. She has a past medical history of stroke and mild dementia. Following medical optimization, what is the most appropriate treatment modality?
Intramedullary nail
Hemiarthroplasty
Closed reduction percutaneous pinning
Total hip arthroplasty
Sliding hip screw
At baseline, with minimal ambulatory status and dependence on a 24-hour home health aide, the best treatment choice is hemiarthroplasty.
Arthroplasty is the gold standard for displaced femoral neck fractures in the elderly. In community ambulators with relative independent lives, total hip arthroplasty (THA) is recommended. For minimal ambulator, hemiarthroplasty is recommended.
van den Bekerom et al. randomized 252 patients over 70-years-old to either THA or hemiarthroplasty for displaced femoral neck fractures. With increased blood loss, operative time and dislocation risk, they did not recommend THA unless there was good preoperative ambulatory status, and/or pre-existing osteoarthritis or rheumatoid arthritis.
Figure A exhibits a displaced femoral neck fracture Incorrect answers:

Question 48:

Options:

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

Correct Answer: Acetabular revision arthroplasty

Explanation:

Question 49:

Options:

Distal femoral varus osteotomy
Autologous chondrocyte implantation (ACI)
Fresh osteochondral allograft (OCA) transplantation
Arthroscopic microfracture

Correct Answer: Fresh osteochondral allograft (OCA) transplantation

Explanation:

Question 50:

Figure 4a shows the radiograph of a 20-year-old man who has an injury to the right shoulder. Figure 4b shows an arthroscopic view (posterior portal). The arrow points to a

Options:

rotator cuff tear.
bare area.
Hill-Sachs defect.
Bankart tear.
glenoid fracture.

Correct Answer: Hill-Sachs defect.

Explanation:

DISCUSSION: The radiograph shows an anterior dislocation of the shoulder. A frequently encountered sequela of this is a compression fracture of the posterolateral humeral head, commonly referred to as a Hill-Sachs defect. The arthroscopic view of the glenohumeral joint visualizes the posterior aspect of the humeral head. In the image, the area devoid of cartilage to the right is the bare area. The indentation seen to the left is a Hill-Sachs defect.
REFERENCES: Matsen FA, Thomas SC, Rockwood CA, et al: Glenohumeral instability, in Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998,
pp 611-754.
Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principals of techniques, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.

Question 51:

Options:

10% decrease in amplitude, 50% decrease in latency.
10% decrease in amplitude, 50% increase in latency.
0% loss of amplitude, transient increase in latency.
50% decrease in amplitude, 10% increase in latency.
50% decrease in amplitude, 10% decrease in latency.

Correct Answer: 50% decrease in amplitude, 10% increase in latency.

Explanation:

Question 52:

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

Options:

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

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

Explanation:

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

Question 53:

Which of the following methods is effective in correcting recurrent dislocation following total hip arthroplasty?

Options:

Lateralization of the greater trochanter without advancement
Use of a shorter neck length
Use of a constrained acetabular component
Use of a small diameter head
High cup abduction angle

Correct Answer: Use of a constrained acetabular component

Explanation:

Question 54:

Options:

Popliteal artery
Popliteal vein
Tibial nerve
Popliteus muscle
Soleus muscle

Correct Answer: Popliteus muscle

Explanation:

DISCUSSION: The major risk of performing a high tibial osteotomy is neurovascular injury. The new version of the high tibial osteotomy makes a transverse osteotomy at the level of the tibial tubercle. The osteotome is protected by the oblique belly of the popliteus muscle. The popliteal artery and vein and tibial nerve all lie posterior to the muscle. The soleus muscle originates below this level.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 422.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 480.

Question 55:

Options:

arthroscopy and labral repair.
arthroscopy and supraspinatus repair.
arthroscopy and subscapularis repair.
arthroscopy and supraspinatus and infraspinatus repair.
open repair of the pectoralis major.

Correct Answer: arthroscopy and subscapularis repair.

Explanation:

Question 56:

Options:

Start IV antibiotics, obtain wound swab for culture, perform irrigation and debridement and retain hardware
Start IV antibiotics, obtain deep soft tissue and bone cultures in OR, perform irrigation and debridement and remove hardware
Obtain wound swab for culture, start IV antibiotics, perform irrigation and debridement and remove hardware
Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform irrigation and debridement and remove hardware

Correct Answer: Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform irrigation and debridement and remove hardware

Explanation:

Question 57:

Options:

Failure of patellar polyethylene
Loosening of the femoral component
Loosening of the tibial component
Loosening of the patellar component
Wear-induced osteolysis

Correct Answer: Failure of patellar polyethylene

Explanation:

Question 58:

Options:

Absolute toe pressures of 55 mm Hg
Transcutaneous oxygen level of 20 mm Hg
Arterial brachial indices (ABI) of 1.2 at the level of surgery
ABI 0.3 at the level of surgery
Albumin level of 2.5

Correct Answer: Absolute toe pressures of 55 mm Hg

Explanation:

DISCUSSION: Absolute toe pressures greater than 40 to 50 mm Hg are a good sign of healing potential. An ABI of greater than 0.45 favors healing, but indices greater than 1 are falsely positive due to calcifications in the vessels. Normal albumin is an overall indication of nutritional status.
A transcutaneous oxygen level should be greater than 40 mm Hg for healing.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 113-122.
Pinzur MS, Stuck R, Sage R: Benchmark analysis on diabetics at high risk for lower extremity amputation. Foot Ankle Int 1996;17:695-700.

Question 59:

Options:

Gastrocnemius recession
Keller bunionectomy
Flexor hallucis longus tendon transfer
Planing/excising the superficial half of the medial sesamoid
Dorsiflexion osteotomy of the first metatarsal

Correct Answer: Planing/excising the superficial half of the medial sesamoid

Explanation:

DISCUSSION: Passive dorsiflexion is adequate to accommodate standing erect without excessive pressure, and a gastrocnemius recession may lead to more instability. Complete excision of the medial sesamoid could lead to an iatrogenic hallux valgus deformity. She does not have a cock-up toe deformity; therefore, a flexor hallucis longus tendon transfer is not warranted. There is no significant foot deformity; therefore, a dorsiflexion osteotomy is not warranted. The appropriate procedure is planing of the plantar half of the medial sesamoid, thereby preserving its function while diminishing the excessive pressure.
REFERENCES: Grace DL: Sesamoid problems. Foot Ankle Clin 2000;5:609-627.
Mizel MS, Miller RA, Scioli MW (ed): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 135-150.
Richardson EG: Hallucal sesamoid pain: Causes and surgical treatment. J Am Acad Orthop Surg 1999;7:270-278.

Question 60:

Which of the following agents increases the risk for a nonunion following a posterior spinal fusion?

Options:

Ibuprofen
Intranasal calcitonin
Simvastatin
Gentamycin
Tamoxifen

Correct Answer: Ibuprofen

Explanation:

Question 61:

Options:

Ulnar
Radial
Axillary
Median
Musculocutaneous

Correct Answer: Musculocutaneous

Question 62:

Options:

Contact area and contact pressure both decrease.
Contact area and contact pressure both increase.
Contact area and contact pressure both remain the same.
Contact area increases and contact pressure decreases.
Contact area decreases and contact pressure increases.

Correct Answer: Contact area increases and contact pressure decreases.

Explanation:

Question 63:

Options:

Dislocation of the great toe MTP joint
Rupture of the volar plate
Fracture of the lateral sesamoid
Fracture of the lateral sesamoid and rupture of the plantar plate
Subluxation of the sesamoids

Correct Answer: Fracture of the lateral sesamoid and rupture of the plantar plate

Explanation:

Question 64:

EXT1

Options:

This patient has multiple hereditary exostoses. Widening of the metaphysis is characteristic of multiple hereditary exostoses. Large sessile osteochondromas arise from the metaphysis and a large osteochondroma arises from the medial metaphysis with a characteristic cartilaginous cap. The computed tomography scan shows the widening and abnormal tubulation of the bone.
No evidence of malignancy exists in this large osteochondroma. The cartilage cap is regular with no areas of bone destruction. One should also look for a soft tissue mass, which often shows areas of focal calcifications. No soft tissue masses are present in this patient.
It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Correct Answer: It is important to remember that this condition is autosomal dominant. The putative tumor suppressive gene mutation is EXT1, EXT2. The risk of low-grade chondrosarcoma occurring in this condition is approximately 10%.

Explanation:

slide 1 slide 2 slide 3
A patient presents with a hard leg mass and pain with activity. The anteroposterior and lateral radiographs are shown in Slide 1 and Slide 2. An axial computed tomography scan is shown in Slide 3. Which of the following would be the most appropriate treatment:

Question 65:

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

Options:

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

Correct Answer: Diffusion through pores in the end plates

Explanation:

Question 66:

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 67:

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete’s shoulder?

Options:

Improve flexibility
Strengthen muscles
Enhance power and endurance
Regain neuromuscular control
Perform functional drills

Correct Answer: Improve flexibility

Explanation:

Question 68:

What is the most common non-anesthetic-related reversible cause of sustained changes in intraoperative neurophysiologic monitoring signals during spinal surgery? Review Topic

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypertension

Correct Answer: Patient positioning

Explanation:

Question 69:

Options:

Biopsy
Resection
A CT scan
An MRI scan
Observation

Correct Answer: Observation

Question 70:

Options:

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

Correct Answer: Stemmed hemiarthroplasty

Explanation:

DISCUSSION: The radiograph and intraoperative photograph show osteonecrosis with near complete head loss/collapse. A stemmed implant is more appropriate in this patient because there is very little bone to support a resurfacing implant. In a younger patient, a glenoid implant should be delayed as long as possible because of the eventual need for revision secondary to glenoid loosening and wear, especially in a young active male. The hemiarthroplasty may be converted to a total shoulder arthroplasty in the future.
REFERENCES: Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-221.
Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient.
J Arthroplasty 2003;18:792-798.

Question 71:

Which clinical signs are consistent with the diagnosis of cauda equina syndrome?

Options:

Saddle anesthesia, hyperreflexia, quadriceps weakness
Decreased motor function in the quadriceps and gastrocnemius, hyperreflexia,? and saddle anesthesia
More than 5 beats of clonus, saddle anesthesia, and bowel incontinence
Urinary retention, saddle anesthesia, and extensor hallucis longus weakness

Correct Answer: Urinary retention, saddle anesthesia, and extensor hallucis longus weakness

Explanation:

DISCUSSION
Cauda equina syndrome is a lower-motor neuron deficit. Hyperreflexia, clonus, and other upper-motor neuron findings would not be seen. Saddle anesthesia, motor weakness, and neurogenic bladder are elements critical to the diagnosis of cauda equina syndrome.
RECOMMENDED READINGS
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PubMed PMID: 2936744.
View
Abstract at PubMed
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. Review. PubMed PMID: 18664636.
View Abstract at
PubMed
CLINICAL SITUATION FOR QUESTIONS 78 THROUGH 80
Figures 78a and 78b are the axial and sagittal MR images of an otherwise healthy 24-year-old woman who has had 8 weeks of severe leg pain without weakness.
A B

Question 72:

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Options:

Inferior glenohumeral ligament
Acromioclavicular (AC) ligaments
Coracoclavicular ligaments
Coracoacromial ligament The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened, and there is marked fracture displacement. This signifies disruption to the coracoclavicular ligaments. The inferior glenohumeral ligament is important to glenohumeral joint stability, but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects two parts of the scapula (coracoid and acromion) and is part of the arch that supports the rotator cuff.

Correct Answer: Acromioclavicular (AC) ligaments

Explanation:

Question 73:

The nucleus pulposus of the intervertebral disk consists of chondrocyte-like cells that have a limited vascular supply and generate energy through which of the following?

Options:

Anaerobic glycolysis
Kreb's cycle
Ketosis
Gluconeogenesis
Lipogenesis

Correct Answer: Anaerobic glycolysis

Explanation:

Question 74:

Anterior subluxation in a throwing athlete is most commonly the result of

Options:

avulsion of the inferior glenohumeral ligament from the glenoid.
avulsion of the inferior glenohumeral ligament from the humerus.
fracture of the anterior glenoid rim.
excessive capsular laxity from microtrauma.
a large Hill-Sachs lesion.

Correct Answer: excessive capsular laxity from microtrauma.

Explanation:

Question 75:

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 76:

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Options:

Biceps tendon
Coracohumeral ligament
Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament

Correct Answer: Biceps tendon

Explanation:

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,
ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 77:

- Figure 35 shows a postoperative radiograph of a femur fracture proximal to a total knee prosthesis that was treated by open reduction and blade plate fixation 9 months ago. What is the most likely reason the previously well seated screw has backed out of the central portion of the plate?

Options:

Infection
Nonunion
Improper screw length
Osteonecrosis of the distal fragment
Use of a cortical screw instead of a cancellous screw

Correct Answer: Nonunion

Explanation:

Question 78:

A 15-year-old girl with a midshaft fibular lesion has histologic findings consistent with Ewing’s sarcoma. Following induction chemotherapy, local control typically consists of

Options:

radiation therapy only.
curettage and bone grafting.
wide resection.
below-knee amputation.
observation.

Correct Answer: wide resection.

Explanation:

Question 79:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis (TLSO) until the fracture has healed
Immediate mobilization in a TLSO, continuing until the fracture has healed
Anterior corpectomy with strut grafting and placement of anterior fixation
Anterior corpectomy and strut grafting followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation

Correct Answer: Posterior spinal fusion and instrumentation

Explanation:

DISCUSSION: The injury pattern is that of a burst fracture at L1 contiguous with a compression fracture at T12. There is associated kyphosis and slight spondylolisthesis of T12 on L1. Treatment of this type of burst fracture in neurologically intact patients is somewhat controversial, with at least one study demonstrating equal long-term results comparing nonsurgical treatment to surgical treatment. In this study, however, body casts were used initially in the nonsurgical group. Moreover, because this patient has multiple fractures, spinal fracture stabilization should be considered to facilitate early mobilization. Surgical stabilization and fusion via a posterior approach is the best treatment option in this patient. Anterior decompression is not necessary since the patient is neurologically intact.
REFERENCES: McLain RF, Benson DR: Urgent surgical stabilization of spinal fractures in polytrauma patients. Spine 1999;24:1646-1654.
Wood K, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit: A prospective, randomized study.
J Bone Joint Surg Am 2003;85:773-781.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 80:

Options:

Lymphocentigraphy
Colonoscopy
Bronchoscopy
Embolization of the femoral lesion
Bone marrow aspiration

Correct Answer: Embolization of the femoral lesion

Explanation:

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 81:

Options:

The child is a victim of neglect
The child had no symptoms of pain
He was allowed to return to school wearing the cast
Concerns of cost
Follow-up instructions were not effectively communicated

Correct Answer: The child is a victim of neglect

Explanation:

Question 82:

-Radiographs are shown in Figures 89a through 89c. What is the most likely diagnosis?

Options:

Medial tibial plateau fracture
Chronic medial collateral ligament injury
Anterior cruciate ligament (ACL) rupture
Acute lateral collateral ligament rupture

Correct Answer: Anterior cruciate ligament (ACL) rupture

Question 83:

What is the recommended treatment of a skeletally immature 12-year-old boy who has an anterior cruciate ligament-deficient knee?

Options:

Reduced activity, rehabilitation exercises, and functional bracing until the patient is near skeletal maturity
Bone-patellar tendon-bone autograft reconstruction
Allograft reconstruction
Hamstring tendon intra-articular repair using a centrally placed tibial tunnel and an over-the-top femoral attachment
Extra-articular repair

Correct Answer: Reduced activity, rehabilitation exercises, and functional bracing until the patient is near skeletal maturity

Explanation:

Question 84:

Options:

Annual monitoring of serum metal ion levels
Repeated MRI with MARS in 6 months
Conversion of the THA to a cobalt alloy femoral head and polyethylene bearing
Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Correct Answer: Conversion of the THA to a ceramic femoral head with an inner titanium sleeve and polyethylene bearing

Explanation:

Question 85:

Options:

Improved skeletal muscle strength and secondary spinal support
Neuromodulation via presynaptic inhibition in the dorsal horn of the spinal cord
Distraction sensory input
Enhancement of muscle metabolic activity with improved lactic acid excretion
Placebo effect

Correct Answer: Neuromodulation via presynaptic inhibition in the dorsal horn of the spinal cord

Explanation:

Question 86:

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

Options:

Methotrexate
Gold
Hydroxychloroquine
TNF-a inhibitors
Smoking

Correct Answer: Smoking

Explanation:

DISCUSSION: Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature.
REFERENCES: Bibbo C, Anderson RB, Davis WH, et al: The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: Analysis of 725 procedures in 104 patients. Foot Ankle Int 2003;24:40-44.
Bibbo C, Goldberg JW: Infections and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int
2004;25:331-335.
Sorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg 2003;238:1-5.

Question 87:

Options:

Fracture of the ulnar component
Disengagement of the axle of the prosthesis
Failure of the triceps mechanism repair
Periprosthetic fracture of the humerus
Periprosthetic fracture of the ulna

Correct Answer: Failure of the triceps mechanism repair

Explanation:

Question 88:

A 12-year-old girl is seen for left ankle pain. Radiographs reveal osteochondritis dissecans (OCD) involving the talus. What should the parents be told regarding management?

Options:

No treatment is required because spontaneous healing is common.
Nonsurgical management typically relieves pain and results in radiographic healing in less than 12 weeks.
Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.
Hyperbaric oxygen treatment is helpful.
Ankle fusion is frequently necessary.

Correct Answer: Nonsurgical management frequently relieves pain but often may not result in radiographic healing even 6 months after treatment.

Explanation:

Question 89:

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Options:

Sling immobilization
Displacement and comminution
Age less than 40 years old
Immediate motion exercises
Male

Correct Answer: Sling immobilization

Explanation:

Question 90:

Options:

a long arm cast for 6 weeks, followed by a short arm cast for 6 weeks.
vascularized bone graft from the 1,2 intercompartmental supraretinacular artery.
open reduction and internal fixation with a differential pitch screw via a dorsal approach.
open reduction and internal fixation with a differential pitch screw via a volar approach
a removable thumb spica splint.

Correct Answer: open reduction and internal fixation with a differential pitch screw via a dorsal approach.

Explanation:

Question 91:

What is the most common complication following total disk arthroplasty in the lumbar spine?

Options:

Implant migration
Deep venous thrombosis
Transient retrograde ejaculation
Transient radicular leg pain
Incisional hernia

Correct Answer: Transient radicular leg pain

Explanation:

Question 92:

Options:

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

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 93:

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

Options:

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

Correct Answer: Flexible nailing of the femur and tibia

Explanation:

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur.
REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures:
A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654.
Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.
Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

Question 94:

A patient sustains a transection of the posterior cord of the brachial plexus from a knife injury. This injury would affect all of the following muscles EXCEPT?

Options:

Subscapularis
Latissimus dorsi
Supraspinatus
Teres minor
Brachioradialis

Correct Answer: Subscapularis

Explanation:

Question 95:

Options:

closed reduction and cast immobilization.
closed reduction, carpal tunnel release, and cast immobilization.
open reduction and ligament repair via a dorsal approach.
open reduction and ligament repair via a volar approach.
open reduction and ligament repair via dorsal and volar approaches and an extended carpal tunnel release.

Correct Answer: open reduction and ligament repair via dorsal and volar approaches and an extended carpal tunnel release.

Explanation:

DISCUSSION: A spectrum of perilunate injury patterns exists, with the dorsal trans-scaphoid perilunate fracture-dislocation being the most common. Perilunate injuries are highly unstable complex carpal disruptions that are not amenable to closed treatment. Open reduction and internal fixation is necessary to accurately restore carpal alignment via fracture reduction and fixation and intercarpal ligament repair. Controversy exists regarding the need for dorsal or combined dorsal and volar approaches. Based on the radiographic findings of a volar dislocation of the lunate and the associated median nerve injury, the patient requires open reduction and internal fixation via combined dorsal and volar approaches with a concomitant carpal tunnel release.
REFERENCES: Herzberg G, Forissier D: Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502.
Melone CP Jr, Murphy MS, Raskin KB: Perilunate injuries: Repair by dual dorsal and volar approaches. Hand Clin 2000;16:439-448.
Herzberg G, Comtet JJ, Linscheid RL, et al: Perilunate dislocations and fracture-dislocations:
A multicenter study. J Hand Surg Am 1993;18:768-779.

Question 96:

Options:

Hard cervical orthosis
Immobilization in cervico-thoraco-lumbo-sacral orthosis
Anterior decompression and fusion of C4-C7
Posterior decompression and fusion of C5-C6
Posterior decompression and fusion of C3-T2

Correct Answer: Hard cervical orthosis

Explanation:

Question 97:

What mechanism contributes to strength gains during conditioning of the preadolescent athlete?

Options:

Enhanced neurogenic adaptations
Advanced myogenic adaptations
Increased contractile proteins
Increased short-term energy sources
Thickening of the connective tissue

Correct Answer: Enhanced neurogenic adaptations

Explanation:

Question 98:

Options:

Rotator cuff tear
Epiphyseal stress fracture
Bicipital tendinitis
Internal impingement
Loose body

Correct Answer: Internal impingement

Explanation:

Question 99:

Options:

Inadequate restoration of the joint line
Patellar tendon rupture
Excessive internal rotation of the tibial component
Flexion gap instability
Hyperextension of the femoral component

Correct Answer: Flexion gap instability

Explanation:

DISCUSSION: Instability is a leading cause of failure following total knee arthroplasty. Instability can present as global instability, extension gap (varus/valgus) instability, or flexion gap (anterior/posterior) instability. Treatment options are numerous based on the exact pathology. The radiograph reveals anterior/posterior instability with dislocation consistent with flexion gap instability. A loose flexion gap can allow the femoral component to ride above the tibial cam post mechanism, resulting in dislocation. Distal femoral augments treat extension gap instability, whereas tibial augments can treat both flexion and extension gap instability. Posterior condyle augments at the distal femur can also be used to treat flexion gap instability. Flexion gap instability is further aggravated by extension mechanism incompetence. Note the excessively thin patella on the lateral radiograph.
REFERENCES: Pagnano MW, Hanssen AD, Lewallen DG, et al: Flexion instability after primary cruciate retaining total knee arthroplasty. Clin Orthop 1998;356:39-46.
McAuley J, Engh GA, Ammeen DJ: Treatment of the unstable total knee arthroplasty. Inst Course Lect 2004;53:237-241.
Naudie DD, Rorabeck CH: Managing instability in total knee arthroplasty with constrained and linked implants. Instr Course Lect 2004;53:207-215.

Question 100:

Options:

spinal manipulations.
posterior spinal fusion.
anterior/posterior spinal fusion.
spine staples placed thorascopically.
changing to a ‘spine-core’ flexible brace.

Correct Answer: posterior spinal fusion.

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

Orthopedic Board Review MCQs: Upper Extremity & Trauma | Part 120

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 120

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index