OITE & AAOS Orthopedic Board Review MCQs | Part 128

About This Board Review Set

This is Part 128 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 128

This module focuses heavily on: Ankle, Arthroplasty, Deformity, Foot, Fracture, Hip, Knee, Shoulder.

Sample Questions from This Set

Sample Question 1: What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?...

Sample Question 2: A 45-year-old right hand dominant female sustains a left shoulder injury after falling on ice 2 weeks ago. She is brought to the operating room for surgical intervention and positioned upright in a beach chair. Figures A and B are images ta...

Sample Question 3: A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?...

Sample Question 4: A high school football player asks you about an oral supplement that increases body mass and improves sprint times. He would like to use it to improve performance. What is the most likely agent? Review Topic...

Sample Question 5: Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination...

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

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Explanation

DISCUSSION: A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces.
According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.

Question 2

A 45-year-old right hand dominant female sustains a left shoulder injury after falling on ice 2 weeks ago. She is brought to the operating room for surgical intervention and positioned upright in a beach chair. Figures A and B are images taken from a posterior viewing portal with a 70 degree arthrosope. Figure C demonstrates the surgically repaired structure. Which of the following physical examination maneuvers would have been most likely abnormal in this patient PREOPERATIVELY? Review Topic

Explanation

The repaired structure is the subscapularis tendon, tested frequently with the Lift-off test.
Figure A as viewed from a posterior portal in the beach chair position of the left shoulder demonstrates a subscapularis tear with Figure B demonstrating medial instability of the long head of the biceps tendon. Figure C shows a repaired subscapularis to its footprint with double loaded screw-in anchors. A biceps tenodesis was concomitantly performed.
The key physical exam findings are positive Belly-press and Lift-off maneuvers, as well as weakness in internal rotation and increased passive external rotation. An MRI would confirm the diagnosis with discontinuity of the subscapularis and long-head of the biceps not located in the bicipital groove.
Faruqui et al present a Level 4 retrospective analysis of 52 patients. They found that the use of the belly press, lift-off, and bear hug tests had a collective sensitivity of 81%.
Yoon et al author a Level 2 prospective evaluation of 312 patients that underwent arthroscopic rotator cuff tear surgery. They investigated the sensitivity and specificity of the lift-off, internal rotation lag sign, belly-press, and bear-hug tests to evaluate subscapularis integrity. They found that a positive lift-off test was specific for the finding a full-thickness subscapularis tear. The lift-off, internal rotation lag sign, belly-press, and bear-hug tests show internal rotation strength deficit.
Figure A depicts an abnormal belly-press examination whereby the wrist flexes, and the elbow will fall posteriorly as the patient recruits the posterior deltoid to compensate for lack of the subscapularis. Illustration B demonstrates a normal belly-press examination. Illustration C shows a normal lift off test.
Incorrect Answers:
1: Jerk Test is positive if there is a 'clunk' or pain with the maneuver and is associated with posterior labral pathology. 2: Wright's test is where the shoulder is passively externally rotated and abducted while the patient turns their neck away from the tested extremity. It is a test for thoracic outlet syndrome. 4: Jobe's test is positive with supraspinatus weakness and or impingement. 5: Hornblower's test is positive if the arm falls into internal rotation. It may represent teres minor pathology.

Question 3

A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?

Explanation

DISCUSSION: The long thoracic nerve, which innervates the serratus anterior, is prone to injury because of its superficial location along the chest wall. The long thoracic nerve is derived from the roots of C5, C6, and C7. The spinal accessory nerve innervates the trapezius, and the thoracodorsal nerve innervates the latissimus dorsi. The posterior cord of the brachial plexus provides the axillary and the radial nerves.
REFERENCES: Hollinshead WH: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, pp 259-340.
Marmor L, Bechtal CO: Paralysis of the serratus anterior due to electric shock relieved by transplantation of the pectoralis major muscle: A case report. J Bone Joint Surg Am 1983;45:156-160.

Question 4

A high school football player asks you about an oral supplement that increases body mass and improves sprint times. He would like to use it to improve performance. What is the most likely agent? Review Topic

Explanation

The supplement is creatine. Approximately 17% of high school athletes and about 30% of high school football players use creatine. Creatine is a protein synthesized in the liver and the kidney, circulates in the bloodstream, and is incorporated into muscle. Its use is associated with increased muscle mass, short-term improvement in sprinting, and may allow for increased anaerobic resistance performance. Caffeine and ephedrine are taken orally but do not increase muscle mass. Testosterone and human growth hormone are both associated with increased body mass but must be injected.

Question 5

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. What is the UKA survivorship for a 55-year-old patient, compared with the survivorship for total knee arthroplasty?

Explanation

DISCUSSION:
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact anterior cruciate ligament (ACL). The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph aids the orthopaedic surgeon in determining the correction of the varus deformity and assessing the lateral compartment. An inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared with other age groups, but survivorship is lower for UKA than for TKA. No studies to date have shown any differences in survivorship between fixed-bearing and mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, which occurs in less than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA are low. Arthritis may progress faster in patients with mobile-bearing UKAs than in those with fixed-bearing UKAs.

Question 6

Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Explanation

Injuries to underlying vascular structures associated with clavicle fractures require exploration and stabilization. Brachial plexus injuries recover spontaneously in two thirds of patients. Displaced and segmental fractures may undergo closed reduction. Open treatment of clavicle fractures have been discouraged secondary to technical difficulties and nonunion. A floating shoulder (displaced clavicle and scapular neck fractures is an indication for ORIF but not humeral neck fracture.)

Question 7

What is the next most appropriate step in the orthopaedic management of this patient?

Explanation

Posterior column with articular impaction and a free fragment
Anterior column with articular impaction
Posterior wall with an intra-articular fragment
Posterior wall with articular impaction and a free intra-articular fragment
Posterior wall with articular impaction Corrent answer: 4
The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.
OrthoCash 2020
A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of
normal sexual function and normal vaginal childbirth.
sexual dysfunction (dyspareunia) and normal vaginal childbirth.
normal sexual function and caesarean section childbirth.
sexual dysfunction (dyspareunia) and caesarean section childbirth.
normal sexual function and caesarean section childbirth until hardware removal.
Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is
almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
OrthoCash 2020
A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?

Closed treatment and casting
Open reduction and internal fixation
Primary subtalar arthrodesis
Percutaneous fixation
External fixation
A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.
OrthoCash 2020
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
Radial head resection and lateral collateral ligament repair
Radial head arthroplasty alone
Radial head arthroplasty and lateral collateral ligament repair
Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair
The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.
OrthoCash 2020
A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C).
What is the most appropriate management for the femoral shaft fracture at this point?
Reamed intramedullary nailing
Traction
External fixation
Open plating
Mast suit
The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.
OrthoCash 2020
A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

MRI scan
Physical examination
Workers’ compensation status
Surgeon availability
Patient age
The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
OrthoCash 2020
A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?
Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.
Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
OrthoCash 2020
Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.
The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
OrthoCash 2020
Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?
Spiral
Oblique
Transverse
Segmental
Comminuted
A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.
OrthoCash 2020
A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?

Kocher-Langenbeck
Iliofemoral
Ilioinguinal
Extended iliofemoral
Triradiate approach
The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate
approaches although useful for this fracture, have a higher rate of complications.
OrthoCash 2020
An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

plating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius then pinning of the DRUJ in pronation.
This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
OrthoCash 2020
A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware
The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
OrthoCash 2020
Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?
A primed immune system with an increased risk of a systemic inflammatory response
Nothing since they are no longer in uncompensated shock and their vital signs have normalized
Higher nonunion rates after fracture fixation
Higher infection rates after definitive fracture fixation
Higher complication rates after temporizing external fixation of long bone fractures
Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.
OrthoCash 2020
A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is
intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?

Emergent four compartment fasciotomies
Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture
Elevation of the limb overnight and four compartment fasciotomies in the morning
Elevation of the limb overnight and a recheck of compartment pressures in the morning
Emergent MRI of the knee and leg Corrent answer: 2
The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.
OrthoCash 2020
Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?
The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.
Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
OrthoCash 2020
A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?
Infection
Malunion
Loss of forearm rotation
Refracture
Delayed union/nonunion
Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
OrthoCash 2020
The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?

Anterior superior iliac spine
Sciatic buttress
A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
The most superior portion of the roof of the acetabulum
Iliopectineal line
The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
OrthoCash 2020
A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure

Question 8

A 35-year-old woman who is a recreational runner reports posterior knee pain and tightness in the knee with flexion during running. She denies any history of trauma. Examination reveals normal patellar glide and tilt and no patellar apprehension. Range of motion is 5 degrees to 120 degrees, and quadriceps function and knee ligamentous examination are normal. Radiographs are normal. An MRI scan is shown Figure 18. What is the most likely diagnosis?

Explanation

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T₁- and T₂-weighted images. A lipoma would be bright on the T₁-weighted image only.
REFERENCES: Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.
Brown MF, Dandy DJ: Intra-articular ganglia of the knee. Arthroscopy 1990;6:322-323.

Question 9

A 13-year-old baseball pitcher presents with worsening medial-sided elbow pain. He pitches 7 months out of the year, throws 85 pitches per game and plays in two games per week. His fastball speed is approximately 75mph. He regularly plays outfield once he has been relieved of pitching. Which of the following is most likely contributing to his elbow pain? Review Topic

Explanation

Young athletes who throw greater than 80 pitches per game have an increased risk of shoulder and elbow injury. For a 13-year-old, the recommended maximum number of pitches per game is 75.
Little League elbow is a medial-sided overuse injury that occurs in the skeletally immature athlete. During execution of the baseball pitch, tremendous valgus and extension stresses occur at the elbow. Repetitive microtrauma can ultimately injure the medial epicondyle apophysis, ulnar collateral ligament or the flexor-pronator muscle mass. Limiting the number of pitches and innings played per game, as well as the number of months of competitive pitching per year, has been recommended to prevent these overuse injuries in the young athlete.
Olsen et al performed a case control study to determine risk factors associated with the development of shoulder and elbow injuries in adolescent baseball pitchers. Greater than 8 months of competitive pitching per year, more than 80 pitches per game and a fastball speed of greater than 85mph were all associated with increased risk of injury. Continued pitching despite arm fatigue and pain, being a starting pitcher, greater number of warm-up pitches, participating in showcases and regular use of NSAIDs were also associated with injury. The type of pitch (fastball, changeups and breaking balls) and continued play in a different position once being relieved was not associated with increased risk of injury.
Andrews et al authored a review article on ulnar collateral ligament injuries in throwing athletes. According to the USA Baseball Medical/Safety Advisory Committee, young baseball pitchers should avoid breaking pitches, such as curveballs and sliders, and avoid year-round baseball. A minimum of 3 months of complete rest from pitching per year is vital. Youth pitching coaches should be educated to ensure proper pitching mechanics are being reinforced.
Illustration A is a table depicting the recommended maximum number of pitches by age group.
Incorrect Answers:

Question 10

Varus intertrochanteric osteotomy for coxa valga commonly produces which of the following results?

Explanation

DISCUSSION: The greater trochanter is raised as a by-product of varus osteotomy, and a temporary abductor lag and lurch is common for 6 months following surgery. In the absence of hip joint subluxation, varus intertrochanteric osteotomy has no effect on the center edge angle of Wiberg. Varus osteotomy typically increases femoral offset, thereby improving the abductor lever arm and reducing the hip joint reaction force. Even without taking a wedge, varus osteotomy always produces some degree of shortening.
REFERENCE: Millis MB, Murphy SB, Poss R : Osteotomies about the hip for the prevention and treatment of osteoarthrosis. Instr Course Lect 1996;45:209-226.

Question 11

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Explanation

Pitchers change rotation during adolescent growth with external rotation of the proximal humerus. The result is increased external rotation and decreased internal rotation, resulting in a normal total arc of motion. External rotation lengthens the arc of acceleration, resulting in increased velocity. The shorter arc of internal rotation, associated with a tight posterior capsule, makes deceleration of the arm more difficult, which may lead to overuse injuries.

Question 12

Which of the following statements is true regarding articular cartilage?

Explanation

The one role of collagen in articular cartilage is to provide the structural framework to resist swelling under high osmotic tissue pressures created by aggrecan. Type II collagen is the predominant type in articular cartilage.
Proteoglycans, the most common of which is aggrecan, are produced by chondrocytes and give articular cartilage its hydrophilic properties. Multiple glycosaminoglycans (GAGs), such as chondroitin and keratin can attach to core proteins to form aggrecans. Link proteins then help aggrecans interact with hyaluronic acid. The negative charge of this complex helps create a strong osmotic gradient, which attracts water and increases tissue pressures. Normal aging involves a decrease in the water content of the extracellular matrix while osteoarthritis is associated with increased water content, which leads to loss of strength and elasticity.
Chen et al. evaluated the strain and depth related properties of articular cartilage in bovine models. They found that the zero-strain permeability, zero-strain equilibrium confined compression modulus, and deformation dependence constant differed among the layers of cartilage. They suggest that the complex strain-dependent properties of articular cartilage of different thickness and location have clinical implications for tissue engineering.
Illustration A is a diagram depicting the extracellular matrix of articular cartilage. Incorrect Answers:

Question 13

Figures 15a and 15b are intrasurgical photographs from the posterolateral viewing portal that were taken at the beginning and end of a right shoulder arthroscopic procedure performed on a 54-year-old man. This technique demonstrates superior results compared to traditional arthroscopic techniques when evaluating which outcome?

Explanation

CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 17
Figure 16 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop," and then he needed help walking off the field. His knee is visibly swollen.

Question 14

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 15

The plate seen in Figure 48a was applied to the fracture seen in Figure 48b, and is functioning in what capacity?

Explanation

DISCUSSION: A Weber type B ankle fracture occurs with a supination external rotation mechanism of injury. The fibula generally fails with a spiral fracture pattern. The lag screws provide compression, and the plate acts to neutralize rotational and angular bending forces. A buttress plate resists vertical shear forces. A tension band is used over areas that may fail in tension, such as an olecranon fracture. Compression is provided by the lag screws, and distraction is again resisted by the lag screws.
REFERENCE: Mazzoca AD: Principles of internal fixation, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 308-309.

Question 16

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Explanation

Question 17

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Explanation

A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle. Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexor-pronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

Question 18

A patient is treated with volar plating for a distal radius fracture. The CT scan shown in Figure 15 is obtained after union of the fracture because the patient reports ongoing symptoms. The prominent hardware is most likely injuring what tendon?

Explanation

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 19

A 32-year-old man is brought to the emergency department after being involved in an MVC. He is found to have a closed left femoral shaft fracture (Figures A and B) and a Glasgow Coma Scale (GCS) score of 13. A CT scan of the head is performed and demonstrates no significant bleeding. He has no other injuries and is hemodynamically stable. Which of the following statements is true?

Explanation

Early stabilization of femur fractures in patients with concomitant head injuries has been found to have no increased risk of worsening neurologic outcomes.
Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggests that intramedullary nails done acutely
leads to decreased pulmonary complications, decreased thromboembolic events, improved rehabilitation, decreased length of stay and cost of hospitalization, and improved GCS scores on discharge. However, it is important to note that intraoperative hypotension should be avoided in these patients, as it has been associated with worsening outcomes following acute intramedullary nailing of the femur.
Starr et al. performed a retrospective study to determine if the timing of treatment of femur fractures in patients with an associated head injury had an effect on the risk of pulmonary and CNS complications. They found that delaying fracture stabilization (> 24 hours) made pulmonary complications 45 times more likely, while early fracture stabilization had no effect on the risk of CNS complications.
McKee et al. performed a retrospective case-control study to determine the effect of early intramedullary nailing of femoral shaft fractures on the neurologic outcome of patients with multiple injuries and a concomitant head injury. They found no significant differences between the two groups in terms of early mortality, length of hospital/ICU stay, level of neurologic disability, or results of cognitive testing. Their results support the continued early intramedullary nailing of femoral fractures for patients with a concomitant head injury.
Richards et al. performed a retrospective study evaluating lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation (< 24 hours) and its effects on pulmonary complications (defined as mechanical ventilation lasting ≥ 5 days). They found that a median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥ 5 days, whereas a median preoperative lactate of 2.8 mmol/L was not.
Figures A and B are radiographs demonstrating a transverse femoral shaft fracture.
Incorrect Answers:
OrthoCash 2020

Question 20

A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint. He denies any history of similar symptoms. What is the first step in evaluation?

Explanation

DISCUSSION: The patient’s symptoms are typical for gouty arthropathy, and the diagnosis can only be confirmed with aspiration and visualization of the crystals. A concomitant infection also must be ruled out; therefore, it is important to obtain a cell count and culture. Colchicine may have a role in gouty management, but the diagnosis must be confirmed. Allopurinol is not effective in acute gouty arthropathy. Measurement of serum uric acid levels is often not helpful in making a definitive diagnosis. Steroid injections should be deferred until cell count and culture results indicate no accompanying infection.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.
Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA, WB Saunders, 1991,

pp 1712-1718.

Question 21

Figures 29a and 29b show the AP radiograph and CT scan of a 70-year-old man who has left thigh pain. Serum protein electrophoresis shows a monoclonal gammopathy. Additional radiographs of the femur show other lesions. Management should consist of

Explanation

DISCUSSION: The underlying diagnosis is multiple myeloma. Because the patient has a large lucent lesion in the peritrochanteric region of the left proximal femur, the risk of pathologic fracture is high. Consideration should be given to prophylactic internal fixation with a locked intramedullary rod. The lesion does not appear to be a sarcoma requiring wide resection and endoprosthetic reconstruction. Neither chemotherapy nor radiation therapy alone is likely to result in long-term stabilization of the proximal femur. Postoperative treatment with bisphosphonates and radiation therapy is indicated to decrease the risk of future pathologic fractures. The patient should also be referred to a medical oncologist for medical management.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 364.
Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.

Question 22

A 17-year-old male football player is seen 1 week after developing symptoms of infectious mononucleosis in the middle of the season. Examination reveals evidence of splenomegaly. He and his parents want to know if he can play in a game the following day. What is the most appropriate recommendation? Review Topic

Explanation

Infectious mononucleosis (IMN) is a self-limiting viral (Epstein-Barr virus) infection that affects mostly adolescents. One of the clinical findings in IMN is splenomegaly. Unfortunately, the splenomegaly is palpable only 50% of the time. The risk for spontaneous splenic rupture is highest 3 weeks after the onset of symptoms. Thus, most clinicians recommend return to contact sports after 4 weeks from the onset of symptoms. This patient presented 1 week after the onset of symptoms, so he can return to play in 3-4 weeks from the time he was examined. The athlete should be afebrile, well hydrated, and asymptomatic. Airway obstruction is usually not of concern. Disease transmission to teammates is possible in the acute phases.

Question 23

Figure below shows the radiograph obtained from a 76-year-old woman who has sharp pain in her groin, thigh, and buttocks that worsens with activity. She has been dealing with this pain for more than a year but is otherwise healthy. Recently, she has begun to notice night pain. The pain no longer responds to NSAIDs. She would like to be able to dance at her daughter's wedding in 4 months and wonders how best to proceed. What is the best next step?

Explanation

DISCUSSION:
The next best course of action is total hip arthroplasty. The patient is an otherwise healthy woman requesting pain relief and expresses a desire to be dancing in 4 months. She has had more than 6 months of symptoms that are classic hip osteoarthritis symptoms, with pain in the groin and thigh. Severe osteoarthritis is seen in the radiograph as well. NSAIDs are no longer working. Given the objective findings, the subjective reports, and the duration of symptoms, this patient merits surgery. Consideration for steroid injection is reasonable, but given her desire to be dancing in 4 months, an injection would increase her risk of infection if total hip arthroplasty were to be performed within 3 months of the
injection.

Question 24

A 45-year-old previously healthy woman has experienced weakness and fatigability for 2 months. She states she feels best in the morning, but tires easily with exertion. If she sits and rests her strength improves, but she easily tires with each activity. When her fatigue is most severe, she has double vision. Physical examination is positive for ptosis with upward gaze after 20 seconds. When she holds her arms out straight she shows good initial strength, but rapidly decreasing strength with time. What is the pathologic cause of her muscle weakness? Review Topic

Explanation

The patient has myasthenia gravis, which has its onset in middle age and causes progressive weakness because of the loss of acetylcholine receptors secondary to autoimmune antibodies at the NM junction. Rest periods allow uptake of acetylcholine and initial strength, but easy fatigability. Treatment is aimed at immunomodulation; acetyl cholinesterase inhibitors often coupled with thymectomy can control symptoms. Decreased release of acetylcholine at the NM junction is the effect of a nondepolarizing drug or toxin botulinum. Patients with muscular dystrophy lack dystrophin that acts at the sarcolemma to regulate calcium channels, and onset of this condition occurs at a younger age. The decrease in myelin indicates Charcot-Marie-Tooth disease and is often seen with long axon degeneration, such as in the feet and lower legs.

Question 25

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

Explanation

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

Question 26

Which of the following pieces of equipment currently offers the greatest opportunity for lowering the number of equestrian injuries? Review Topic

Explanation

Ball and associates reported that "horseback riding was more dangerous than motorcycle riding." In a 10-year study of major traumatic injuries, they reported that 151 (2%) of 7,941 trauma patients had major equestrian injuries (injury severity score
> or = 12). Injuries included the chest (54%), head (48%), abdomen (22%), and extremities (17%). Only 9% of riders wore helmets, and 64% believed the accident was preventable. The authors noted that "helmet and vest use will be targeted in future injury prevention strategies." In another study, Frankel and associates noted that helmet use was only documented in 34% of riders. Although orthopaedic injuries are common, knee pads, wrist guards, boots, and quick release stirrups would most likely have less impact on injury prevention.

Question 27

A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?

Explanation

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 28

A 70-year-old man undergoes removal of an infected total hip arthroplasty (THA) and insertion of an articulating antibiotic-loaded spacer to treat a deep periprosthetic hip infection. While in a nursing home receiving intravenous antibiotics 3 weeks after surgery, the patient trips and falls. Examination reveals swelling in the mid and distal thigh, intact skin and neurovascular structures, and severe pain with knee or hip movement. Radiographs of the femur are shown in Figures 1 through 4. What is the most appropriate treatment for the fracture below the implant?

Explanation

DISCUSSION:
This patient has a type C periprosthetic femoral fracture. The articulating spacer is not involved in the fracture, which is well distal to the implant. The most appropriate treatment is open reduction and internal fixation of the fracture. Traction is not appropriate for this fracture because the injury can be treated surgically despite the history of previous hip infection. Traction would also be needed for at least 5 weeks and would delay the surgical treatment of the periprosthetic fracture until the time of second-stage revision THA. The fracture is fairly distal, and revision to a longer antibiotic-loaded implant or uncemented stem is not suitable for this fracture pattern, because it extends well past the isthmus. A femoral stem in the distal fragment would provide little stability for the fracture. Removal of the articulating spacer and reimplantation using a long-stem fluted uncemented hip replacement is not appropriate, because it would be premature to reimplant the man's hip while he is still receiving treatment for a deep hip infection.

Question 29

A resident arrives to the operating room late for a LEFT carpal tunnel release procedure. The patient is prepped and draped under general anaesthesia, and the attending surgeon and assistant are about to make an incision to the RIGHT carpal tunnel. The resident mentions to the attending surgeon that surgery was booked for the opposite limb, but he ignores the residents confers by saying the surgical mark is under the drape. What would be the most appropriate course of action for the resident at this time? Review Topic

Explanation

The most appropriate course of action for the resident at this time would be to perform a surgical timeout prior to the operation.
Wrong-site surgery is completely preventable by having the surgeon, in consultation with the patient when possible, place his or her initials on the operative site using a permanent marking pen and then operating through or adjacent to his or her initials. The intended site should be marked such that the mark will be visible after the patient has been prepped and draped. A "time-out" procedure should be done before the initiating of any surgical procedure to confirm the type of procedure, site, and side with all operating room personnel including residents.
Haynes et al. reviewed the effect of surgical safety checklists before surgery on the morbidity and mortality in a global population. They found the rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).
Incorrect Answers:

Question 30

Long-term alendronate (Fosamax) use for osteoporosis has been associated with which of the following?

Explanation

Alendronate is a bisphosphonate that inhibits the ruffled border of the osteoclast. When used long term, this class of medication prevents the normal bone remodeling process. Long-term use has recently been shown to be associated with insufficiency
fractures of the femur. Osteonecrosis of the jaw has been described but not in other anatomic locations. Scurvy occurs because of a lack of vitamin C and use of bisphosphonates is not associated with uterine cancer or a detached retina.

Question 31

-A 32-year-old man who is a smoker sustained an open tibial fracture and underwent a staged treatment with placement of an intramedullary nail. Four weeks after surgery, he developed a pseudomonas deepwound infection. What is the strongest predictor of persistent infection if implants are retained until fracture union?

Explanation

Question 32

A 41-year-old male underwent intramedullary nailing for a low-energy left femoral shaft fracture. At his follow-up appointment, he complains that his feet are pointing in opposite directions when walking. Using the imaging study shown in Figure A, which of the following represents this patient's left femur malalignment?

Explanation

Figure A shows axial CT scan slices of the pelvis and knee. On the operative left side, there is an internal rotation malalignment of 21° compared to the contralateral side (44°-23°=21°).
Radiographic rotational malalignment after fixation of femoral shaft fractures may be measured by comparing the femoral anteversion of both femurs. This can be determined by measuring the angle between a line tangential to the dorsal bony contours of the femoral condyles and a line drawn through the axis of the femoral neck. Rotational differences of less than 10° are considered variations of normal.
Jaarsma et al. reviewed rotational malalignment after intramedullary nailing of femoral fractures. They report that rotational measurements by CT are superior to clinical assessment. They note a high incidence of malrotation after IM nailing of fractures. This has shown to be in the range 15% to 30%.
Figure A shows left femoral malrotation using CT-torsion measurements with axial cuts of the femoral neck and distal femoral condyles. Note the normal anteversion of the right femur (23 degrees; normal range 10-25).
Incorrect Answers:

Question 33

Which of the following findings is an indication for adjunctive use of high-dose steroids?

Explanation

DISCUSSION: According to NASCIS III, the high-dose steroid protocol involves infusion of 30 mg/kg methylprednisolone followed by 5.4 mg/kg/h for 24 hours if the patient has sustained a spinal cord injury within the last 3 hours. The drip is continued for 48 hours if administration is started between 3 and 8 hours of the onset of neurologic deficit. No benefit has been conclusively demonstrated with steroids administered beginning 8 hours or longer after injury. Steroid use is not indicated for nerve root deficits, brachial plexus deficits, or gunshot wounds.
REFERENCES: Kellam JF, Fischer TJ, Tornetta P III, Bosse MJ, Harris MB (eds): Orthopaedic Knowledge Update: Trauma 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 319-328.
Bracken MB, Shepard MJ, Holford TR, et al: Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: Results of the Third National Acute Spinal Cord Injury randomized controlled trial. National Acute Spinal Cord Injury Study. JAMA 1997;277:1597-1604.

Question 34

A 24-year-old professional male soccer player has lower abdominal pain on exertion. He has pain with resisted hip adduction and with sit-ups. There is no palpable inguinal hernia with a Valsalva maneuver. Nonsurgical management has failed to provide relief. After ruling out malignancies, what is the next most appropriate step in management? Review Topic

Explanation

The patient has a sports hernia or athletic pubalgia. The exact nature of this pathology is not well understood. MRI scans are not very helpful in making a diagnosis. In high-performance athletes who have failed to respond to nonsurgical management, surgical intervention is needed to strengthen the anterior pelvic floor. Additional nonsurgical management at this point will not improve symptoms. Cortisone injection will not strengthen the pelvic floor. CT scan of the pelvis is valuable to rule out bony injuries such as osteitis pubis. Ultrasound of the scrotum will have no additional diagnostic use in management of this patient.

Question 35

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of

Explanation

DISCUSSION: Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed.
REFERENCES: Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.
Sangeorzan BJ, Veith RG, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joint by arthrodesis. Foot Ankle 1990;10:193-200.

Question 36

A 21-year-old college student reports hearing a pop and has acute pain laterally over the ankle after twisting it during a recreational basketball game. Examination 1 hour after the injury reveals minimal swelling and ecchymosis. The anterior drawer sign is positive. Radiographs reveal no evidence of a fracture. What is the best course of action?

Explanation

DISCUSSION: Even though the patient has a grade 3 ankle ligament injury, studies have shown that 95% of patients with a grade 3 injury that may include a complete tear of the ligaments will heal successfully with conservative functional management. Extensive diagnostic evaluation with stress radiographs, CT, and MRI is not indicated. Surgical reconstruction is not indicated because of the overwhelming success of conservative management; however, in the few patients where late instability develops, surgical reconstruction offers an excellent outcome.
REFERENCES: Carne P: Nonsurgical treatment of ankle sprains using the modified Sarmiento brace. Am J Sports Med 1989;17:253-257.
Hamilton WG: Sprained ankles in ballet dancers. Foot Ankle 1982;3:99-102.

Question 37

An article in a leading orthopaedic journal describes a randomized controlled study comparing 2 popular and comparable surgical methods for fixation of hip fractures. Patients were randomized by a predetermined computer-generated list. There was approximately 20% crossover between treatment groups. Evaluation of study outcomes (clinical and radiographs) was performed by one of the surgeons participating in the study. Enrollment goals for appropriate power were achieved and final 1-year follow-up was obtained for 65% of patients. According to Oxford Group criteria, what is the appropriate level of evidence for this study? Review Topic

Explanation

Although this is a randomized controlled study, there is substantial crossover between the treatment groups, evaluation could not be blinded (radiographs) and was performed by one of the surgeons, and follow-up was moderate. According to Oxford Group criteria, this would be a Level II study.

Question 38

A 66-year-old woman with known poorly controlled rheumatoid arthritis reports that for the past 4 weeks she has been unable to extend the metacarpophalangeal (MCP) joints of her right hand index, middle, ring and little fingers. She cannot hyperextend the thumb interphalangeal joint. Active wrist extension is possible, but shows radial deviation. Examination reveals mild synovitis at the wrist and MCP joints of the affected hand. There is no ulnar deviation at the MCP joints with normal alignment. When the MCP joints are passively extended, the patient is unable to maintain them in this position. There is no piano key sign at the distal ulna. Passive wrist motion shows a normal tenodesis effect. Which of the following would most likely confirm your diagnosis? Review Topic

Explanation

There are many causes of inability to extend the MCP joints in a patient with rheumatoid arthritis. The most common cause is rupture of the extensor tendons. An intact tenodesis test suggests that the extensor tendons are intact, thus surgical exploration is not indicated and would not confirm the diagnosis. The patient has normal alignment of the fingers without ulnar deviation, suggesting that there are no MCP dislocations to account for the inability to extend the MCP joints; therefore, radiographs would not confirm the diagnosis. The most likely cause of inability to extend the fingers in this patient is posterior interosseous nerve (PIN) palsy. Electrodiagnostic studies would confirm the presence of PIN palsy. An MRI of the elbow may show synovitis at the radiocapitellar joint, which can cause the PIN palsy. This finding however, is nonspecific and many patients without PIN palsy would also demonstrate synovitis at the radiocapitellar joint. Therefore, although an MRI would be helpful in localizing a potential cause of PIN compression, it would not in itself confirm the diagnosis.

Question 39

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 40

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Explanation

Induction coupling stimulates bone growth by increasing expression of BMP7, BMP2, TGF-beta1, and by increasing osteoblasts proliferation. Induction coupling has not been shown to have the effect of decreasing osteoclast differentiation.
In basic science studies, electrical stimulation (i.e. induction coupling), has been shown to promote bone healing via release of growth factors that induce osteoblast differentiation/proliferation. Electrical current can be placed around bone in various ways, creating a current to stimulate growth factor release and subsequent osteoblast proliferation.
Aaron et al. summarized, in a systematic review, the effects of various types of electrical stimulation on bone and bone healing. Regardless of type (i.e. inductive coupling, capacitive coupling, direct current), they report electricity and/or electromagnetic fields promote gene expression of growth factors that promote an osteogenic environment.
Illustration A depicts a cathode placed directly to allograft with a subcutaneously placed electrical stimulator. Illustration B depicts cathodes placed anteriorly and posteriorly around the hip, connected to an outside power source to create the necessary current. Illustration C depicts an inductive coil placed laterally on the skin in order to create an electrical current.
Incorrect answers:

Question 41

A year-old man with a body mass index of 31 had a month gradual onset of right medial knee pain. Examination revealed a small effusion, stable ligaments, a normally tracking patella, and mild medial joint line tenderness. Standing radiographs show mild medial joint space narrowing. Effective treatment at this stage of early medial compartmental osteoarthritis includes

Explanation

DISCUSSION:
According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee (Nonarthroplasty), level 1 evidence confirms that weight loss and exercise benefit patients with knee osteoarthritis. The other responses have either inclusive evidence (a valgus-directing brace) or no evidence to support their use (glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day as well as
arthroscopic debridement and lavage).

Question 42

A 24-year-old man sustained a grade IIIb open tibial fracture and an ipsilateral grade IIIa femoral fracture in a motorcycle accident. He is unresponsive, intubated, and has a Glasgow Coma Scale score of 8. He is resuscitated and taken to the operating room for definitive orthopaedic care. Which of the following intraoperative problems will most likely adversely affect his long-term outcome?

Explanation

DISCUSSION: Traumatic brain injury is considered to be either primary or secondary. Primary injury is direct or impact damage to the brain, and secondary injury can have intracranial or systemic causes. While treatment has little impact on primary brain injury, secondary brain injury can be avoided. There are also many causes of intracranial secondary brain injury, including intracranial hypertension or cerebral edema. There are many causes of systemic secondary brain injury, but none has a greater impact on outcome than hypotension or hypoxia. In fact, the occurrence of hypotension postinjury causes a 10- to 15-fold increase in mortality. In a series by Pietropaoli and associates, the mortality rate for head-injured patients that were normotensive during surgery was 25%, but if they were hypotensive the mortality rate was 82%. In the same series, the number of patients with a Glasgow Coma Scale score of either 4 or 5 dropped from 58% in those patients that were normotensive during surgery to 6% in those patients that became hypotensive during surgery. Efforts to avoid hypotension postinjury and especially during surgery should be of primary importance.
REFERENCES: Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-222.
Pietropaoli JA, Rogers FB, Shackford SR, Wald SL, Schmoker JD, Zhuang J: The deleterious effects of intraoperative hypotension on outcome in patients with severe head injury. J Trauma 1992;33:403-407.
Schmeling GJ, Schwab JP: Polytrauma care: The effect of head injuries and timing of skeletal fixation. Clin Orthop 1995;318:106-116.
Townsend RN, Lheureau T, Protech J, Reimer B, Simon D: Timing fracture repair in patients with severe brain injury (Glascow Coma Scale score <9). J Trauma 1998;44:977-983.

Question 43

A defect in the gene coding for fibrillin-1 would lead to which diagnosis? Review Topic

Explanation

A defect in fibrillin-1 is the underlying cause of Marfan Syndrome.
Marfan Syndrome is a genetic disorder of connective tissue typically caused by a mutation in the gene coding for the fibrillin-1 protein. Affected patients are typically very tall with long limbs and thin fingers and toes. Marfan Syndrome patients have many common features including ectopic lens, aortic root dilation, scoliosis, protrusio acetabuli, and ligamentous laxity.
Shirley et al. present a review of Marfan Syndrome with emphasis on the musculoskeletal manifestations including ligamentous laxity, protrusio acetabuli, and scoliosis. They note that scoliosis in these patients, when compared to those with idiopathic scoliosis, commonly progresses faster, is more resistant to bracing, and has a higher association with dural ectasia.
Dean presents a review of Marfan Syndrome and its underlying genetic cause of a mutation in fibrillin. They state that diagnosis can be made using the Ghent nosology (see Illustration A) which can diagnose or rule out the condition in 86% of patients. They caution using these criteria in young children as some features of Marfan Syndrome may not present until later ages.
Illustration A is a summary of the 2010 Revised Ghent nosology for diagnosing Marfan Syndrome.
Incorrect Answers:

Question 44

Figure 1 is the clinical photograph of a 64-year-old man who crashed while riding his motorcycle. An examination reveals his long-finger metacarpophalangeal (MP) joint is stuck in extension. He cannot passively or actively flex at the MP joint. A hand radiograph is seen in Figure 2. Which interposed structure is preventing reduction?

Explanation

EXPLANATION:
This patient has a dorsally dislocated MP joint. In these cases, the volar plate can be displaced dorsal to the metacarpal head, preventing reduction. Although early publications described a “noose effect” of the lumbrical and flexor tendons, the primary block to reduction is the volar plate. Simple MP dislocations can be reduced closed by flexing the wrist and then gently sliding the base of the proximal phalanx over the end of the metacarpal. Longitudinal traction on the finger will only incarcerate the volar plate further and should be avoided. Patients with complex dislocations that fail closed reduction require open
reduction.

Question 45

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

Explanation

DISCUSSION: Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury.
REFERENCES: Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Gerber C, Sebesta A: Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report. J Shoulder Elbow Surg 2000;9:483-490.

Question 46

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

Explanation

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

Question 47

What do the T2-weighted, fat-saturated MRI scans shown in Figures 76a through 76d reveal? Review Topic

Explanation

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 48

What artery provides the only direct vascularizaton to both the intraneural and extraneural blood supply of the ulnar nerve just proximal to the cubital tunnel?

Explanation

DISCUSSION: The superior ulnar collateral, inferior ulnar collateral, and posterior ulnar recurrent arteries provide consistent vascular supply to the ulnar nerve. This supply is segmental in nature. No identifiable direct anastomosis is seen between the superior ulnar collateral and the posterior ulnar recurrent arteries. The inferior ulnar collateral artery provides the only direct vascularization to the nerve and is located in the region just proximal to the cubital tunnel. The segmental nature of the blood supply to the ulnar nerve underscores the importance of its preservation during transposition.
REFERENCE: Yamaguchi K, Sweet FA, Bindra R, et al: The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J Shoulder Elbow Surg 1999;8:17-21.

Question 49

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 50

A 42-year-old woman is brought to the emergency department following a motor vehicle accident. She has sustained multiple injuries, and she is intubated and pharmacologically paralyzed. Sagittal cervical CT scans through the right cervical facets, the left cervical facets, and the midline are shown in Figures 12a through 12c, respectively. Definitive management of her cervical injury should consist of Review Topic

Explanation

The CT scans reveal an occipital-cervical dissociation with subluxation of the occipitocervical joints bilaterally. Definitive management should consist of an occipital-cervical fusion with instrumentation. Immobilization in a Philadelphia collar is inadequate for this highly unstable injury, and halo immobilization, while affording adequate temporary immobilization, is not appropriate definitive management for this ligamentous injury. The patient does not have an injury at C4-C5 or C6-C7.

Question 51

The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Explanation

Figure 50A: AP pelvis with a 1 cm lucency in the calcar region of the femoral neck and diffuse osteopenia of the proximal femur. Figure 50B: CT scan of the same patient showing a well demarcated lcm lesion in the femoral neck with an obvious nidus. Careful evaluation of the radiographs is critical in this question. First the obvious osteoid osteoma must be recognized. From there answers 2 and 3 can be eliminated. Neither radiograph reveals any sign that treatment has occurred, and the CT scan shows no signs of extensive involvement, thus answer 5 should also be eliminated. The real key is believing that such diffuse osteoporosis could occur in such a young child, as Jones described in his article from 1969.

Question 52

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Explanation

Question 53

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Explanation

DISCUSSION:
This situation represents a definitively and chronically infected knee replacement. Antibiotic therapy alone might suppress the infection but would not eradicate it. Debridement and polyethylene exchange would be appropriate treatment for an early postoperative infection. The treatment of choice is to perform a two-stage debridement and reconstruction. Although not among the listed choices, an aspiration or culture could be done presurgically and might help clinicians identify the best antibiotics to treat the condition. Antibiotic selection would not affect the need for the two-stage reconstruction, however.

Question 54

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured? Review Topic

Explanation

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.

Question 55

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Explanation

The patient presents with MRI suggestive of far lateral disc herniation at the L3-L4 disc space. He would be expected to have symptoms in L3 nerve distribution, near the medial epicondyle of the femur. Associated motor manifestations may include quadriceps weakness and/or diminished patellar reflex.
Far lateral disc herniations constitute approximately 5-10 percent of disc hernations in the lumbar spine. Given the more vertical anatomy of lumbar nerve roots, at a given disc level, a central or paracentral herniation will affect the traversing nerve root (e.g. nerve root of level below) and a far lateral herniation will affect the exiting nerve root (e.g. nerve root of the level above). Similar to the more common central and paracentral herniations, approximately 90% of patients will improve without surgical intervention. When surgical intervention is needed, the paraspinal approach of Wiltse is utilized.
Marquadt et al. reported long term outcomes of surgical management of far lateral disc herniations. At an average of 146 months follow up, 56.3% of patients had complete relief of symptoms and 27.6% had permanent residual symptoms. Over 75% of patients subjectively rated their outcomes as excellent.
Figure A and B are T2 and T1 axial MRI images, respectively, showing the L3-L4 disc space with a left far lateral disc herniation. Figure C is a left parasagittal T2 MRI image showing impingement on the L3 nerve root. Structures are labeled in illustration A. Illustration B shows the dermatomes of the lower extremity.
Incorrect Answers:

Question 56

A 19-year-old woman reports persistent neck pain for 2 years. Pain is relieved with aspirin. A bone scan shows intense uptake in the superior, posterior portion of the C3 vertebral body. A sagittal CT reconstruction is shown in Figure 5. Treatment should consist of

Explanation

DISCUSSION: The CT scan shows an osteoblastic nidus pathognomic for an osteoid osteoma. Surgical treatment should include an en bloc excision of the lesion. Surgical treatment is not mandatory because the lesion often becomes asymptomatic over time. This lesion is not amenable to radiofrequency ablation due to its proximity to the spinal cord. A complete corpectomy is not necessary to adequately resect the lesion, as only the nidus needs to be removed. Radiation therapy and antibiotics are not appropriate treatments for an osteoid osteoma. Posterior C2-C3 fusion will not address the pathology.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
Hadjipavlou AG, Lander PH, Marchesi D, et al: Minimally invasive surgery for ablation of osteoid osteoma of the spine. Spine 2003;28:E472-E477.

Question 57

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Explanation

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions

(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 58

What is the preferred treatment of a patient with breast cancer and a pathologic fracture of the clavicle in her dominant arm?

Explanation

DISCUSSION: Closed management should be attempted for upper extremity pathologic fractures, particularly the clavicle. If nonunion or pain persists, surgery may be indicated. Radiofrequency ablation is not indicated for subcutaneous bones. Early motion is likely to cause increased pain and disability.
REFERENCES: Weber KC, Lewis VO, Randall RL, Lee AK, Springfield D: An approach to the management of the patient with metastatic bone disease. Instr Course Lect 2004;53:663-676.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons 2002, p 331.

Question 59

A 12-year-old boy reports knee discomfort after prolonged strenuous activities. He denies knee swelling or catching and has no pain with activities of daily living. A radiograph is shown in Figure 4. Prognosis for the pathology shown is most influenced by

Explanation

DISCUSSION: While many factors play a role in the outcome of osteochondritis dissecans, ample evidence has shown that the prognosis is most influenced by the growth status of the plates. If the growth plates are open, the chance of a successful outcome is significantly greater than if they are closed.
REFERENCES: Federico DJ, Lynch JK, Jokl P: Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197.
Linden B: Osteochondritis dissecans of the femoral condyles: A long-term follow-up study. J Bone Joint Surg Am 1977;59:769-776.

Question 60

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan? Review Topic

Explanation

The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.

Question 61

Figure 91 is the radiograph of a 20-year-old man who kicked a door while intoxicated. At the emergency department, his leg is placed into a long-leg cast. After 2 hours, he reports increasing pain, numbness, and tingling in his toes. What is the most appropriate initial treatment?

Explanation

Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 62

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

Explanation

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

Question 63

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Explanation

DISCUSSION: Left ventricular hypertrophy by voltage is a nonspecific diagnosis, especially in athletes with an asthenic body habitus. High vagal tone in endurance athletes may result in first degree or even type I second degree (ie, Wenckebach) AV block in endurance athletes. High vagal tone results in resting sinus bradycardia in many trained athletes. A I-II/IV systolic ejection murmur is occasionally found in healthy athletes; however, when the murmur increases in intensity with maneuvers that decrease ventricular filling, such as standing or the Valsalva maneuver, dynamic obstruction that is the result of hypertrophic obstructive cardiomyopathy should be suspected. Nonspecific STT wave changes in the lateral leads on ECG are not uncommon in highly trained athletes; thus, they are nonspecific for ischemic heart disease.
REFERENCES: Pelliccia A, Maron BJ, Culasso F, DiPaolo FM, et al: Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278-284.
Maron BJ, Thompson PD, Puffer JC, McGrew CA: Cardiovascular preparticipation screening of competitive athletes: A statement for health professionals from the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association. Circulation 1996;94:850-856.

Question 64

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Explanation

DISCUSSION: The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
REFERENCES: Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intra-articular calcaneal fractures: Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95.

Question 65

A 12-year-old girl has back pain after falling 20 feet and landing in the sitting position. She has no fractures or other injuries, and her neurologic examination is normal. A lateral radiograph, transverse CT scan, and reformatted sagittal CT scan are shown in Figures 25a through 25c. Which of the following methods is associated with the best long-term outcome? Review Topic

Explanation

The patient has a displaced burst fracture. Fusion with instrumentation has shown better results than casting alone. Posterior fusion with instrumentation, with sagittal plane correction, yields the best results. Decompression occurs indirectly with correction of the kyphosis. Anterior decompression is unnecessary.

Question 66

Figures 39a through 39c show a clinical photograph and the radiographs of a 32-year-old woman who has been unable to actively extend her dominant ring and small finger for the past two weeks. She has no history of trauma and has minimal pain. Examination reveals full passive range of motion (ROM) of the fingers. Active ROM of the wrist is extension of 40 degrees and flexion of 35 degrees. Active forearm pronation is 45 degrees, and supination is 50 degrees. Treatment should consist of

Explanation

The patient has acute rupture of the extensor tendons to the fifth and fourth fingers. Her X-rays show generalized severe arthritis, consistent with rheumatoid arthritis, in the distal radius and ulna, the carpals, and MCPs. There also appears to be a sharp osteophyte on the dorsal surface of the distal ulna (Fig 39c). Rheumatoid arthritis affects both joints and tendons because both are lined with synovium. The distal ulna typically becomes roughened with a sharp edge which acts
“like a buzzsaw” on the overlying tendons. This is called a Vaughan-Jackson lesion when extensor tendons are ruptured at the distal radial-ulnar joint. Of the dorsal/extensor compartments, typically the digiti minimi is involved first and further ruptures progress radially as the hand ulnarly deviates and the other tendons sublux and are brought within range of the “buzzsaw.” The cited articles state that after a dorsal exposure the hypertrophic tenosynovium is removed from each tendon sytematically, and the wrist joint then evaluated. Any bony spicules which may further damage tendons are removed, and the distal ulna is excised. Tendon transfers, grafts, or repairs are then performed. Surgical results tend to be better with single or double tendon ruptures than with multiple tendon ruptures.

Question 67

A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year. The pain is worse with weight bearing and is better with rest and the use of an ankle brace. What findings are shown on the MRI scans shown in Figures 18a through 18c?

Explanation

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath. This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.
REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction). Foot Ankle Clin 1997;2:241-260.
Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures. Foot Ankle 1992;13:208-214.

Question 68

A 13-year-old gymnast has had recurrent right elbow pain for the past year. She denies any history of trauma. Rest and anti-inflammatory drugs have failed to provide relief. Examination reveals no localized tenderness and only slight loss of both flexion and extension (10 degrees). What is the most likely diagnosis?

Explanation

DISCUSSION: Osteochondritis of the capitellum is characterized by pain, swelling, and limited motion. Catching, clicking, and giving way also can occur. It commonly affects athletes who participate in competitive sports with high stresses, such as pitching or gymnastics.
REFERENCES: Krijnen MR, Lim L, Willems WJ: Arthoscopic treatment of osteochondritis dissecans of the capitellum: Report of 5 female athletes. Arthroscopy 2003;19:210-214.
Schenck RC, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996;3:439-456.

Question 69

A 55-year-old woman has slowly increasing pain at the distal end of her little finger that is exacerbated by cold temperatures. She denies any history of trauma to her hands and is employed as a school teacher. The histology of the resected specimen is shown in Figure 71. What is the most likely diagnosis?

Explanation

DISCUSSION: Glomus tumors are rare vascular lesions typically occurring about the nail of the distal phalanx of the hand. The diagnostic “triad” of glomus tumors consists of local pain, sensitivity to cold, and paroxysmal pain. They tend to present with pain as the most typical symptom and this can be exacerbated by changes in temperature that is felt to cause a vascular response within the lesion. The biopsy specimen confirms a glomus tumor showing the typical vascular spaces surrounded by glomus epithelioid glomus cells.
REFERENCES: Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.
McDermott EM, Weiss AP: Glomus tumors. J Hand Surg Am 2006;31:1397-1400.

Question 70

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

Explanation

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

Question 71

A year-old man reports symptomatic medial knee pain that has become progressively worse during the past year. MRI reveals a complex, posterior horn medial meniscus tear with associated medial lateral and patellofemoral cartilage defects. Radiographs reveal medial joint space narrowing and osteophytes in the other compartments. What treatment is most likely to provide long-term, durable relief of symptoms?

Explanation

DISCUSSION:
Total knee replacement is a well-established surgery for diffuse, symptomatic osteoarthritis of the knee joint, and its efficacy has been shown in many studies. According to the 2008 AAOS Clinical Practice Guideline, Treatment of Osteoarthritis of the Knee, arthroscopy in the setting of existing osteoarthritis is efficacious for relieving the signs and symptoms of a torn meniscus but not for osteoarthritis. Likewise, in young and active patients, clinical outcomes show improvement after realignment osteotomy for single- compartment osteoarthritis. Unicondylar knee replacement is not indicated for tricompartmental disease
of the knee.

Question 72

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

Explanation

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

Question 73

A 55-year-old woman with a long history of low back and left lower extremity pain has failed to respond to exhaustive nonsurgical management. MRI scans show bulging and degeneration at L3-4 and L4-5 as well as a normal disk at L2-3 and L5-S1. She undergoes provocative lumbar diskography at L3-4, L4-5, and L5-S1. Post-diskography axial CT images of L3-4 and L4-5 are shown in Figures 6a and 6b, respectively. The injections at L3-4 and L4-5 produce no pain. The injection at L5-S1 produces 10/10 concordant back pain with radiation to the lower extremity. What is the most appropriate recommendation at this time?

Explanation

DISCUSSION: The results of this patient’s lumbar diskography are equivocal at best. The two disks most likely to be her pain generators, based on their MRI appearance, produced 10/10 pain, however it was nonconcordant and did not reproduce any of her typical left-sided radicular symptoms. The only disk that produced concordant back pain was the normal disk at the L5-S1 level and it reproduced radicular symptoms on the side opposite of her typical pain. Based on these findings, it would be difficult to select a level or levels to include in a lumbar fusion. As such, continued nonsurgical management is the safest treatment option at the current time. Brox and associates reported on a randomized clinical trial comparing lumbar fusion to cognitive intervention and exercise and found similar results in both groups, with significantly less risk in the latter.
REFERENCES: Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.
Carragee EJ: Clinical practice: Persistent low back pain. N Engl J Med 2005;352:1891-1898.

Question 74

A 48-year-old man undergoes arthroscopy to repair a rotator cuff tear. During the arthroscopy, the tear is characterized and found to involve the entire supraspinatus and a majority of the infraspinatus tendons. After mobilization, the posterior rotator cuff can reach the greater tuberosity. However, the supraspinatus tendon cannot reach its insertion point at the greater tuberosity. What is the most appropriate treatment? Review Topic

Explanation

If a complete rotator cuff repair is not possible, a partial rotator cuff repair should still be considered and is the appropriate treatment for this patient. In patients with an irreparable massive rotator cuff tear, acromioplasty with coracoacromial ligament
release, reverse acromioplasty, and tenotomy of the biceps tendon may improve shoulder pain. If these procedures fail, then a muscle transfer procedure can also be considered in select patients. If, however, a portion of the rotator cuff can be repaired, even partial repair can balance the coronal and axial forces about the shoulder to restore the kinematics of the joint. Reverse total shoulder arthroplasty is not appropriate for this relatively young patient.

Question 75

A 31-year-old man sustained a closed injury to his arm in a motor vehicle accident 16 months ago. Treatment of the fracture consisted of intramedullary nailing of the humerus. He now reports pain with minimal activities. Clinical examination and laboratory studies suggest no signs of infection. Radiographs are seen in Figures 12a through 12c. Treatment should now consist of

Explanation

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,

an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 76

A 72-year-old man was involved in an automobile accident 4 weeks ago. Initially he noted pain about his nondominant left shoulder, which resolved within a few weeks after the accident. He now describes trouble with gripping and carrying items in his left hand. Radiographs are shown in Figures 20a through 20c. His signs and symptoms are the result of injury to which of the following ligaments?

Explanation

DISCUSSION: The radiographs reveal a gap between the scaphoid and lunate bones, indicative of disruption of the scapholunate ligament complex. The three components of the complex are the dorsal scapholunate ligament, the volar (or palmar) scapholunate ligament, and the proximal fibrocartilaginous membrane, listed in decreasing yield strength. Disruption of the stout dorsal interosseous ligament is required for scapholunate dissociation to occur.
REFERENCES: Berger RA: The ligaments of the wrist: A current overview of anatomy with considerations of their potential functions. Hand Clin 1997;13:63-82.
Cohen MS, Taleisnik J: Direct ligamentous repair of scapholunate dissociation with capsulodesis augmentation. Tech Hand Up Extrem Surg 1998;2:18-24.

Question 77

What complication is more likely following excessive medial retraction of the anterior covering structures during the anterolateral (Watson-Jones) approach to the hip?

Explanation

DISCUSSION: The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful leading to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insufficiency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 325.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-17, 4-18.

Question 78

A patient undergoes cartilage implantation requiring amplification of donor cells. Which of the following statements best describes the transplants?

Explanation

DISCUSSION: Chondrocytes are obtained from cartilage harvested from non-weight-bearing areas of the knee. The extracellular matrix is digested, and the chondrocytes are expanded for later transplantation. Cells implanted into a defect are secured with a flap of periosteum. Cells are expanded to obtain 20 to 50 times the original number of cells to transplant at a cell density of 3x10^-7 cells/mL. There is a direct relationship between cell number and biosynthetic activity. Osteochondral lesions of up to 8 mm may be treated with autologous transplant alone; larger depth lesions should be bone grafted at the time of harvest. Mesenchymal stem cells differentiate easily into fibrous tissue, bone, and fat; conversion of mesenchymal stem cells into cartilage in vitro currently is difficult to accomplish. Goldberg and Caplan, however, were able to obtain cartilage repair using mesenchymal stem cells transplanted into defects in rabbits in vivo. In animal studies, fluorescent-labeled cells persist for at least 14 weeks, integrate with the surrounding normal margins, and become part of the repaired tissue replete with sulfated proteoglycans and type II collagen.
REFERENCES: Brittberg M, Peterson L, Sjogren-Jansson E, et al: Articular cartilage engineering with autologous chondrocyte transplantation. J Bone Joint Surg Am

2003;85:109-115.
Caplan AI, Elyaderani M, Mochizuki Y, et al: Principles of cartilage repair and regeneration. Clin Orthop 1997;342:254-269.

Question 79

An otherwise healthy 25-year-old man with an isolated closed mid-diaphyseal femoral fracture undergoes intramedullary nailing. Compared with nonreamed nailing, reamed femoral nailing is associated with a higher rate of Review Topic

Explanation

Bhandari and associates, in a meta-analysis, concluded that sufficient evidence exists to suggest that reamed intramedullary nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing. Tornetta and Tiburzi, in a prospective randomized study, determined that reamed canal preparation led to faster healing of distal fractures treated with statically locked intramedullary nails. Blood loss was greater in the reamed group, but this did not translate into increased transfusion requirements. In this series, there was no advantage to nail insertion without reaming. In a prospective randomized multicenter study, the overall incidence of acute respiratory distress syndrome (ARDS) was found to be low with primary stabilization of femoral shaft fractures with intramedullary nailing. There was no difference in the incidence of ARDS between the reamed and unreamed groups. In a retrospective study performed by Handolin and associates, intramedullary nailing of long bone fractures in patients with multiple injuries and with a coexisting pulmonary contusion did not impair pulmonary function or outcome. No study has convincingly demonstrated an increased trend toward infection with reamed femoral intramedullary nailing.

Question 80

A 74-year-old man reports progressive left hip pain with weight-bearing activities. A radiograph is shown in Figure 30. What is the most likely underlying diagnosis?

Explanation

DISCUSSION: The radiograph shows enlargement of the bone, coarse trabeculation, a blastic appearance, and thickening of the cortex, revealing the classic appearance of Paget’s disease in the sclerotic phase, the most common presentation. While lymphoma may present as a blastic lesion, it will not have the same enlargement, coarse trabeculation of bone, and the significant sclerosis seen here.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 211-215.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 1947-2000.

Question 81

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Explanation

Anorexia athletica is a newer term that may generally replace the "triad" of disordered eating, menstrual dysfunction, and osteoporosis. True osteoporosis is actually relatively uncommon in the female athlete, and thus the traditional diagnostic criteria are rarely met. In anorexia athletica, multiple signs and symptoms are used to reach the diagnosis. Specifically, however, a diagnosis of anorexia athletica requires the absence of any affective disorder, such as depression.

Question 82

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Explanation

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased rates of infection. Neither fixation method would increase the time to healing.

Question 83

A 15-year-old boy has had pain in the right shoulder for the past 3 months. He denies any history of trauma and has no constitutional symptoms. Examination reveals a large firm mass in the proximal arm. A radiograph and MRI scan are shown in Figures 27a and 27b. Biopsy specimens are shown in Figures 27c and 27d. Management should consist of

Explanation

DISCUSSION: The patient has an aneurysmal bone cyst. The fluid-fluid levels seen on the MRI scan are typical for aneurysmal bone cyst, and the histology is consistent with a cystic lining. Vascular lakes, multinucleated giant cells, reactive bone, fibrovascular tissue, and an absence of atypical cells or numerous mitoses are seen histologically. Aneurysmal bone cysts will typically continue to grow and cause further bone destruction; therefore, observation is not recommended. Steroid injections are not effective. A thorough curettage of the cyst lining and bone grafting are required. Wide resection and chemotherapy are reserved for more aggressive tumors. There is no evidence of infection radiographically or histologically. Telangiectatic osteosarcoma should also be considered in the differential diagnosis; therefore, biopsy is an important part of the work-up.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 232-233.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-196.

Question 84

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 85

A woman with a neck and chest tumor has weakness in the biceps and paresthesias in the thumb. Brachioradialis and infraspinatus function are normal. The lesion is affecting which of the following structures?

Explanation

DISCUSSION: The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 334.

Question 86

A 30-year-old man reports pain and weakness in his right arm. Examination reveals grade 4 strength in wrist flexion and elbow extension, decreased sensation over the middle finger, and decreased triceps reflex. These symptoms are most compatible with impingement on what spinal nerve root?

Explanation

DISCUSSION: Motor impulses to the triceps, wrist flexion and elbow extension, and sensation to the middle finger are associated most commonly with the C7 root.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 125.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 87

A 35-year-old carpenter sustained an injury to his dominant shoulder in a fall. He reports that he felt a sharp tearing sensation as he held on to a scaffold to keep from falling. Examination reveals swelling and ecchymosis down the upper arm, weakness to internal rotation, and deformity of the anterior axilla. He has good strength in external rotation and no apprehension with instability testing. Radiographs are normal. Management should consist of

Explanation

DISCUSSION: The findings are classic for a pectoralis major tendon avulsion. Deformity of the anterior axillary fold is a classic finding, and ecchymosis down the arm suggests that the injury is at the humeral attachment rather than at the musculotendinous junction. Good external rotation strength indicates that function in the supraspinatus and infraspinatus has been preserved. The treatment of choice for a tendon avulsion in a young individual is early surgical repair. Conversely, if the injury is within the muscle or at the musculotendinous junction, initial nonsurgical management is recommended. If the location of the injury cannot be determined by physical examination, then MRI of the pectoralis major can be helpful.
REFERENCES: Hanna CM, Glenny AB, Stanley SN, et al: Pectoralis major tears: Comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202-206.
Connell DA, Potter HG, Sherman MF, et al: Injuries of the pectoralis major muscle: Evaluation with MR imaging. Radiology 1999;210:785-791.

Question 88

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Explanation

DISCUSSION: Use of systemic steroids has been implicated in the development of nontraumatic osteonecrosis of the humeral head. Staging of the disease is most relevant to prognosis and treatment. Cruess has described a widely accepted staging system. Several authors have shown that patients who have a lower stage of disease (ie, stage I or II) have a much less likely chance of progression compared with those who are in the later stages (IV and V).
REFERENCES: Cruess RL: Osteonecrosis of bone: Current concepts as to etiology and pathogenesis. Clin Orthop 1986;208:30-39.
Cruess RL: Steroid-induced avascular necrosis of the humeral head: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.
Rutherford CS, Cofield RH: Osteonecrosis of the shoulder. Orthop Trans 1987;11:239.
Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Relationship of disease stage, extent, and cause to natural history. J Shoulder Elbow Surg 1999;8:559-564.

Question 89

A 15-year-old diver has had persistent, activity-related low back pain for the past 2 months. He denies any history of trauma. Examination reveals that the pain is localized to the lumbosacral junction, and there are no radicular symptoms. The pain is worse with back extension. Neurologic examination is normal, as are AP, lateral, and oblique radiographs of the lumbosacral spine. Further evaluation should include

Explanation

DISCUSSION: Spondylolysis may develop as a stress fracture resulting from repetitive hyperextension during athletic activities. In young people, the pars interarticularis is thin, the neural arch has not yet reached maximum strength, and the intravertebral disk is less resistant to shear. While clinical symptoms may lead to the suspicion of spondylolysis, radiographic confirmation may be difficult in early cases. Plain radiographs may be negative initially, and the plain MRI scan may not offer good visualization of the pars. A bone scan with SPECT is very sensitive initially. CT scans with regular axial and reverse-gantry angled cuts may help determine the type of fracture and the course of treatment.
REFERENCES: Congeni J, McCulloch J, Swanson K: Lumbar spondylolysis: A study of natural progression in athletes. Am J Sports Med 1997;25:248-253.
Harvey CJ, Richenberg JL, Saifuddin A, Wolman RL: The radiological investigation of lumbar spondylolysis. Clin Radiol 1998;53:723-728.

Question 90

Standard guidelines necessitate the use of intraoperative neurophysiological monitoring for patients undergoing surgery for which condition?

Explanation

DISCUSSION
There are currently no official guidelines on the appropriate use of neuromonitoring in spine surgery. In general, use of neuromonitoring is at surgeon discretion and often is based on the surgeon's perceived risk for neurologic injury during surgery and medicolegal concerns. In most reports,
neuromonitoring is considered useful in cases of deformity correction, spinal cord decompression, instrumentation placement, and revision surgery. However, even for some of these cases, studies have shown limited benefits of neuromonitoring and substantial associated costs.
RECOMMENDED READINGS
Lall RR, Lall RR, Hauptman JS, Munoz C, Cybulski GR, Koski T, Ganju A, Fessler RG, Smith ZA. Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurg Focus. 2012 Nov;33(5):E10. doi: 10.3171/2012.9.FOCUS12235. Review. PubMed PMID: 23116090. View Abstract at PubMed Peeling L, Hentschel S, Fox R, Hall H, Fourney DR. Intraoperative spinal cord and nerve root monitoring: a survey of Canadian spine surgeons. Can J Surg. 2010 Oct;53(5):324-8. PubMed PMID: 20858377. View Abstract at PubMed
Garces J, Berry JF, Valle-Giler EP, Sulaiman WA. Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient outcome? Ochsner J. 2014 Spring;14(1):57-61. PubMed PMID: 24688334. View Abstract at PubMed

Question 91

A 32-year-old man has posttraumatic arthritis after undergoing open reduction and internal fixation of a left acetabular fracture. A total hip arthroplasty is performed, and the radiograph is shown in Figure 18. What is the most common mode of failure leading to revision in this group of patients?

Explanation

DISCUSSION: Acetabular component loosening has been reported as the most common mode of failure following total hip arthroplasty in patients with a previous acetabular fracture. Following acetabular fracture and subsequent open reduction and internal fixation, the bone quality and vascularity are compromised, thus reducing the success rate of acetabular component cementless fixation.
REFERENCES: Jimenez ML, Tile M, Schenk RS: Total hip replacement after acetabular fracture. Orthop Clin 1997;28:435-446.
Romness DW, Lewallen DG: Total hip arthroplasty after fracture of the acetabulum: Long-term results. J Bone Joint Surg Br 1990;72:761-764.

Question 92

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

Explanation

DISCUSSION: Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis.
REFERENCES: Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983, chapter 5.

Question 93

A 5-year-old boy reports intermittent left elbow pain. History reveals that he injured his elbow 4 months ago, but had no treatment. He is now using his arm normally but reports pain almost daily. Examination reveals tenderness over the lateral epicondyle and a prominence is evident. Range of motion is from -5 2010 Pediatric Orthopaedic Examination Answer Book • 55 degrees to 120 degrees. Radiographs are shown in Figure 67. Management should include

Explanation

DISCUSSION: The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.
REFERENCES: Wattenbarger JM, Gerardi J, Johnson CE: Late open reduction internal fixation of lateral condyle fractures. J Pediatr Orthop 2002;223:94-398.
Flynn JC: Nonunion of slightly displaced fractures of the lateral humeral condyle in children: An update. J Pediatr Orthop 1989;9:691-696.

Question 94

An 85-year-old right hand dominant male sustains a fall onto his elbow while trying to get out of the car. His past medical history is significant for diabetes, congestive heart failure, and COPD. He lives in a nursing home, and is able to ambulate at baseline without and assistive devices. What would be the ideal definitive surgical treatment options in this patient? Review Topic

Explanation

This elderly low-demand patient would most benefit from a total elbow arthroplasty (TEA) done through a direct posterior tricep sparing approach.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, and suffer less complications with TEA than ORIF in select cases.
Sorensen et al evaluated short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus by evaluating 24 consecutive cases. Twenty of the patients were followed for almost 2 years, and their MEPS were 15 excellent, 4 good and 1 fair result. They concluded that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.
Mckee et al conducted a prospective, randomized, controlled trial to compare
functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary total elbow arthroplasty (TEA). They randomized 42 patients and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF, based on the MEPS.
Illustration A shows radiographs of a TEA. Incorrect Answers:

Question 95

..Figures 107a through 107c are the radiograph, CT, and bone scan of a 68-year-old man. While walking, he collapsed and was unable to ambulate because of pain and deformity in his right leg. What is the most appropriate next step?

Explanation

RESPONSES FOR QUESTIONS 108 THROUGH 111
Glomus tumor
Diffuse pigmented villonodular synovitis (PVNS)
Extra-abdominal fibromatosis
Schwannoma
Hemangioma
Please match the characteristics below to the condition listed above.

Question 96

A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs are shown in Figures 10a and 10b. Definitive management should consist of

Explanation

DISCUSSION: The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.
REFERENCES: May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.
Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

Question 97

03 The sagittal oblique MRI scan shown in Figure 70 reveals a lesion in the shoulder that typically affects what neurologic structure?

Explanation

Ganglion cysts in the shoulder has been reported in the literature and when they occur in the shoulder typically compress the suprascapular nerve at the spinoglenoid notch primarily affecting the infraspinatus muscle, but depending on their size may also affect the supraspinatus motor brances.
The cysts form either because of a lesion of the capsulolabral complex at the superior/posterosuperior glenoid in the shoulder or because of myxoid degeneration of the capsule.
back to this question next question

Question 98

By which mechanism can a true aneurysm of the ulnar artery result?

Explanation

Figures 1 and 2 are the radiographs of a 17-year-old boy who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Question 99

A B C Figures 91a through 91c are CT images of a 76-year-old man who was involved in a motor vehicle collision. Which of the following scenarios would pose a contraindication to closed reduction of this injury prior to MR imaging?

Explanation

DISCUSSION
This patient has bilateral jumped facet joints at C6-7. Although MR imaging is useful for revealing disk herniations, cord injuries, and bony fragments, early closed reduction to restore anatomic alignment may be attempted prior to MR imaging because reduction will decrease pressure on the cord. There have been reports of catastrophic outcomes with closed reduction in patients who are intubated when disk fragments are pushed into the spinal cord. Consequently, closed reduction should be attempted only in awake and cooperative patients for whom neurologic status monitoring is possible. MR imaging is generally performed after reduction is attempted (successful or not).
RECOMMENDED READINGS
Initial closed reduction of cervical spine fracture-dislocation injuries. Neurosurgery. 2002 Mar;50(3 Suppl):S44-50. Review. PubMed PMID: 12431286. View Abstract at PubMed Radcliff K, Sonagli MA, Delasotta L, Singh N, Morrison E, Levine AM, Vaccaro AR. Cervical facet fractures and dislocations. In: Zigler JE, Eismont FJ, Garfin SR, Vaccaro AR, eds. Spine Trauma. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:441-464.
Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler JM. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine (Phila Pa 1976). 1999 Jun 15;24(12):1210-7. PubMed PMID: 10382247. View Abstract at PubMed
Wimberley DW, Vaccaro AR, Goyal N, Harrop JS, Anderson DG, Albert TJ, Hilibrand AS. Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report. Spine (Phila Pa 1976). 2005 Aug 1;30(15):E433-8. PubMed PMID: 16094262. View Abstract at PubMed

Question 100

A B C Figures 89a through 89c are the radiographs of a 35-year-old woman who has had 7 years of progressive ankle pain. She experiences stiffness and pain despite the use of an ankle-foot orthosis. Examination reveals pain along the anterior tibiotalar joint without tenderness to the subtalar or talonavicular joints. What is the most appropriate surgical intervention?

Explanation

DISCUSSION
This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552. View Abstract at PubMed
Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289. View Abstract at PubMed
Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890. View Abstract at PubMed
Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818. View Abstract at PubMed
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683. View Abstract at PubMed

Full Question & Answer Text (for Search Engines)

Question 1:

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Options:

Tension band plating
Antiglide plating
Bridge plating
Neutralization plating
Submuscular plating

Correct Answer: Tension band plating

Explanation:

Question 2:

Options:

Jerk Test
Wright's Test
Lift-off test
Jobe's test
Hornblower's test

Correct Answer: Lift-off test

Explanation:

Question 3:

A 56-year-old woman who underwent axillary node dissection 4 months ago now reports shoulder pain, weakness of forward elevation, and obvious winging of the scapula. What structure has been injured?

Options:

Long thoracic nerve
Spinal accessory nerve
Thoracodorsal nerve
Lower trunk of the brachial plexus
Posterior cord of the brachial plexus

Correct Answer: Long thoracic nerve

Explanation:

Question 4:

Options:

Creatine
Caffeine
Testosterone
Human growth hormone
Ephedrine

Correct Answer: Creatine

Explanation:

Question 5:

Options:

Equal at 10 years
Lower at 10 years
Higher at 10 years
Not known when using a mobile-bearing UKA

Correct Answer: Lower at 10 years

Explanation:

Question 6:

- Which of the following conditions associated with a closed fracture of the clavicle indicates the need for open reduction and internal fixation?

Options:

Injury to the subclavian artery
Injury to the brachial plexus
Segmental fracture
100% displacement
Associated displaced surgical neck fracture of the humerus

Correct Answer: Injury to the subclavian artery

Explanation:

Question 7:

What is the next most appropriate step in the orthopaedic management of this patient?

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Closed reduction

Explanation:

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
OrthoCash 2020
Which of the following findings best describes the acetabular fracture shown in Figure 38?
Posterior column with articular impaction and a free fragment
Anterior column with articular impaction
Posterior wall with an intra-articular fragment
Posterior wall with articular impaction and a free intra-articular fragment
Posterior wall with articular impaction
Corrent answer: 4
The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.
OrthoCash 2020
A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of
normal sexual function and normal vaginal childbirth.
sexual dysfunction (dyspareunia) and normal vaginal childbirth.
normal sexual function and caesarean section childbirth.
sexual dysfunction (dyspareunia) and caesarean section childbirth.
normal sexual function and caesarean section childbirth until hardware removal.
Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is
almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
OrthoCash 2020
A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?
Closed treatment and casting
Open reduction and internal fixation
Primary subtalar arthrodesis
Percutaneous fixation
External fixation
A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.
OrthoCash 2020
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
Radial head resection and lateral collateral ligament repair
Radial head arthroplasty alone
Radial head arthroplasty and lateral collateral ligament repair
Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair
The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.
OrthoCash 2020
A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C).
What is the most appropriate management for the femoral shaft fracture at this point?
Reamed intramedullary nailing
Traction
External fixation
Open plating
Mast suit
The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.
OrthoCash 2020
A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?
MRI scan
Physical examination
Workers’ compensation status
Surgeon availability
Patient age
The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
OrthoCash 2020
A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?
Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.
Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
OrthoCash 2020
Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and
talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.
The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
OrthoCash 2020
Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?
Spiral
Oblique
Transverse
Segmental
Comminuted
A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.
OrthoCash 2020
A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?
Kocher-Langenbeck
Iliofemoral
Ilioinguinal
Extended iliofemoral
Triradiate approach
The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate
approaches although useful for this fracture, have a higher rate of complications.
OrthoCash 2020
An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes
plating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius then pinning of the DRUJ in pronation.
This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
OrthoCash 2020
A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?
Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware
The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
OrthoCash 2020
Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?
A primed immune system with an increased risk of a systemic inflammatory response
Nothing since they are no longer in uncompensated shock and their vital signs have normalized
Higher nonunion rates after fracture fixation
Higher infection rates after definitive fracture fixation
Higher complication rates after temporizing external fixation of long bone fractures
Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.
OrthoCash 2020
A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is
intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?
Emergent four compartment fasciotomies
Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture
Elevation of the limb overnight and four compartment fasciotomies in the morning
Elevation of the limb overnight and a recheck of compartment pressures in the morning
Emergent MRI of the knee and leg
Corrent answer: 2
The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.
OrthoCash 2020
Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?
The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.
Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
OrthoCash 2020
A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?
Infection
Malunion
Loss of forearm rotation
Refracture
Delayed union/nonunion
Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
OrthoCash 2020
The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?
Anterior superior iliac spine
Sciatic buttress
A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
The most superior portion of the roof of the acetabulum
Iliopectineal line
The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
OrthoCash 2020
A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure

Question 8:

Options:

Baker’s cyst
Torn medial meniscus
Patellofemoral pain syndrome
Lipoma
Ganglion cyst of the cruciates

Correct Answer: Ganglion cyst of the cruciates

Explanation:

DISCUSSION: Ganglia involving the cruciate ligaments have been recently reported as a cause of knee pain that interferes with knee flexion and extension. The symptoms are poorly localized in this patient and not along the medial joint line, making the diagnosis of a torn medial meniscus less likely. In addition, the MRI findings do not show a significant medial meniscal lesion. A Baker’s cyst is usually posteromedial and extends posterior to the interval between the medial head of the gastrocnemius and semimembranosus. MRI scans show a fluid-filled lesion with an increased signal on T
1
- and T
2
-weighted images. A lipoma would be bright on the T
1
-weighted image only.
REFERENCES: Deutsch A, Veltri DM, Altchek DW, et al: Symptomatic intraarticular ganglia of the cruciate ligaments of the knee. Arthroscopy 1994;10:219-223.
Brown MF, Dandy DJ: Intra-articular ganglia of the knee. Arthroscopy 1990;6:322-323.

Question 9:

Options:

The number of months he plays per year
The number of pitches he throws per game
The number of games he plays per week
His fastball speed
Playing in another position once being relieved of pitching

Correct Answer: Playing in another position once being relieved of pitching

Explanation:

Question 10:

Varus intertrochanteric osteotomy for coxa valga commonly produces which of the following results?

Options:

Decreased abductor lever arm
Increased hip joint reaction force
Increased center edge angle
Abductor lag and lurch
Lengthening of the leg

Correct Answer: Abductor lag and lurch

Explanation:

Question 11:

What adaptations occur in the dominant shoulder of throwers compared to their nondominant shoulder? Review Topic

Options:

Humeral anteversion with a normal total arc of motion
Tight posterior capsule with a normal total arc of motion
Lengthening of the anterior capsule with a decreased total arc of motion
Increased external rotation with a decreased total arc of motion
Decreased internal rotation with an increased total arc of motion

Correct Answer: Tight posterior capsule with a normal total arc of motion

Explanation:

Question 12:

Which of the following statements is true regarding articular cartilage?

Options:

The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties
Water accounts for approximately 25% of the mass of cartilage
Multiple aggrecan molecules link together to form glycosaminoglycans
The positive charge formed by aggrecan molecules helps to create the high osmotic swelling pressure of cartilage
Type II collagen helps prevent swelling of articular cartilage which would otherwise occur due to high osmotic pressures

Correct Answer: The hydrophilicity of type II collagen molecules gives cartilage its viscoelastic properties

Explanation:

Question 13:

Options:

Time to healing
Retear rate
Functional outcome scores
Postsurgical pain scores

Correct Answer: Retear rate

Explanation:

DISCUSSION
The images reveal a medium-sized tear of the rotator cuff. As more clinical studies are published comparing double-row with single-row rotator cuff repair, it has become clear that the retear rate is lower with a double-row construct for small and medium-sized tears. This may be attributable to the stronger time-zero repair construct that double-row repair provides. No study to date has demonstrated a significant difference in clinical outcomes (functional and pain scores at any time) or time to healing between the 2 techniques.
CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 17
Figure 16 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop," and then he needed help walking off the field. His knee is visibly swollen.

Question 14:

A 14-year-old boy reports progressive right wrist pain. Radiographs are shown in Figure 3a, and a photomicrograph is shown in Figure 3b. What is the most likely diagnosis?

Options:

Enchondroma
Nonossifying fibroma
Chondromyxoid fibroma
Osteosarcoma
Chondrosarcoma

Correct Answer: Chondromyxoid fibroma

Explanation:

DISCUSSION: The radiographs show a benign-appearing, well-defined lytic lesion with a thin rim of surrounding reactive bone. The photomicrograph shows spindle cells with a myxoid cartilaginous matrix. These findings are diagnostic of chondromyxoid fibroma. This is a rare, benign tumor that usually causes pain and can be locally aggressive.
REFERENCES: Lersundi A, Mankin HJ, Mourikis A, et al: Chondromyxoid fibroma: A rarely encountered and puzzling tumor. Clin Orthop Relat Res 2005;439:171-175.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 103-111.

Question 15:

The plate seen in Figure 48a was applied to the fracture seen in Figure 48b, and is functioning in what capacity?

Options:

Buttress
Neutralization
Tension band
Compression
Distraction

Correct Answer: Neutralization

Explanation:

Question 16:

-If a physician elects to shorten a femur by 4 cm for traumatic bone loss treatment and places an intramedullary nail for fixation, which deformity will be created in the lower extremity?

Options:

Patella alta
Medial mechanical axis deviation
Lateral mechanical axis deviation
Increased anatomic tibiofemoral angle
Translation of the anatomical axis of the femur

Correct Answer: Medial mechanical axis deviation

Question 17:

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Options:

Resisted forearm pronation and wrist flexion with a clenched fist
Resisted forearm supination and wrist extension with a clenched fist
Dynamic valgus stress test
Milking maneuver
Pinch grip test

Correct Answer: Milking maneuver

Explanation:

Question 18:

Options:

Extensor pollicis brevis (EPB)
Extensor carpi radialis brevis (ECRB)
Extensor digitorum communis (EDC)
Extensor carpi ulnaris (ECU)
Extensor carpi radialis longus (ECRL)

Correct Answer: Extensor digitorum communis (EDC)

Explanation:

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 19:

Options:

Early stabilization of the patient's femur fracture places him at risk for increased pulmonary complications
Surgical intervention should be delayed due to the patient's head injury
Damage control orthopaedics (DCO) using external fixation is indicated for this patient
Early stabilization of the patient's femur fracture does not place the patient at increased risk for worsening neurologic outcomes
A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture

Correct Answer: A concomitant chest injury would always be a contraindication to early fixation of the patient's femur fracture

Explanation:

Question 20:

A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint. He denies any history of similar symptoms. What is the first step in evaluation?

Options:

Serum uric acid level studies and administration of indomethacin
Administration of colchicine
Administration of allopurinol
Aspiration with evaluation of crystals, cell count, and culture
Aspiration with evaluation of crystals and steroid injection

Correct Answer: Aspiration with evaluation of crystals, cell count, and culture

Explanation:

Question 21:

Options:

chemotherapy, wide resection, and endoprosthetic reconstruction.
radiation therapy only.
chemotherapy only.
prophylactic internal fixation with a locked intramedullary rod.
open curettage, bone grafting, dynamic hip screw fixation, and radiation therapy.

Correct Answer: prophylactic internal fixation with a locked intramedullary rod.

Explanation:

Question 22:

Options:

It is safe to return to play right away.
It is safe to return to play if there is no airway obstruction from adenopathy.
It is safe to play due to the low risk of disease transmission to other players.
It is safe to play after 3 to 4 weeks.
It is unsafe to play the next season.

Correct Answer: It is safe to play after 3 to 4 weeks.

Explanation:

Question 23:

Options:

Radiograph-guided steroid injection followed by total hip arthroplasty 6 weeks later
Total hip arthroplasty
Physical therapy
Referral back to her spine surgeon

Correct Answer: Physical therapy

Explanation:

Question 24:

Options:

Ig antibodies at the neuromuscular (NM) junction
Decreased release of acetylcholine at the NM junction
Decrease in myelin sheath of axonal nerves with loss of NM junction
Absence of dystrophin with excess calcium at sarcolemma

Correct Answer: Ig antibodies at the neuromuscular (NM) junction

Explanation:

Question 25:

Options:

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

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

Explanation:

Question 26:

Which of the following pieces of equipment currently offers the greatest opportunity for lowering the number of equestrian injuries? Review Topic

Options:

Knee pads
Wrist guards
Boots
Helmets
Quick release stirrups

Correct Answer: Helmets

Explanation:

Question 27:

Options:

Surgery on the wrong patient
Surgery on the wrong side
Incorrect procedure performed
Intraoperative death
Surgery on the wrong level

Correct Answer: Surgery on the wrong level

Explanation:

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 28:

Options:

Balanced traction to address concern for persistent infection with reoperation
Open reduction and internal fixation of the fracture with a lateral plate and screws
Removal of the articulating spacer and revision to a longer-stem antibiotic-loaded articulating spacer
Removal of the articulating spacer and reimplantation using a long-stem fluted uncemented hip replacement

Correct Answer: Open reduction and internal fixation of the fracture with a lateral plate and screws

Explanation:

Question 29:

Options:

Ask the nurse to call the medical director
Ask the surgeon to revisit the surgical safety checklist
Assume the booking form was incorrect and proceed with the operation
Leave the operating room to ask a family member
Read the last clinical note for clarification

Correct Answer: Ask the nurse to call the medical director

Explanation:

Question 30:

Long-term alendronate (Fosamax) use for osteoporosis has been associated with which of the following?

Options:

Scurvy
Detached retina
Uterine carcinoma
Osteonecrosis of the femoral head
Diaphyseal femoral insufficiency fractures

Correct Answer: Diaphyseal femoral insufficiency fractures

Explanation:

Question 31:

Options:

Open fracture
Smoking history
Pseudomonas organism
Tibia fracture DISCUSSION -Berkes and associates showed that in a single-center retrospective study of all patients treated with open reduction and internal fixation of extremity fractures that resulted in early postsurgical deep wound infections, the only variables that showed statistical significance were history of open fracture as the initial injury or use of an intramedullary nail. Smoking history, intraoperative cultures showing pseudomonas species, and involvement of the lower extremity were not significant. Rightmire and associates examined patients at longer follow up, and showed smoking to be a risk factor for clinical failure.

Correct Answer: Open fracture

Question 32:

Options:

Internal rotation malalignment of 44 degrees
External rotation malalignment of 44 degrees
Internal rotation malalignment of 21 degrees
External rotation malalignment of 21 degrees
Internal rotation malalignment of 63 degrees

Correct Answer: Internal rotation malalignment of 44 degrees

Explanation:

Question 33:

Which of the following findings is an indication for adjunctive use of high-dose steroids?

Options:

C6 level injury secondary to a unilateral facet fracture-dislocation with weakness of wrist extension
C6 burst fracture with no neurologic deficit
L3 burst fracture with cauda equina syndrome
Incomplete spinal cord injury in a patient 24 hours after injury
Complete C6 level deficit in patient with spinal shock and a fracture-dislocation at C5 on C6 5 hours after injury

Correct Answer: Complete C6 level deficit in patient with spinal shock and a fracture-dislocation at C5 on C6 5 hours after injury

Explanation:

Question 34:

Options:

Additional nonsurgical management
Referral to a sports hernia surgeon
Ultrasound of the scrotum
CT of the pelvis
Cortisone injection

Correct Answer: Referral to a sports hernia surgeon

Explanation:

Question 35:

Options:

lateral column lengthening.
open reduction and internal fixation.
double arthrodesis (talonavicular and calcaneocuboid joints).
tarsometatarsal arthrodesis.
medial displacement calcaneal osteotomy and tendon transfer.

Correct Answer: tarsometatarsal arthrodesis.

Explanation:

Question 36:

Options:

Stress radiographs to evaluate the ankle ligaments
MRI to evaluate possible ligamentous injury
CT to evaluate possible osteochondral injury
Functional brace treatment
Surgical repair of the ankle ligaments

Correct Answer: Functional brace treatment

Explanation:

Question 37:

Options:

Level I
Level II
Level III
Level IV

Correct Answer: Level II

Explanation:

Question 38:

Options:

Radiographs of the hand
Radiographs of the cervical spine
Electrodiagnostic studies of the affected upper extremity
Surgical exploration of the extensor tendon ruptures
MRI of the elbow

Correct Answer: Electrodiagnostic studies of the affected upper extremity

Explanation:

Question 39:

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 40:

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Options:

Increased proliferation of osteoblasts
Decreased osteoclast differentiation
Increase release of TGF-beta1
Increased expression of BMP2
Increased expression of BMP7

Correct Answer: Increased proliferation of osteoblasts

Explanation:

Question 41:

Options:

glucosamine 1,500 mg/day and chondroitin sulfate 800 mg/day.
weight loss through dietary management and low-impact aerobic exercises.
arthroscopic debridement and lavage.
a valgus-directing brace.

Correct Answer: weight loss through dietary management and low-impact aerobic exercises.

Explanation:

Question 42:

Options:

Blood loss during debridement
Prolonged tourniquet time
Failure to stabilize both fractures with intramedullary nails
Episodic hypotension
Loss of dorsalis pedis pulse

Correct Answer: Episodic hypotension

Explanation:

Question 43:

A defect in the gene coding for fibrillin-1 would lead to which diagnosis? Review Topic

Options:

Osteogenesis Imperfecta
Neurofibromatosis
Achondroplasia
Pseudoachondroplasia
Marfan Syndrome

Correct Answer: Osteogenesis Imperfecta

Explanation:

Question 44:

Options:

Flexor tendons
Lateral band
Lumbrical
Volar plate

Correct Answer: Volar plate

Explanation:

Question 45:

Options:

Inferior glenohumeral ligament
Middle glenohumeral ligament
Superior labrum
Subscapularis tendon
Supraspinatus tendon

Correct Answer: Subscapularis tendon

Explanation:

Question 46:

Options:

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

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

Explanation:

Question 47:

What do the T2-weighted, fat-saturated MRI scans shown in Figures 76a through 76d reveal? Review Topic

Options:

Posterior cruciate ligament (PCL) tear, isolated
PCL tear and medial meniscus tear
Anterior cruciate ligament (ACL) tear, isolated
ACL tear and medial meniscus tear

Correct Answer: ACL tear and medial meniscus tear

Explanation:

Question 48:

What artery provides the only direct vascularizaton to both the intraneural and extraneural blood supply of the ulnar nerve just proximal to the cubital tunnel?

Options:

Superior ulnar collateral
Inferior ulnar collateral
Posterior ulnar recurrent
Brachial
Ulnar

Correct Answer: Inferior ulnar collateral

Explanation:

Question 49:

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 50:

Options:

anterior diskectomy and fusion at C4-C5.
immobilization in a Philadelphia collar and voluntary flexion and extension radiographs when awake.
occipital-cervical fusion with instrumentation.
halo immobilization for 12 weeks.
left C6 superior facetectomy and posterior fusion at C6-C7 with instrumentation.

Correct Answer: occipital-cervical fusion with instrumentation.

Explanation:

Question 51:

- The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Options:

disuse osteopenia
paraendocrine effect of the tumor
abnormally increased density on the right side
side effect of the treatment of the lesion
extensive tumor involvement of the left hip

Correct Answer: disuse osteopenia

Explanation:

Question 52:

Figures 233a through 233c are the radiographs and biopsy specimen of a 32-year-old woman who has had progressive ankle pain for 6 months. What is the most appropriate treatment option?

Options:

Radiotherapy alone
Intralesional curettage
Intralesional curettage with adjuvants
Wide surgical resection and radiotherapy
Neoadjuvant chemotherapy and wide resection

Correct Answer: Intralesional curettage with adjuvants

Question 53:

A 70-year-old woman who underwent total knee replacement 18 months ago has had 3 weeks of moderate drainage from a previously healed wound. What is the most appropriate treatment?

Options:

Vacuum-assisted wound closure dressing
Intravenous antibiotics for 6 weeks, followed by long-term oral antibiotic administration
Irrigation and debridement, followed by polyethylene exchange
Two-stage debridement and reconstruction

Correct Answer: Two-stage debridement and reconstruction

Explanation:

Question 54:

Options:

Fourth cervical nerve root
Upper trunk of the brachial plexus
Middle trunk of the brachial plexus
Lateral cord of the brachial plexus
Axillary nerve

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 55:

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Options:

Pain/parasthesias near the medial malleolus due to impingement of L4 nerve root
Pain/parasthesias near the medial malleolus due to impingement of L3 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L4 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L3 nerve root
Intermittent claudication due to impingement on segmental vessel

Correct Answer: Intermittent claudication due to impingement on segmental vessel

Explanation:

Question 56:

Options:

radiation therapy.
en bloc excision.
posterior fusion at C2-C3 with instrumentation.
CT-guided aspiration followed by IV antibiotics.
radiofrequency ablation.

Correct Answer: en bloc excision.

Explanation:

DISCUSSION: The CT scan shows an osteoblastic nidus pathognomic for an osteoid osteoma. Surgical treatment should include an en bloc excision of the lesion. Surgical treatment is not mandatory because the lesion often becomes asymptomatic over time. This lesion is not amenable to radiofrequency ablation due to its proximity to the spinal cord. A complete corpectomy is not necessary to adequately resect the lesion, as only the nidus needs to be removed. Radiation therapy and antibiotics are not appropriate treatments for an osteoid osteoma. Posterior C2-C3 fusion will not address the pathology.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 351-366.
Hadjipavlou AG, Lander PH, Marchesi D, et al: Minimally invasive surgery for ablation of osteoid osteoma of the spine. Spine 2003;28:E472-E477.

Question 57:

The need for postoperative allogeneic blood transfusions after total hip arthroplasty has been shown to be reduced when using

Options:

cementless fixation.
suction drains.
general anesthesia.
preoperative erythropoietin injections.
low-molecular-weight heparin.

Correct Answer: preoperative erythropoietin injections.

Explanation:

DISCUSSION: In a prospective study, 216 patients were randomized into three groups consisting of low-dose preoperative erythropoietin, high-dose preoperative erythropoietin, and placebo control. All patients were treated for 4 weeks prior to total hip arthroplasty. Both the low- and high-dose erythropoietin groups had a significantly lower rate of blood transfusions
(p < 0.001) after surgery.
REFERENCES: Waddell JP: Evidence-based orthopedics. J Bone Joint Surg Am 2001;83:788.
Feagan BG, Wang CJ, Kirkley A, et al: Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty: A randomized, controlled, trial. Ann Intern Med 2000;133:845-854.

Question 58:

What is the preferred treatment of a patient with breast cancer and a pathologic fracture of the clavicle in her dominant arm?

Options:

Surgical stabilization
Sling
Physical therapy
Wide resection
Radiofrequency ablation

Correct Answer: Sling

Explanation:

Question 59:

Options:

weight.
gender.
the knee compartment involved.
open or closed growth plates.
limb alignment.

Correct Answer: open or closed growth plates.

Explanation:

Question 60:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

Question 61:

Options:

Elevate leg on pillows
Administer IV morphine
Observation of the patient
Bivalve and spread the cast
Apply ice to the lower extremity

Correct Answer: Administer IV morphine

Explanation:

The patient appears to have some indications of a compartment syndrome: increasing pain and signs of nerve compression. Tibia fractures also should heighten the suspicion for a compartment syndrome. Two basic mechanisms of compartment syndrome are that an increase in volume occurs in an enclosed space or there is a decrease in size of the space. In this situation, both are likely occurring; post-fracture swelling is occurring within a closed space and if a cast is in place that may constrict the space even more. One way to increase the available space for swelling would be to bivalve and spread the cast. If the extremity has been casted, then it is vitally important that the cast is bivalved and the surrounding soft dressings under the cast be removed so that all external compression of the compartment has been eliminated. In the face of compartment syndrome, elevation of the limb, masking the pain with morphine, application of ice, or observation alone are all inappropriate.
(SBQ12TR.88) When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?
A fracture of the radial head requiring ORIF
A highly comminuted radial head fracture requiring radial head arthroplasty or resection
An MCL injury requiring repair
A type I avulsion fracture of the coronoid
An anteromedial coronoid fracture
A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture. Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
Incorrect answers:
(SBQ12TR.78) A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure A. What would be the most appropriate treatment for this patient at this time?
Review
Topic
Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 62:

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

Options:

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

Correct Answer: Anterior band of the inferior glenohumeral ligament complex

Explanation:

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

Question 63:

Which of the following findings is likely to be pathologic in a thin, well-conditioned endurance athlete?

Options:

Left ventricular hypertrophy by voltage on electrocardiography (ECG)
Primary AV block on ECG
II/IV systolic murmur increased with standing and Valsalva maneuver
Nonspecific STT wave changes in the lateral leads on ECG
Resting sinus bradycardia at 40 beats per minute

Correct Answer: II/IV systolic murmur increased with standing and Valsalva maneuver

Explanation:

Question 64:

A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Options:

Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware

Correct Answer: Wound dehiscence

Explanation:

DISCUSSION: The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
REFERENCES: Sanders R: Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.
Sanders R, Fortin P, DiPasquale T, et al: Operative treatment in 120 displaced intra-articular calcaneal fractures: Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993;290:87-95.

Question 65:

Options:

Hyperextension casting of the thoracolumbar spine for 6 weeks
In situ posterior fusion with instrumentation
Posterior fusion with instrumentation, with sagittal plane correction
Posterior decompression, followed by posterior fusion with instrumentation, with sagittal plane correction
Anterior decompression and partial corpectomy, with anterior instrumentation

Correct Answer: Posterior fusion with instrumentation, with sagittal plane correction

Explanation:

Question 66:

Options:

Total wrist replacement and bridge grafts
palmar shelf arthroplasty and tendon transfers
Darrach distal ulna resection, dorsal tenosynosynovectomy, and tendon transfers
Radioscaphate fusion, extensor tenodesis, and Darrach distal ulna resection
Total wrist fusion and tendon transfers

Correct Answer: Darrach distal ulna resection, dorsal tenosynosynovectomy, and tendon transfers

Explanation:

Question 67:

Options:

The flexor digitorum longus tendon is ruptured.
The posterior tibial tendon has a normal appearance.
The posterior tibial tendon has a physiologic amount of fluid in its sheath.
The posterior tibial tendon is completely ruptured and retracted (type III tear).
The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Correct Answer: The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Explanation:

Question 68:

Options:

Recurrent valgus overload (medial collateral ligament sprain)
Posterior lateral rotatory instability
Biceps tendinitis
Medial epicondylitis
Osteochondritis of the capitellum

Correct Answer: Osteochondritis of the capitellum

Explanation:

Question 69:

Options:

Inclusion cyst
Schwannoma
Scleroderma
Paranychia
Glomus tumor

Correct Answer: Glomus tumor

Explanation:

DISCUSSION: Glomus tumors are rare vascular lesions typically occurring about the nail of the distal phalanx of the hand. The diagnostic “triad” of glomus tumors consists of local pain, sensitivity to cold, and paroxysmal pain. They tend to present with pain as the most typical symptom and this can be exacerbated by changes in temperature that is felt to cause a vascular response within the lesion. The biopsy specimen confirms a glomus tumor showing the typical vascular spaces surrounded by glomus epithelioid glomus cells.
REFERENCES: Zook EG, Brown RE: The perionychium, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 1353-1380.
McDermott EM, Weiss AP: Glomus tumors. J Hand Surg Am 2006;31:1397-1400.

Question 70:

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

Options:

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

Correct Answer: Obtain a radiograph of the hip

Explanation:

Question 71:

Options:

High tibial osteotomy
Total knee replacement
Unicondylar knee replacement
Arthroscopic partial meniscectomy

Correct Answer: Total knee replacement

Explanation:

Question 72:

Options:

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

Correct Answer: no differences in long-term results.

Explanation:

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

Question 73:

Options:

Consider fusion surgery
Intradiskal ozone therapy
Lumbar laminectomy
Vertebral augmentation
Cognitive intervention and exercise

Correct Answer: Cognitive intervention and exercise

Explanation:

DISCUSSION: The results of this patient’s lumbar diskography are equivocal at best. The two disks most likely to be her pain generators, based on their MRI appearance, produced 10/10 pain, however it was nonconcordant and did not reproduce any of her typical left-sided radicular symptoms. The only disk that produced concordant back pain was the normal disk at the L5-S1 level and it reproduced radicular symptoms on the side opposite of her typical pain. Based on these findings, it would be difficult to select a level or levels to include in a lumbar fusion. As such, continued nonsurgical management is the safest treatment option at the current time. Brox and associates reported on a randomized clinical trial comparing lumbar fusion to cognitive intervention and exercise and found similar results in both groups, with significantly less risk in the latter.
REFERENCES: Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.
Carragee EJ: Clinical practice: Persistent low back pain. N Engl J Med 2005;352:1891-1898.

Question 74:

Options:

Conversion to a latissimus dorsi muscle tendon transfer
Acromioplasty and coracoacromial ligament release
Reverse acromioplasty (tuberoplasty)
Reverse total shoulder arthroplasty
Partial repair of the rotator cuff

Correct Answer: Partial repair of the rotator cuff

Explanation:

Question 75:

Options:

open reduction and exchange humeral nailing.
a custom orthosis and an external bone stimulator.
removal of the humeral nail and external fixation.
removal of the humeral nail and plate fixation with bone grafting.
open bone grafting and an internal bone stimulator.

Correct Answer: removal of the humeral nail and plate fixation with bone grafting.

Explanation:

DISCUSSION: The use of locked nailing for the treatment of established nonunion of the humerus has produced poor results. Since humeral nailing has already failed, exchange humeral nailing without bone grafting has an even less change of success. To increase the likelihood of achieving bony union, the treatment of choice is removal of the humeral nail, dynamic compression plating, and bone grafting.
REFERENCES: Zuckerman J, Giordanno C, Rosen H: Treatment of humeral shaft non-unions, in Bigliani L (ed): Complications of shoulder surgery. Baltimore, MD, William & Wilkins, 1993, pp 173-190.
Jupiter JB: Complex non-union of the humeral diaphysis: Treatment with a medial approach,
an anterior plate, and a vascularized fibular graft. J Bone Joint Surg Am 1990;72:701-707.

Question 76:

Options:

Volar scapholunate interosseous
Dorsal scapholunate interosseous
Long radiolunate
Short radiolunate
Dorsal intercarpal

Correct Answer: Dorsal scapholunate interosseous

Explanation:

DISCUSSION: The radiographs reveal a gap between the scaphoid and lunate bones, indicative of disruption of the scapholunate ligament complex. The three components of the complex are the dorsal scapholunate ligament, the volar (or palmar) scapholunate ligament, and the proximal fibrocartilaginous membrane, listed in decreasing yield strength. Disruption of the stout dorsal interosseous ligament is required for scapholunate dissociation to occur.
REFERENCES: Berger RA: The ligaments of the wrist: A current overview of anatomy with considerations of their potential functions. Hand Clin 1997;13:63-82.
Cohen MS, Taleisnik J: Direct ligamentous repair of scapholunate dissociation with capsulodesis augmentation. Tech Hand Up Extrem Surg 1998;2:18-24.

Question 77:

What complication is more likely following excessive medial retraction of the anterior covering structures during the anterolateral (Watson-Jones) approach to the hip?

Options:

Numbness over the anterolateral thigh
Ischemia to the leg
Quadriceps weakness
Abductor insufficiency
Foot drop

Correct Answer: Quadriceps weakness

Explanation:

DISCUSSION: The femoral nerve is the most lateral structure in the anterior neurovascular bundle. The femoral artery and vein lie medial to the nerve. Retractors placed in the anterior acetabular lip should be safe, although neurapraxia of the femoral nerve may occur if retraction is prolonged or forceful leading to quadriceps weakness. The femoral artery and nerve are well protected by the interposed psoas muscle. Damage to the lateral femoral cutaneous nerve, causing numbness over the anterolateral thigh, can occur while developing the interval between the tensor fascia latae and sartorious in the anterior (Smith-Petersen) approach but less likely in the Watson-Jones approach. Superior gluteal injury and accompanying abductor insufficiency may occur during excessive splitting of the glutei during the direct lateral (Hardinge) approach. Foot drop secondary to sciatic injury is more common with a posterior exposure or posterior retractor placement.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 325.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-17, 4-18.

Question 78:

A patient undergoes cartilage implantation requiring amplification of donor cells. Which of the following statements best describes the transplants?

Options:

There is a linear relationship between biosynthetic activity and the number of chondrocytes seeded.
Osteochondral lesions of 12 mm in size may be treated with chondrocyte transplantation alone.
Mesenchymal stem cells are harvested and allowed to differentiate to chondrocytes ex vivo.
The cellular carrier has no effect on biosynthetic activity.
In animal studies using fluorescent-labeled articular chondrocytes, donor cells are found to persist for up to 5 years.

Correct Answer: There is a linear relationship between biosynthetic activity and the number of chondrocytes seeded.

Explanation:

DISCUSSION: Chondrocytes are obtained from cartilage harvested from non-weight-bearing areas of the knee. The extracellular matrix is digested, and the chondrocytes are expanded for later transplantation. Cells implanted into a defect are secured with a flap of periosteum. Cells are expanded to obtain 20 to 50 times the original number of cells to transplant at a cell density of 3x10
-7
cells/mL. There is a direct relationship between cell number and biosynthetic activity. Osteochondral lesions of up to 8 mm may be treated with autologous transplant alone; larger depth lesions should be bone grafted at the time of harvest. Mesenchymal stem cells differentiate easily into fibrous tissue, bone, and fat; conversion of mesenchymal stem cells into cartilage in vitro currently is difficult to accomplish. Goldberg and Caplan, however, were able to obtain cartilage repair using mesenchymal stem cells transplanted into defects in rabbits in vivo. In animal studies, fluorescent-labeled cells persist for at least 14 weeks, integrate with the surrounding normal margins, and become part of the repaired tissue replete with sulfated proteoglycans and type II collagen.
REFERENCES: Brittberg M, Peterson L, Sjogren-Jansson E, et al: Articular cartilage engineering with autologous chondrocyte transplantation. J Bone Joint Surg Am
2003;85:109-115.
Caplan AI, Elyaderani M, Mochizuki Y, et al: Principles of cartilage repair and regeneration. Clin Orthop 1997;342:254-269.

Question 79:

Options:

union.
symptomatic pulmonary complications.
infection.
transfusion requirements.
required secondary procedures.

Correct Answer: union.

Explanation:

Question 80:

A 74-year-old man reports progressive left hip pain with weight-bearing activities. A radiograph is shown in Figure 30. What is the most likely underlying diagnosis?

Options:

Infection
Lymphoma
Paget’s disease
Massive bone infarct
Old pelvic trauma

Correct Answer: Paget’s disease

Explanation:

DISCUSSION: The radiograph shows enlargement of the bone, coarse trabeculation, a blastic appearance, and thickening of the cortex, revealing the classic appearance of Paget’s disease in the sclerotic phase, the most common presentation. While lymphoma may present as a blastic lesion, it will not have the same enlargement, coarse trabeculation of bone, and the significant sclerosis seen here.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 211-215.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 1947-2000.

Question 81:

The term anorexia athletica refers to a problem whose criteria include all of the following, EXCEPT Review Topic

Options:

gastrointestinal complaints.
restriction of caloric intake.
presence of an affective disorder.
weight loss.
menstrual dysfunction.

Correct Answer: presence of an affective disorder.

Explanation:

Question 82:

Compared with percutaneous pinning with Kirschner wires (K-wires), the treatment of metacarpal neck fractures with cannulated intramedullary screws is associated with

Options:

increased rates of soft-tissue infection.
greater initial construct stiffness and peak load until failure.
a slower return of digital range of motion.
an earlier time to bony union.

Correct Answer: greater initial construct stiffness and peak load until failure.

Explanation:

EXPLANATION:
In a biomechanical study, headless compression screws showed superior load to failure, higher three-point bending strength, and greater strength in axial loading compared with percutaneous K-wire fixation for metacarpal neck fractures. Headless compression screws provide greater initial stability to allow earlier motion in the postoperative period. No data comparing infection rates between the two methods of fixation are available; however, it is assumed that K-wires placed outside of the skin would have increased
rates of infection. Neither fixation method would increase the time to healing.

Question 83:

Options:

observation.
steroid injection.
curettage and bone grafting.
wide resection with neoadjuvant chemotherapy.
debridement, irrigation, and intravenous antibiotics.

Correct Answer: curettage and bone grafting.

Explanation:

Question 84:

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 85:

Options:

C6
Upper trunk
Middle trunk
Posterior cord
Lateral cord

Correct Answer: Lateral cord

Explanation:

DISCUSSION: The lateral cord terminates as the musculocutaneous nerve and also contributes sensory fibers to the median nerve. Involvement of the C6 root or upper trunk could potentially cause weakness of the infraspinatus and the brachioradialis. The middle trunk and the posterior cord do not contribute motor fibers to the thumb or sensory fibers to the thumb.
REFERENCE: Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments and Tumors. Philadelphia, PA, WB Saunders, 1995, p 334.

Question 86:

Options:

Correct Answer: C7

Explanation:

Question 87:

Options:

physical therapy for range of motion and strengthening following a decrease in pain and swelling.
shoulder arthroscopy for diagnosis and treatment of a possible labral tear.
open exploration and repair of a pectoralis major tendon avulsion.
MRI of the rotator cuff.
immobilization in a sling and swathe for 3 to 6 weeks, followed by mobilization and strengthening.

Correct Answer: open exploration and repair of a pectoralis major tendon avulsion.

Explanation:

Question 88:

What is the most significant prognostic factor in nontraumatic osteonecrosis of the humeral head?

Options:

Duration of symptoms
Age of the patient
Total amount of steroid use
Stage of the disease
Status of the rotator cuff

Correct Answer: Stage of the disease

Explanation:

Question 89:

Options:

flexion and extension radiographs of the lumbosacral spine.
diskography.
an MRI scan of the lumbosacral spine.
a bone scan with single proton emission computed tomography (SPECT).
a renal ultrasound.

Correct Answer: a bone scan with single proton emission computed tomography (SPECT).

Explanation:

Question 90:

Standard guidelines necessitate the use of intraoperative neurophysiological monitoring for patients undergoing surgery for which condition?

Options:

Primary lumbar disk herniation
Adolescent idiopathic scoliosis
Cervical spondylotic myelopathy
No conditions; there are no official guidelines

Correct Answer: No conditions; there are no official guidelines

Explanation:

DISCUSSION
There are currently no official guidelines on the appropriate use of neuromonitoring in spine surgery. In general, use of neuromonitoring is at surgeon discretion and often is based on the surgeon's perceived risk for neurologic injury during surgery and medicolegal concerns. In most reports,
neuromonitoring is considered useful in cases of deformity correction, spinal cord decompression, instrumentation placement, and revision surgery. However, even for some of these cases, studies have shown limited benefits of neuromonitoring and substantial associated costs.
RECOMMENDED READINGS
Lall RR, Lall RR, Hauptman JS, Munoz C, Cybulski GR, Koski T, Ganju A, Fessler RG, Smith ZA. Intraoperative neurophysiological monitoring in spine surgery: indications, efficacy, and role of the preoperative checklist. Neurosurg Focus. 2012 Nov;33(5):E10. doi: 10.3171/2012.9.FOCUS12235. Review. PubMed PMID: 23116090.
View Abstract at PubMed
Peeling L, Hentschel S, Fox R, Hall H, Fourney DR. Intraoperative spinal cord and nerve root monitoring: a survey of Canadian spine surgeons. Can J Surg. 2010 Oct;53(5):324-8. PubMed PMID: 20858377.
View
Abstract at PubMed
Garces J, Berry JF, Valle-Giler EP, Sulaiman WA. Intraoperative neurophysiological monitoring for minimally invasive 1- and 2-level transforaminal lumbar interbody fusion: does it improve patient outcome? Ochsner J. 2014 Spring;14(1):57-61. PubMed PMID: 24688334.
View
Abstract at PubMed

Question 91:

Options:

Infection
Heterotopic ossification
Dislocation
Periprosthetic fracture
Acetabular component loosening

Correct Answer: Acetabular component loosening

Explanation:

Question 92:

Options:

Flexor hallucis longus and flexor hallucis brevis
Flexor hallucis longus and adductor hallucis
Flexor hallucis brevis and adductor hallucis
Flexor hallucis longus and abductor hallucis
Flexor hallucis brevis and abductor hallucis

Correct Answer: Flexor hallucis brevis and adductor hallucis

Explanation:

DISCUSSION: Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis.
REFERENCES: Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.
Sarrafian SK: Anatomy of the Foot and Ankle. Philadelphia, PA, JB Lippincott, 1983, chapter 5.

Question 93:

Options:

open reduction and internal fixation.
cast immobilization.
percutaneous pin fixation.
observation, with follow-up in 3 months.
an MRI scan of the elbow.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 94:

Options:

ORIF through an olecranon osteotomy with 90-90 plating
Total elbow arthroplasty through an anterolateral approach between the brachialis and biceps
Acute elbow fusion
ORIF through a tricep splitting approach with parallel plating
Total elbow arthroplasty through a direct posterior tricep sparing approach

Correct Answer: Total elbow arthroplasty through an anterolateral approach between the brachialis and biceps

Explanation:

Question 95:

Options:

Staging studies to assess the extent of disease
Immediate stabilization of the fracture with an intramedullary nail
Curetting and bone culture
Segmental resection of the tibia and allograft reconstruction DISCUSSION… This patient has a pathologic fracture; in patients older than age 50, the most likely diagnosis is metastatic carcinoma or hematopoietic malignancy. A systemic work-up with staging imaging studies and laboratory tests as outlined by Rougraff and associates will identify the primary site of disease in approximately 90% of patients. A biopsy may not be necessary, and this protocol will also effectively exclude a primary sarcoma in the vast majority of patients. The other options all initiate treatment without first evaluating for extent of disease and diagnosis. If this turns out to be a sarcoma, stabilization or curetting the lesion might make subsequent limb salvage difficult or impossible. Segmental resection adds unnecessary morbidity to the surgical procedure in the more common circumstance that this is revealed to be metastatic carcinoma.

Correct Answer: Staging studies to assess the extent of disease

Explanation:

Question 96:

Options:

closed reduction and casting.
external fixation and percutaneous pinning of the distal radius.
open reduction and internal fixation of the distal radius.
open reduction and internal fixation of the distal radius and open repair of the ulnar styloid.
nonbridging external fixation of the distal radius.

Correct Answer: open reduction and internal fixation of the distal radius.

Explanation:

DISCUSSION: The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.
REFERENCES: May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.
Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

Question 97:

03 The sagittal oblique MRI scan shown in Figure 70 reveals a lesion in the shoulder that typically affects what neurologic structure?

Options:

– Axillary nerve
– Musculocutaneous nerve
– Long thoracic nerve
– Suprascapular nerve to the infraspinatus muscle
– Suprascapular nerve to the supraspinatus muscle back answer Question 199.03

Correct Answer: – Suprascapular nerve to the infraspinatus muscle

Explanation:

Question 98:

By which mechanism can a true aneurysm of the ulnar artery result?

Options:

Blunt trauma
Stab wound
Gunshot wound
Arterial catheterization True aneurysms contain all arterial layers. As such, they occur following an arterial injury that allows the vessel to gradually dilate. A true aneurysm is more uniform in shape and is characterized by having an endothelial lining. True aneurysms result from repeated blunt trauma or vessel diseases that weaken the wall. A pseudoaneurysm, or false aneurysm, results from an arterial wall penetration. The extravasated hematoma subsequently organizes and then recanalizes. The lumen of this false aneurysm has no endothelial lining. Pseudoaneurysms result from penetrating injuries from external sources or from fractures.

Correct Answer: Blunt trauma

Explanation:

Figures 1 and 2 are the radiographs of a 17-year-old boy who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Question 99:

Options:

American Spinal Injury Association Impairment Scale Grade B neurologic deficit
Nondisplaced frontal bone fracture
Obtunded status and a blood alcohol concentration higher than 0.2%
Presence of facet fractures

Correct Answer: Obtunded status and a blood alcohol concentration higher than 0.2%

Explanation:

DISCUSSION
This patient has bilateral jumped facet joints at C6-7. Although MR imaging is useful for revealing disk herniations, cord injuries, and bony fragments, early closed reduction to restore anatomic alignment may be attempted prior to MR imaging because reduction will decrease pressure on the cord. There have been reports of catastrophic outcomes with closed reduction in patients who are intubated when disk fragments are pushed into the spinal cord. Consequently, closed reduction should be attempted only in awake and cooperative patients for whom neurologic status monitoring is possible. MR imaging is generally performed after reduction is attempted (successful or not).
RECOMMENDED READINGS
Initial closed reduction of cervical spine fracture-dislocation injuries. Neurosurgery. 2002 Mar;50(3 Suppl):S44-50. Review. PubMed PMID: 12431286.
View Abstract at PubMed
Radcliff K, Sonagli MA, Delasotta L, Singh N, Morrison E, Levine AM, Vaccaro AR. Cervical facet fractures and dislocations. In: Zigler JE, Eismont FJ, Garfin SR, Vaccaro AR, eds. Spine Trauma. 2nd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:441-464.
Vaccaro AR, Falatyn SP, Flanders AE, Balderston RA, Northrup BE, Cotler JM. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine (Phila Pa 1976). 1999 Jun 15;24(12):1210-7. PubMed PMID: 10382247.
View
Abstract at PubMed
Wimberley DW, Vaccaro AR, Goyal N, Harrop JS, Anderson DG, Albert TJ, Hilibrand AS. Acute quadriplegia following closed traction reduction of a cervical facet dislocation in the setting of ossification of the posterior longitudinal ligament: case report. Spine (Phila Pa 1976). 2005 Aug 1;30(15):E433-8. PubMed PMID: 16094262.
View
Abstract at PubMed

Question 100:

Options:

Total ankle arthroplasty (TAA)
Ankle arthrodesis
Tibiotalocalcaneal arthrodesis
Anterior tibial exostectomy with Achilles lengthening

Correct Answer: Ankle arthrodesis

Explanation:

DISCUSSION
This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar
arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.
RECOMMENDED READINGS
Easley ME, Adams SB Jr, Hembree WC, DeOrio JK. Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-68. doi: 10.2106/JBJS.J.00126. Review. PubMed PMID: 21915552.
View Abstract at PubMed
Spirt AA, Assal M, Hansen ST Jr. Complications and failure after total ankle arthroplasty. J Bone Joint Surg Am. 2004 Jun;86-A(6):1172-8. PubMed PMID: 15173289.
View Abstract at
PubMed
Ajis A, Henriquez H, Myerson M. Postoperative range of motion trends following total ankle arthroplasty. Foot Ankle Int. 2013 May;34(5):645-56. doi: 10.1177/1071100713481433. Epub 2013 Mar 11. PubMed PMID: 23478890.
View Abstract at PubMed
Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006 Mar;88(3):526-35. PubMed PMID: 16510818.
View Abstract at PubMed
Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001 Feb;83-A(2):219-28. PubMed PMID: 11216683.
View Abstract at PubMed

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

Orthopedic Board Review MCQs: Arthroplasty, Foot & Ankle, Trauma | Part 128

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 128

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index