Orthopedic Board Review MCQs: Trauma, Shoulder & Knee | Part 130

Botulinum toxin is used to treat vasospastic disorders of the hand such as the Raynaud phenomenon to improve digital perfusion and reduce pain. Botulinum toxin enables which transmitter to be unopposed, resulting in vasodilation?

Figures 1 through 3 demonstrate the MRIs obtained from a 36-year-old man with an injury to the elbow. The expected result of nonsurgical treatment would be weakness of

Figures 1 and 2 are the right shoulder MRI scans of a 22-year-old right-handed professional male volleyball player with 4 months of right shoulder pain. The pain began insidiously and is exacerbated by overhead activities and hitting during games. He has maintained a daily program of shoulder stretching and strengthening exercises but has experienced a steady decline in function to the point of not being able to participate in volleyball. Examination reveals some mild atrophy at the posterior shoulder, full forward elevation, mild weakness of external rotation on the right shoulder, negative empty-can testing, positive O’Brien’s and negative apprehension. Surgical intervention would aim to resolve pathology related to which nerve?

In the anterior cruciate ligament-deficient knee, what structure provides an important secondary restraint to anterior tibial translation? Review Topic

Figure 14 shows the clinical photographs and radiograph of an 8-year-old girl who has a progressive equinus deformity of the right ankle. There is no history of trauma or infection. What is the most likely diagnosis?

A 15-year-old girl who swims the breaststroke has had hip pain after training excessively for a national level competition. Based on the MRI scans shown in Figures 5a through 5c, what is the most likely diagnosis?

Complications following a reverse shoulder prosthesis occur most frequently when performed for what diagnosis? Review Topic

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

Figure 1 shows the radiograph of a 60-year-old woman who underwent a previous operation for great toe pain 20 years ago. She has had increasing pain over the past 5 years and now reports pain with any motion, swelling, and clicking. She also reports pain under the ball of foot. What is the most appropriate management to alleviate her metatarsalgia and great toe pain?

A 45-year-old man undergoes an anterior cervical diskectomy and fusion at C5-6 and C6-7 with instrumentation. During the first postoperative visit at 1 week, the patient reports difficulty swallowing and mild anterior cervical tightness. The anterior wound is benign and the patient denies any dyspnea or shortness of breath. A postoperative radiograph is seen in Figure 25. What is the most appropriate management at this time?

A 51-year-old woman with shoulder pain responds transiently to a subacromial injection and physical therapy exercise program. When her symptoms recur, an arthroscopic subacromial decompression is recommended. During the surgery, a partial-thickness articular-sided supraspinatus tear is noted. The supraspinatus footprint is exposed for 3 mm from the articular margin. The remaining intra-articular structures are normal. Inspection from the bursal surface reveals the tendon to be intact. What is the most appropriate course of management? Review Topic

An active 66-year-old man who underwent total shoulder arthroplasty 3 years ago now reports pain. Laboratory studies reveal an elevated erythrocyte sedimentation rate and C-reactive protein. Intraoperative frozen section reveals greater than 10 white blood cells per high power field on two slides and the Gram stain reveals gram-positive cocci in clusters. What is the most appropriate surgical treatment to eradicate the infection and maintain function? Review Topic

Figure 9 shows the AP radiograph of a 65-year-old man who has knee pain and swelling. What is the most likely diagnosis?

Which of the following lesions most closely resembles Ewing’s sarcoma histologically?

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?

The failure of the acetabular component shown in Figure 15 is most likely the result of the use of a 32-mm head and

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

A 12-year-old boy has a head-on head collision while playing soccer. He had no loss of consciousness but has persistent headaches for 2 weeks. The patient is now back to school and has no headaches. What is the best next step?

A healthy 64-year-old man just underwent an uncomplicated shoulder arthroplasty for severe glenohumeral osteoarthritis. Intraoperatively, 60 degrees of external rotation was obtained. Postoperatively, he starts on a range-of-motion program. What limitations are recommended?

What is the most common cause of early failure for patellofemoral arthroplasty?

A 37-year-old electrician is diagnosed with a frozen shoulder after sustaining an electrical injury at work 2 weeks ago. Examination reveals that he cannot actively or passively externally rotate or abduct the arm. The glenohumeral joint and scapula move in a 1:1 ratio. Radiographs are shown in Figures 15a and 15b. The best course of action should be

When harvesting iliac crest bone graft during a posterior spinal decompression and fusion, injury to what structure can result in painful neuromas or numbness over the skin of the buttocks?

Figure 7 shows the MRI scan of a 23-year-old competitive rugby player who has anterior ankle pain and swelling. He states that he has been playing for many years and has sprained his ankle several times. Examination will reveal what specific hallmark feature?

Which of the following patients is considered the most appropriate candidate for an isolated split posterior tendon transfer?

Radiographs of an 80-year-old woman with back pain reveal a compression fracture. Which of the following imaging studies best evaluates the acuity of the fracture?

A 20-year-old man reports painless snapping about the lateral aspect of the right hip. He denies any history of trauma. Examination reveals no limp or tenderness. Hip range of motion is full, and there is good strength. Radiographs are normal. What anatomic structure is most likely causing these symptoms?

A 14-year-old Little League pitcher who plays in 2 leagues concurrently has pain in his throwing shoulder while pitching but not at rest.

A B C Figures 62a through 62c are the MR images and CT scan of a 65-year-old man with a history of diabetes mellitus, hypertension, and smoking. He has a 6-week history of increasing midback pain, lower extremity pain, and weakness. What is the most likely diagnosis, and how should this diagnosis be confirmed?

Figure 89a is the radiograph of a 24-year-old man who was involved in a motor vehicle accident. A closed reduction is performed and a post-reduction CT scan is shown in Figure 89b. What is the next most appropriate step in management?

Compared with retention of the native patella in primary total knee arthroplasty, routine patellar resurfacing is associated with

The use of a screw between the clavicle and the coracoid process to maintain the clavicle and acromioclavicular (AC) joint in a reduced position is a treatment option for AC joint separations. Screw removal is generally recommended after soft-tissue healing. What effect does this rigid coracoclavicular fixation have on shoulder kinematics?

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

Ganglion cysts about the wrist most commonly arise from what structure?

A patient reports persistent anterior shoulder pain following a forceful external rotation injury to the shoulder. An MRI scan is shown in Figure 4. The patient remains symptomatic despite 3 months of nonsurgical management. Treatment should now consist of Review Topic

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?

The mother of a 5-year-old child reports that he has had a fever of 103°F (39.4°C), leg swelling, and has been unwilling to bear weight on his right lower leg for the past 7 days. Examination reveals point tenderness at the distal femur. Aspiration at the metaphysis yields 10 mL of purulent fluid, and a Gram stain reveals gram-positive cocci. In addition to hospital admission, management should include

Based on the type of articulation shown in Figure 32, wear is not affected by which of the following factors?

A 17-year-old African American high school football player is in the afternoon session of an August “2-a-day” practice. He tells his trainer he is experiencing weakness, dizziness, and nausea. The ambient temperature is 31°C with a relative humidity of 70%. An examination by the team trainer reveals a body temperature of 39°C and headache, chills, confusion, and disorientation. What is the most likely diagnosis?

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

Following a fall from a height of 5 feet, a patient reports pain along the lateral border of the foot. The CT scan shown in Figure 54 indicates what pathology?

Treatment of adhesive capsulitis has a high failure rate when the underlying cause is

A 42-year-old woman who has had an 18-month history of severe low back pain is referred to your office for surgical evaluation. She reports that the pain initially began with right lower extremity pain and management consisted of oral analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. She has seen a chiropractor as well as a pain management specialist and she is status-post epidural steroid injections. She has also completed exhaustive physical therapy, as she is a certified athletic trainer and runs a health fitness program at a community hospital. Currently, she denies lower extremity pain and her pain is isolated to her low back and is subjectively graded as 8/10, with 10 being the worst pain she has ever experienced. The pain is interfering with her activities of daily living and she is seeking definitive treatment. Figures 32a through 32c show current MRI scans. Based on the current available medical literature, what is the most appropriate treatment? Review Topic

Figures 21a through 21c show the MRI scans of a 21-year-old football player who sustained a valgus knee injury while changing direction. Examination reveals swelling and tenderness along the medial aspect of the knee. There is a positive Lachman test, 3+ valgus laxity at 30 degrees, and 1+ valgus laxity at 0 degrees extension. The anterior drawer test is increased with the tibia in external rotation. The increase in the anterior drawer test with the tibia in external rotation is most likely the result of

A minimally invasive plate osteosynthesis is seen in Figure 15. The resultant fracture healing can best be attributed to a fixation construct that was

A 38-year-old man reports a 2-week history of acute lower back pain with radiation into the left lower extremity. There is no history of trauma and no systemic signs are noted. Examination reveals a positive straight leg test at 35 degrees on the left side and a contralateral straight leg raise on the right side. Motor testing demonstrates mild weakness of the gluteus medius and weakness of the extensor hallucis longus of 3+/5. Sensory examination demonstrates decreased sensation along the lateral aspect of the calf and top of the foot. Knee and ankle reflexes are intact and symmetrical. Radiographs demonstrate no obvious abnormality. MRI scans show a posterolateral disk hernation. The diagnosis at this time is consistent with a herniated nucleus pulposus at

A 42-year-old man with a history of renal cell carcinoma has progressive weakness in the lower extremities for the past 3 weeks. The patient desires intervention. A sagittal T 2 -weighted MRI scan is shown in Figure 9a, and a sagittal contrast enhanced T 1 -weighted MRI scan is shown in Figure 9b. He currently ambulates minimal distances with a walker. His life expectancy is 8 months. Treatment of the spine lesion should consist of

Figures 5a and 5b show the radiograph and MRI scan of a patient who has severe mechanical neck pain but no neurologic problems. Biopsy and work-up show the lesion to be a solitary plasmacytoma. Treatment should consist of

A 72-year-old woman who fell on her right shoulder while using a treadmill is now unable to elevate her right arm. An MRI scan is shown in Figure 7. What is the most likely diagnosis?

The Lisfranc ligament connects the base of the

A 45-year-old male falls off his motorcycle and injures his arm. AP and lateral radiographs reveal an ulnar shaft fracture, 30 degrees apex anterior, and a radial head dislocation. Which direction is the radial head most likely dislocated?

Smoking has been associated with lower fusion rates in both cervical and lumbar fusion. Which of the following statements best describes an explanation for these findings?

Posterior sternoclavicular dislocations are most commonly associated with which of the following complications?

Which of the following is the best method of initial pelvic stabilization for a patient with hemodynamic instability and the pelvic ring injury seen in Figure 199?

Intramedullary nailing of proximal tibial shaft fractures are technically demanding, and use of an extended medial parapatellar incision with a semiextended technique can prevent what common deformity at the fracture site?

A patient falls off a roof and sustains the fracture shown in Figure 29. What is the most likely complication that results from injury to the structure that is located at the arrow?

During total hip arthroplasty, what characteristic of irradiated (10 Mrad) and subsequently melted highly cross-linked polyethylene should provide a more wear-resistant construct than traditional gamma-irradiated (2.5-4 Mrad)-in-air polyethylene mated with the same head?

A 51-year-old woman with no preoperative neurologic deficit is undergoing elective anterior cervical diskectomy and fusion (ACDF) with plating and fusion for a C5-6 disk herniation with right-sided neck pain. Thirty minutes into the surgery the neurophysiologic monitoring shows a rapid drop and then loss of amplitude in the right cortical somatosensory-evoked potential waveform. All other waveforms remained normal and unchanged, including right-sided cervical (subcortical) and peripheral (Erb’s point), and those from the left-sided upper extremity and both lower extremities. What is the most likely cause of the change? Review Topic

• What is the most common nerve injury following a Monteggia fracture-dislocation of the forearm in adults?

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk? Review Topic

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

A 27-year-old runner training for his first marathon reports lateral knee pain after an unusually long training run. He states that the most significant pain occurs while running downhill. Examination of the patient while he is laying on the unaffected side reveals increased pain when manual pressure is applied to the lateral femoral epicondylar area during knee range of motion of 30° to 45°. What is the most likely diagnosis?

Which of the following patients requires preoperative noninvasive cardiac testing?

Figures 59a and 59b are the radiographs of a 7-year-old boy who was seen 1 week after he underwent a closed reduction and casting in the emergency department after a fall on an outstretched arm. What is the most appropriate next step for this patient? Review Topic

A 78-year-old man with ankylosing spondylitis sustains a minor fall. Shortly afterward he experiences sudden worsening of his chronic back pain and is brought to the emergency department by his caregiver. Radiographs and a CT scan of the spine do not show a clear fracture. What is the most appropriate next step?

A 56-year-old woman presents with left hip pain and diminishing range of motion. Examination reveals pain with range of motion of the hip. Radiographs reveal multiple calcific lesions within the hip and well-preserved joint space. MRI scan shows thickened synovium nodular loose bodies with decreased signal on T1 and T2. What is the best next step?

The main blood supply to the lateral two thirds of the talar body is provided by the

Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg. What examination findings are most consistent with the pathology seen in the radiographs?

A 46-year-old male construction worker has right hip pain that has failed to respond to nonsurgical management. His body mass index (BMI) is 32, he is 6’2” tall, and he has no other medical comorbidities. AP and lateral radiographs of the right hip are shown in Figures 23a and 23b. The patient inquires about his suitability for metal-on-metal hip resurfacing. The patient should be educated that he is at higher risk for failure secondary to which of the following?

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

During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?

A year-old woman has severe anterior knee pain. Her radiographs indicate end-stage patellofemoral compartment osteoarthritis. The tibiofemoral compartments are preserved. Extensive nonsurgical treatment has failed to provide relief, and she is offered patellofemoral arthroplasty (PFA). What is the most common long-term mode of failure for PFA using an implant with an onlay prosthesis design?

• Which of the following medicolegal relationships between an attending surgeon and a resident assistant applies when a patient files a malpractice suit relating to surgical complications following a total knee arthroplasty?

A 56-year-old male presents to your office with a primary complaint of pain in his lower back that extends down his left leg when he walks. He states he rides a stationary bike without pain, but he has severe pain walking more than two blocks. On exam he has 5/5 strength in all major muscle groups, and his sensation is intact to light touch in all dermatomes. He has no upper motor neuron signs. The pain has been going on for about a year, and he has had no improvement with physical therapy or anti-inflammatory medication. Figure A is an upright lateral radiograph of his lumbar spine. Figures B is his sagittal MRI, and Figure C is an axial image through L4/5. Assuming this patient is going to undergo surgery, what is most important in ensuring longterm symptomatic relief? Review Topic

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

When converting the knee shown in Figure 20 to a total knee arthroplasty, satisfactory outcome can be expected in what percent of patients?

What is the best approach to reduce and stabilize a displaced volar lunate facet fracture of the wrist?

An elderly woman with radiographic evidence of spinal stenosis reports difficulty walking and calf pain that is relieved by rest and a change of position. The most likely cause of pain is ischemia of the

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

A 7-year-old boy has a swollen and deformed right arm after falling off his bicycle. Radiographs reveal a completely displaced posterolateral supracondylar humeral fracture. Examination reveals a warm, pink hand and forearm but absent pulses. What is the next most appropriate step in management?

What structure is most often injured in a volar proximal interphalangeal joint dislocation?

A 79-year-old healthy male has 1 year of progressively worse left hip pain. He denies any significant weight loss but does complain of night pain. Radiograph and MRI are shown in Figures A & B. Bone scan and histology is shown in Figures C-E. What is the definitive treatment of this?

• A patient undergoes an acute repair of a laceration of the median nerve in the antecubital fossa. A lack of functional recovery 6 months later is most likely due to

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?

The husband of a 22-year-old woman has hypophosphatemic rickets. The woman has no orthopaedic abnormalities, but she is concerned about her chances of having a child with the same disease. What should they be told regarding this disorder?

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms?

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

A 19-year-old football player is taken off the field because of fatigue. Examination reveals a rash shown in Figure A. Oral examination reveals findings shown in Figure B. Posterior cervical glands are palpable. A mass is palpable in the left upper quadrant. Which of the following is true regarding the most likely diagnosis? Review Topic

Dislocation following primary total hip arthroplasty is more likely to occur in which of the following situations?

01 (left). What is the most appropriate next step?

A 40-year-old man who is a manual laborer has had 3 years of worsening medial-sided left knee pain that has inhibited his ability to work. He reports undergoing a left subtotal medial meniscectomy 10 years ago. He has been treated with nonsteroidal anti-inflammatory drugs and two different corticosteroids, with the most recent injection given 1 month ago. Each injection provided him with a few weeks of pain control. His medical history is unremarkable, and he has smoked 20 cigarettes per day for the last 15 years. His BMI is 22. On examination, he has varus alignment of the involved leg and medial joint line tenderness and no lateral or patellofemoral pain. His knee range of motion is 3° shy of full extension to 130° of flexion. He has negative Lachman and posterior drawer test results. He demonstrates no lateral thrust with ambulation. What imaging study is most appropriate to determine treatment options for this patient?

A workers' compensation carrier for a local manufacturing company requests a second opinion on a 59-year-old man who sustained a crush injury to his foot and leg at work 6 months ago. His leg and foot were pinned between a forklift and a wall when an employee he was supervising lost control of the forklift. The employer suspects that the injured worker is malingering because the treating physician released him to work, but he has not returned to work. Which of the following elements of your history will best help you determine that the injured worker does not want to return to work out of fear of a confrontation with the employee he was supervising?

Figure 18a shows the initial lateral radiograph of a 6-year-old girl who sustained a fracture in a motor vehicle accident and was treated in a cast 1 year ago. She now has the valgus deformity seen in Figure 18b. Treatment should consist of

A 1-year-old infant has the hand deformities shown in Figure 40. What pathologic process is the most likely cause of these deformities?

Fixed hyperextension of the metatarsophalangeal joint is associated with

A 7-year-old girl who sustained a type III posteromedial extension supracondylar fracture underwent a closed reduction at the time of injury. Figure 27a shows the position of the fracture fragments prior to percutaneous medial and lateral pin fixation. Following surgery, healing was uneventful and the patient regained a full painless range of motion. Fifteen months after the injury, she now reports loss of elbow motion and moderate pain with activity. A current AP radiograph is shown in Figure 27b. What is the most likely cause of her symptoms?

Clinical evidence suggests that grafts for replacing a torn anterior cruciate ligament often stretch after surgery. What is the most probable mechanism for this behavior?

Figure 11 shows the radiograph of a 3-year-old girl who sustained a proximal radius injury. Appropriate initial management should include

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

A 12-year-old girl with foot pain who has been diagnosed with hereditary motor sensory neuropathy is seen for the foot deformity shown in Figure 59a. A “block test” is performed and shown in Figure 59b. What is the most appropriate management for this patient?

5 standard deviations below young normals (< -2.5). The Z-score represents a comparison to age-matched normals.