OITE & AAOS Orthopedic Board Prep MCQs: Part 138

About This Board Review Set

This is Part 138 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 138

This module focuses heavily on: Arthroplasty, Fracture, Hip, Nerve, Tendon.

Sample Questions from This Set

Sample Question 1: The stiffness of a 16-mm femoral stem is mostly influenced by the...

Sample Question 2: A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?...

Sample Question 3: In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic...

Sample Question 4: Two years ago, a 63-year-old man underwent right total hip arthroplasty (THA) with a modular femoral head-neck and neck-stem prosthesis (a photograph of the removed implantis shown in Figure 181). He now has increasing hip pain. Radiographs...

Sample Question 5: A 38-year-old female with a grade IIIB open tibia fracture is scheduled to undergo definitive fixation and subsequent flap coverage with the orthopaedic and plastic surgery teams. She is met in the pre-operative area by the surgical intern ...

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

The stiffness of a 16-mm femoral stem is mostly influenced by the

Explanation

DISCUSSION: The stiffness is most influenced by the geometry, in particular the diameter of the stem. The bending rigidity increases to the fourth power of the radius. The elastic modulus of the material increases as a direct linear relationship. The surface coating does not affect the bending rigidity greatly unless it increases the diameter significantly.
REFERENCE: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, p 458.

Question 2

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Explanation

Training increases turnover of type I collagen, promoting both synthesis and degradation of collagen and a net increase synthesis of type I collagen in tendon-related tissue. Strenuous endurance training has resulted in decreased collagen cross-links, suggesting increased collagen turnover, but decreased collagen maturation. In human studies, physical training results in increased turnover of collagen. Synthesis and degradation are elevated initially when beginning an exercise program, but degradation products decrease overall. It is not known if activity levels in humans affect the diameter of collagen fibrils or the cross-sectional area of tendons.

Question 3

In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic

Explanation

A winged scapula is most often associated with Parsonage-Turner syndrome, a condition thought to be due to an inflammatory or immune-mediated mechanism. Certain muscles are predisposed, particularly the serratus anterior muscle innervated by the long thoracic nerve. Other less common nerve lesions (eg, the spinal accessory and dorsal scapular nerves) may also cause winged scapulae.

Question 4

Two years ago, a 63-year-old man underwent right total hip arthroplasty (THA) with a modular femoral head-neck and neck-stem prosthesis (a photograph of the removed implant is shown in Figure 181). He now has increasing hip pain. Radiographs reveal a stable hip arthroplasty and elevated serum cobalt and chromium levels. MR imaging is obtained, and, based on these findings, the patient’s hip is revised. Which corrosion type likely is responsible for this THA failure?

Explanation

DISCUSSION
Micromotion at the femoral head-neck or stem-neck junction can lead to fretting corrosion. Fretting corrosion is among the most common causes of failure in modular components. Modularity gives surgeons additional intraoperative flexibility but has resulted in corrosion-related failure and an implant recall. Although titanium and cobalt-chrome contain a protective surface oxide layer, continued micromotion at the modular junction may disrupt the protective layer, resulting in fretting corrosion. This may eventually lead to excessive metal ion formation and painful synovitis that necessitates a revision procedure. Galvanic corrosion is attributable to a mismatch in electrochemical gradients between dissimilar metals. Crevice or pitting corrosion occurs in fatigue cracks because of differences in oxygen tension.

Question 5

A 38-year-old female with a grade IIIB open tibia fracture is scheduled to undergo definitive fixation and subsequent flap coverage with the orthopaedic and plastic surgery teams. She is met in the pre-operative area by the surgical intern and paperwork is completed per institutional protocol. She is then brought back to the operating room. Which of the following is true regarding the pre-surgical timeout?

Explanation

If both teams are present, a single timeout is sufficient for the entire procedure. If one team is absent, a second timeout needs to be completed prior to start of the second part of the procedure.
The WHO pre-surgical safety checklist involves assessment at three points during an operative procedure: before induction of anesthesia, before skin incision, and before the patient leaves the operating room. Some components of the checklist include
confirming IV access and allergies, administration of antibiotic prophylaxis, and surgical site verification. The surgeon has been shown to be the most effective team member at reducing complications when using the checklist.
Haynes et al. evaluated the effects of the WHO pre-surgical checklist on perioperative complication rates at eight international sites. They found a significant reduction in rates of complications and death in patients over the age of 16 undergoing noncardiac procedures after implementation of the checklist.
Illustration A shows the WHO pre-surgical checklist Incorrect Answers:
present for the timeout. Answer 2: The implant representative is not necessary for the timeout. Answer 4: The attending surgeon needs to be present in the same OR for the timeout. Answer 5: The timeout has been shown to decrease rates of complication and death.

Question 6

MRI results are shown in Figure 1 for a 22-year-old, right-hand dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event. He has altered his weight-lifting activities and tried over-the-counter ibuprofen without benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

Explanation

A 45-year-old woman diagnosed with lateral epicondylitis undergoes an open debridement of the extensor carpi radialis brevis. During surgery, resection extends posterior to the equator of the radiocapitellar joint. Postoperatively, she complains of persistent pain, despite appropriate rehabilitation. What other physical examination finding is she likely to have?
A. Pain with elbow extension in forearm pronation
B. Mechanical symptoms when rising from a chair
C. Valgus instability
D. Tenderness over the medial collateral ligament (MCL)
Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.
56- A 75-year-old man presents with complaints of shoulder pain, bruising, and weakness following a fall onto his outstretched hand. He underwent an uncomplicated anatomic total shoulder arthroplasty 5 years prior with good range of motion and strength. His current radiographs are shown in Figures 1 and 2. What is the most appropriate next step to restore this patient’s function?

Question 7

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Explanation

RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 8

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

Explanation

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

Question 9

A 72-year-old man has had persistent pain after undergoing a hemiarthroplasty 18 months ago. Radiographs are shown in Figures 50a and 50b. What is the most likely cause of his problem?

Explanation

DISCUSSION: The radiographs demonstrate a rapid erosion of the bipolar component into the acetabulum. Although acetabular erosion is more common with unipolar hip arthroplasties, it can occur with bipolar components. Haidukewych and associates noted a very low erosion rate but none in the first 2 years. The second finding on the radiographs is the linear radiolucency progressing from the joint toward the end of the stem at the cement-bone interface suggesting chronic infection or diffuse loosening. The persistent pain since implantation also suggests chronic infection. High activity levels and osteoporosis do not lead to acetabular erosion in the first 2 years after hemiarthroplasty. While the cement technique is suboptimal, loosening and erosion should not be expected from this alone. An oversized bipolar head would extrude and not erode.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118-126.
Lestrange NR: Bipolar hemiarthroplasty for 496 hip fractures. Clin Orthop Relat Res 1990;251:7-19.
Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, p 158.

Question 10

The oblique radiograph of the foot and the CT scan shown in Figures 10a and 10b show a patient whose symptoms have failed to respond to rest and non-steroidal anti-inflammatory drugs. What is the best course of action?

Explanation

DISCUSSION: The radiograph and MRI scan show elongation and fragmentation of the os peroneum. Although casting, orthoses, and steroid injection may relieve symptoms, excision of the os peroneum and primary repair when necessary, with or without tenodesis of the peroneus longus to the peroneus brevis, have been shown to produce excellent results.
REFERENCES: Haddad SL: Disorders of tendons: Peroneal tendon dysfunction, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,

pp 812-817.
MacDonald BD, Wertheimer SJ: Bilateral os peroneum fractures: Comparison of conservative and surgical treatment and outcomes. J Foot Ankle Surg 1997;36:220-225.

Question 11

Figures 1 and 2 are the radiographs of a 55-year-old man who has a 3-year history of right shoulder pain. He has maximized nonoperative management and is interested in operative treatment. He had an open Bankart repair 20 years ago and did well until a few years ago. What is most important to know when deciding on the best surgical treatment for this patient?

Explanation

The radiographs show severe osteoarthritis of the shoulder. The best surgical option would be an arthroplasty. The major determining factor for which type of arthroplasty to choose is the integrity of the rotator cuff tendons.
Although the radiographs do not reveal any obvious signs of rotator cuff failure, the patient had had an open Bankart 20 years ago. The integrity of the subscapularis tendon following a previous open shoulder procedure is crucial in deciding which type of arthroplasty to consider. Range of motion and infraspinatus strength do not affect the decision-making process, assuming the rotator cuff is intact. Activity level can be important when deciding whether to proceed with an arthroplasty, but it is not as important as the rotator cuff integrity when choosing which
arthroplasty to use.

Question 12

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?

Explanation

DISCUSSION: Glenoid dysplasia is an uncommon anomaly that usually has a benign course but may result in shoulder pain, arthritis, or multidirectional instability. Shoulder pain and instability often improve with shoulder strengthening exercises.
REFERENCES: Wirth MA, Lyons FR, Rockwood CA Jr: Hypoplasia of the glenoid: A review of sixteen patients. J Bone Joint Surg Am 1993;75:1175-1184.
Resnick D, Walter RD, Crudale AS: Bilateral dysplasia of the scapular neck. Am J Roentgenol 1982;139:387-390.

Question 13

What is the incidence and significance of anterior cruciate ligament laxity following tibial eminence fractures in skeletally immature individuals?

Explanation

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior

eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.

J Pediatr Orthop 1984;4:462-464.

Question 14

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

Explanation

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

Question 15

The medial collateral ligament complex of the elbow originates on what portion of the medial epicondyle?

Explanation

DISCUSSION: The medial collateral ligament complex of the elbow consists of three portions: the anterior bundle, the posterior bundle, and a transverse component that has little biomechanic significance. The origin of the ligament is from the central two thirds of the anteroinferior undersurface of the medial epicondyle.
REFERENCE: O’Driscoll SW, Jaloszynski R, Morrey BF: Origin of the medial ulnar collateral ligament. J Hand Surg Am 1992;17:164-168.

Question 16

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Explanation

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

Question 17

A middle-aged man sustains traumatic loss of the second, third, and fourth toes in a lawnmower accident. The wound is grossly contaminated with soil. Penicillin is added to his antibiotic regimen for coverage of what bacteria? Review Topic

Explanation

In farm or soil-contaminated wounds, including lawnmower injuries, penicillin is added to broad-spectrum cephalosporin and aminoglycoside therapy to cover against Clostridium. Psuedomonas is frequently seen after puncture wounds through the shoes. Acinetobacter is generally a hospital-acquired infection.

Question 18

A 47-year-old woman underwent a bunionectomy and hallux valgus correction a few years ago. She now has the complication shown in Figures 38a and 38b. She has no pain with motion of the metatarsophalangeal or interphalangeal joints. What is the best reconstructive option in this setting?

Explanation

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 19

Figure 81 is a lateral thoracic spine radiograph of a 76-year-old man with a history of ankylosing spondylitis who falls and strikes his back. He has moderate thoracic discomfort. An initial examination does not reveal neurologic deficits. He is discharged home that day, but returns 3 days later with profound weakness in his legs. Which imaging study should have been obtained at his initial presentation?

Explanation

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult vertebral fractures that are not readily detectable on radiographs. The treating surgeon must have a high suspicion for fractures in these patients and pursue further imaging of the spine with CT and (often) MRI. Even among patients who are neurologically intact, fracture displacement and neurologic deterioration can occur if fractures are not recognized early and appropriately stabilized. Fractures in patients with ankylosing spondylitis are extremely unstable and are associated with high risk for delayed neurological deterioration. Although plain film imaging of the entire spine should be considered, occult fractures can easily be missed. Imaging of the sacroiliac joints can be helpful to establish the diagnosis of ankylosing spondylitis but would not identify an occult fracture of the vertebra in this patient.
RECOMMENDED READINGS
Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265. View Abstract at PubMed Harrop JS, Sharan A, Anderson G, Hillibrand AS, Albert TJ, Flanders A, Vaccaro AR. Failure of standard imaging to detect a cervical fracture in a patient with ankylosing spondylitis. Spine (Phila Pa 1976). 2005 Jul 15;30(14):E417-9. PubMed PMID: 16025019. View Abstract at PubMed
Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and
complications. Eur Spine J. 2009 Feb;18(2):145-56. doi: 10.1007/s00586-008-0764-0. Epub 2008 Sep 13. Review. PubMed PMID: 18791749. View Abstract at PubMed

Question 20

Figure 1 is the MR image of a 43-year-old man who has left shoulder pain and weakness after a fall. An examination reveals active forward elevation at 120° and positive Yergason and lift-off test examination findings. Arthroscopy reveals that the articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment at this time?

Explanation

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer.

Question 21

A 20-year-old minor league baseball pitcher is diagnosed with a symptomatic torn ulnar collateral ligament (UCL) in his pitching elbow. Nonsurgical management consisting of rest and physical therapy aimed at elbow strengthening has failed to provide relief. He has concomitant cubital tunnel symptoms that worsen while throwing. What is his best surgical option?

Explanation

DISCUSSION: High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Ciccotti MG, Jobe FW: Medial collateral ligament instability and ulnar neuritis in the athlete’s elbow. Instr Course Lect 1999;48:383-391.

Question 22

Following insertion of a cementless femoral component into the total hip arthroplasty construct, the amount of femoral stress shielding is most associated with

Explanation

DISCUSSION
Although material modulus, characteristics of surface, and extent of coating all contribute to stress shielding, poor bone quality is the most important factor associated with stress shielding.

Question 23

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intraoperatively, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

Explanation

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 24

You are interested in learning a new technique for minimally invasive total knee arthroplasty. The Keyhole Genuflex system seems appealing to you because the instrumentation comes with wireless controls. Which of the following represents an acceptable arrangement?

Explanation

Both the AAOS and AdvaMed, the medical device manufacturer's trade organization, have written guidelines that address potential conflicts of interest regarding interactions between physicians and manufacturer's representatives when it comes to patients' best interest. The AAOS feels that the orthopaedic profession exists for the primary purpose of caring for the patient and that the physician-patient relationship is the central focus of all ethical concerns. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict of interest exists. The AAOS believes that it is acceptable for industry to provide financial and other support to orthopaedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopaedic surgeons and industry should benefit the patient and be able to withstand public scrutiny. A gift of any kind from industry should in no way influence the orthopaedic surgeon in determining the most appropriate treatment for his or her patient. Orthopaedic surgeons should not accept gifts or other financial support with conditions attached. Subsidies by industry to underwrite the costs of educational events where CME credits are provided can contribute to the improvement of patient care and are acceptable. A corporate subsidy received by the conference's sponsor is acceptable; however, direct industry reimbursement for an orthopaedic surgeon to attend a CME educational event is not appropriate. Special circumstances may arise in which orthopaedic surgeons may be required to learn new surgical techniques demonstrated by an expert or to review new implants or other devices on-site. In these circumstances, reimbursement for expenses may be appropriate.

Question 25

While experts disagree whether the postpolio syndrome is caused by a reactivation of the dormant virus or by an attritional aging phenomena of muscles that have been overworked over a period of time, both groups recommend which of the following guidelines for optimizing function in this population?

Explanation

DISCUSSION: Most leaders in orthopaedic surgery support Jacqueline Perry’s theory that the postpolio syndrome is an attritional degenerative process that is the result of overuse of muscles and joints that are unable to adequately tolerate overload, and have little functional reserve. For that reason, aerobic conditioning and exercise are important. Overload and exhaustion of involved muscles should be avoided.
REFERENCE: Garrett AL: Poliomyelitis, in Nickel VL (ed): Orthopaedic Rehabilitation. New York, NY, Churchill Livingston, 1982, pp 449-458.

Question 26

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

Explanation

DISCUSSION: The patient’s history, examination, and radiographs are classic for locked posterior dislocation of the glenohumeral joint. Posterior dislocation of the shoulder remains the most commonly missed dislocation of a major joint. Up to 80% are missed on initial presentation. The primary cause for failure to accurately diagnose this injury is inadequate radiographic evaluation. The typical presentation is a shoulder locked in internal rotation with loss of abduction. An axillary view not only will make the definitive diagnosis but will help assess the size of the articular surface defect and help plan treatment. This view can be done expediently as part of every trauma series. The AP view is suspicious for a posteriorly dislocated humerus with loss of the humeral neck profile, a vacant glenoid sign, and an anterior humeral head compression fracture (reverse Hill-Sachs lesion).
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.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosement, IL, American Academy of Orthopaedic Surgeons, 1997, pp 181-189.
Rockwood CA Jr, Thomas SC, Matsen FA III: Subluxations and dislocations about the glenohumeral joint, in Rockwood CA Jr, Green DP, Bucholz RW (eds): Fractures in Adults, ed 3. Philadelphia, PA, JB Lippincott, 1991, vol 1, pp 1058-1065.

Question 27

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

Explanation

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

Question 28

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Explanation

DISCUSSION:
The authors cited in the references examined large databases to determine the risk factors for conversion to total hip arthroplasty after arthroscopic surgery of the hip. In the study by Kester and associates, obesity had an odds ratio (OR) of 5.6 for conversion to hip arthroplasty, whereas age over 60 years had an OR of 3.4, osteoarthritis had an OR of 2.4, and tobacco use had an OR of 1.9.

Question 29

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

Explanation

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

Question 30

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Explanation

Figure A is an AP radiograph demonstrating a displaced femoral neck fracture. Active older patients who present with a displaced femoral neck fracture should be treated with total hip arthroplasty (THA).
Displaced femoral neck fractures can present a challenge to treat. In younger patients with good bone stock a closed vs. open reduction and internal fixation should be attempted. For active older patients a total hip arthroplasty is the best option, especially if there is pre-existing arthritis in the injured hip. THA provides the best function with the least pain and less need for repeat surgery (compared to hemiarthroplasty). For low-demand or debilitated patients, for patients older than age 80, or for those who can not reliably follow hip precautions a hemiarthroplasty provides the lowest risk of dislocation, and thus would be the treatment of choice.
Macaulay et al. present a prospective randomized trial of patients with femoral neck fractures treated with THA vs hemiarthroplasty. They found that functional outcomes and patient satisfaction were higher in the THA group without significant increased risk of complications. Inclusion criteria required patients to be over age 50, be a community ambulator, and were excluded for presence of dementia.
Abboud et al. retrospectively reviewed patients treated with THA for osteoarthritis and compared them to patients treated with THA for a femoral neck fracture. They found no significant difference between the two groups for outcomes or complications.
Figure A is an AP radiograph demonstrating a displaced femoral neck fracture.
Incorrect Answers:

Question 31

-The patient experienced little improvement with activity modification and physical therapy. An intraarticular corticosteroid injection provides excellent but short-lived pain control. She requests surgical treatment for her hip and she is counseled regarding arthroscopy and consent is obtained. Intraoperatively,a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. What treatment is most appropriate considering these findings?

Explanation

DISCUSSION FOR QUESTIONS 26 THROUGH 29
The clinical scenario, examination, and MRI scans are consistent with a pincer-type FAI. The decreased range of motion is secondary to the pain produced by the continued abutment of the femoral head against the anterosuperior acetabulum. Flexing the hip while internally rotating and adducting the leg recreates this contact and is typically painful. No clinical signs suggest sacroiliac joint arthritis, an intra-articular loose body, or trochanteric bursitis, although these are all diagnoses that should be considered in a patient with a painful hip. The most sensitive and specific study to detect an acetabular labral tear is an MRI arthrogram of the hip. This study should be obtained in this patient to evaluate the labrum as well as the status of the articular cartilage. An MRI scan without intra-articular contrast is not as sensitive as an arthrogram. An ultrasound can provide a dynamic assessment of the hip and help in the setting of a snapping hip; however, this study is not reliable to determine the presence of a labral tear. In the setting of pincer FAI, the forced leverage of the anterosuperior femoral head upon the anterior acetabulum results in abnormal forces against the posteroinferior acetabulum. This continued force can lead to a chondral lesion in this location know as a “counter-coup” injury. Chondral lesions of the femoral head are rare in the setting of pincer FAI. The posterosuperior quadrant does not experience increased force and rarely sustains chondral injuries. The patient is a young, active individual with no pre-existing degenerative changes, so repair of the tear with bony resection of the pincer lesion is the most appropriate treatment.A capsulolabral detachment should be repaired because these tears can heal and the labrum functions as a seal, preventing egress of synovial fluid from the joint space. If the pincer lesion is not resected, the patient will continue to experience abnormal contact and the repair will likely fail. There is no evidence that the patient has a cam impingement, and recontouring of the femoral head/neck junction is not appropriate. Simple debridement should be reserved for intrasubstance tears of the labrum, which would not be expected to heal with repair.
CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 32
Figures 30a and 30b 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.

Question 32

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 33

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Explanation

DISCUSSION: If the atlanto-dens interval is greater than 3 mm in an adult, a transverse ligament rupture usually is suspected. The atlanto-dens interval can be seen with CT or in lateral radiographs of the upper cervical spine. Transverse ligament rupture can occur as an isolated entity or in association with an odontoid or a Jefferson’s fracture. Patients with this type of injury usually require fusion.
REFERENCES: Dickman CA, Greene KA, Sonntag VK: Injuries involving the transverse atlantal ligament: Classification and treatment guidelines based upon experience with 39 injuries. Neurosurgery 1996;38:44-50.
Clark CR: The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 362-363.

Question 34

A 6-year-old girl has a painless spinal deformity. Examination reveals 2+ and equal knee jerks and ankle jerks, negative clonus, and a negative Babinski. The straight leg raising test is negative. Abdominal reflexes are asymmetrical. PA and lateral radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management? Review Topic

Explanation

The patient has an abnormal neurologic exam as shown by the abnormal abdominal reflexes. Furthermore, she has a significant curve and is younger than age 10 years. These findings are not consistent with idiopathic scoliosis. MRI will best rule out syringomyelia or an intraspinal tumor. Bracing and surgery are not indicated for this small curvature prior to obtaining an MRI scan.

Question 35

below depicts the radiograph obtained from a year-old woman who began having more right than left hip pain during a recent pregnancy. Physical examination reveals increased range of motion with positive flexion abduction and external rotation and flexion adduction and internal rotation as well as pain with external logroll. Assessment of below reveals

Explanation

DISCUSSION:
Studies have demonstrated that pelvic inclination can dramatically affect the interpretation of radiographs in the dysplastic hip, with 9° of increased pelvic inclination leading to the presence of crossover signs and posterior wall signs. A distance of 30 mm to 50 mm from the sacrococcygeal junction to the pubis is often used to assess the adequacy of pelvic inclination on radiographs, although Siebenrock and associates determined the mean difference to be 32 mm in men and 47 mm in women. In this patient, the pelvic inclination is dramatically increased, leading to overestimation of acetabular retroversion.

Question 36

A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis? Review Topic

Explanation

The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.

Question 37

A 69-year-old man sustains a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in Figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changes in the emergency department. Clinical pictures taken in the office are shown in Figures 27c through 27e. What is the most appropriate management of this soft-tissue wound?

Explanation

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 38

Item Deleted by AAOS Question 40 - Figure 8 shows the AP radiograph of a 38-yea-old woman who has constant pain in her shoulder as the results of a motor vehicle accident. Examination reveals marked restriction in external rotation. Which of the following studies should be ordered to aid in making a diagnosis?

Explanation

Figure eight demonstrates a posterior dislocation. Therefore the simplest, and best test would be the Axillary lateral. Rockwood and Green (fourth edition) discusses several radiographic signs that indicate that a posterior dislocations exists. Absence of the normal elliptical overlap shadow; the vacant glenoid sign; presence of the Trough line; Loss of profile of the neck of the humerus; and void in the inferior or superior glenoid fossa. Furthermore the clinical picture of loss of external rotation should also make one suspect of a posterior dislocation.

Question 39

A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Explanation

Subscapularis repair-Traumatic rupture of the tendon of the subscapularis muscle is caused by forceful hyperextension or external rotation of the adducted arm. A simple clinical maneuver called the "lift-off test", reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon.

Question 40

A toddler is brought in by his parents for evaluation of gait problems. Birth history and neurologic examination are unremarkable. After evaluating femoral torsion, tibial torsion, and foot contour, the diagnosis is excessive internal tibial torsion. The parents should be advised to expect which of the following outcomes?

Explanation

DISCUSSION: Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.
REFERENCES: Canale ST, Beaty JH: Operative Pediatric Orthopaedics. St Louis, MO, Mosby Year Book, 1991, pp 357-385.
Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.

Question 41

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Explanation

DISCUSSION: The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1009-1149.

Question 42

When performing a gastrocnemius recession, what structure should be protected?

Explanation

DISCUSSION: When performing a gastrocnemius slide at the tendinous portion of the gastrocnemius insertion, the sural nerve and saphenous vein, which tend to run midline posterior at this level, must be protected and retracted laterally. An anatomic study of the sural nerve at this level localized the nerve superficial to the deep fascia overlying the gastrocnemius in 42.5% of the cases; deep to the superficial fascia in 57.5% of the cases, and directly applied to the gastrocnemius tendon in 12.5% of cases.
REFERENCES: Pinney SJ, Sangeorzan BJ, Hanen ST Jr: Surgical anatomy of the gastrocnemius resection (Strayer procedure). Foot Ankle Int 2004;25:247-250.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 415-417.

Question 43

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

Explanation

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

Question 44

A B Figures 52a and 52b are the radiographs of a patient who was involved in a motor vehicle collision. He was wearing his seat belt and is now complaining of midthoracic back pain. Radiographs in the emergency department do not reveal a fracture. What is the most appropriate next step?

Explanation

DISCUSSION
Ankylosing spinal disorders, including ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are conditions that make the spine rigid and at risk for 3-column unstable fractures. Spinal fractures in these patients pose high risk for complications and death and patients should be counseled and observed closely. Mortality strongly correlates with older age and increased number of comorbidities.
These spine fractures often are not seen at the time of initial evaluation, and a delay in diagnosis can occur in up to 19% of cases. This is particularly common in the setting of non- or minimally displaced fractures following minor injuries. A delayed diagnosis can lead to displacement of a previously nondisplaced fracture that can incur a high neurologic injury risk. Advanced imaging with a CT scan or MRI should be obtained for patients with ankylosing spinal disorders even when minor injuries occur. Although bracing and observation can be used, posterior multilevel spinal instrumentation is typically required to obtain adequate spinal stabilization.
The radiographs show an osteopenic ankylosed thoracic spine; the anteroposterior radiograph clearly shows fusion of the sacroiliac joints. Recognition of these radiographic findings is important when evaluating patients after an injury.
RECOMMENDED READINGS
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858. View Abstract at PubMed
Hendrix RW, Melany M, Miller F, Rogers LF. Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings. AJR Am J Roentgenol. 1994 Apr;162(4):899-904. PubMed PMID: 8141015. View Abstract at PubMed

Question 45

In patients undergoing elective hip or knee arthroplasty who are not at elevated risk (beyond the risk associated with the surgery) for venous thromboembolism or bleeding, using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism was assigned what grade of recommendation by the 2011 AAOS Clinical Practice Guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty?

Explanation

DISCUSSION:
Using pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism in patients undergoing elective hip or knee arthroplasty who are not at elevated risk beyond that of the surgery itself for venous thromboembolism or bleeding was given a moderate grade of
recommendation in the 2011 AAOS Clinical Practice Guideline referenced above.

Question 46

An 8-year-old boy reports progressive difficulty with walking. Examination reveals muscle weakness, with proximal groups more affected than distal muscles. Deep tendon reflexes are within normal limits. Laboratory studies show a creatine kinase level of 7,200 IU. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: Patients with Becker muscular dystrophy have an abnormality in dystrophin, but unlike patients with Duchenne muscular dystrophy, some dystrophin is present. As a result, the progression of muscle weakness is slower, with the diagnosis typically made after age 8 years. Similar to patients with Duchenne muscular dystrophy, patients with Becker muscular dystrophy have pseudohypertrophy of the calves, markedly increased creatine kinase levels, and X-linked transmission of the condition. In addition, these patients are more prone to cardiomyopathy; a condition that should be carefully evaluated if any surgery is required. Patients with spinal muscular atrophy also have proximal muscle weakness, but the onset of weakness occurs earlier in childhood. These patients also have absent deep tendon reflexes and fasciculations, but pseudohypertrophy is absent and creatine kinase levels are normal. Patients with Emery-Dreifuss dystrophy may have a similar clinical picture to Becker’s muscular dystrophy, but pseudohypertrophy is absent and creatine kinase levels are only mildly elevated. In addition, neck extension, elbow flexion, and ankle equinus contractures develop at an early age. Limb girdle dystrophy is a group of progressive muscular dystrophies that is not associated with pseudohypertrophy or a significant elevation of creatine kinase levels. Guillain-Barre syndrome is a condition associated with results from postinfectious demyelination of the peripheral nerve. These patients have the acute onset of weakness, hypotonia, and areflexia; creatine kinase levels are normal.
REFERENCES: Sussman MD: Muscular dystrophy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1573-1583.
Thompson GH, Berenson FR: Other neuromuscular disorders, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, vol 1, pp 633-676.

Question 47

A 71-year-old woman who reports long-term use of oral steroids for asthma is referred for treatment of a distal humerus fracture. Radiographs reveal diffuse osteopenia and a severely comminuted intra-articular fracture. What is the most appropriate treatment?

Explanation

DISCUSSION: Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.
REFERENCES: Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947.
Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the elderly: The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84:812-816.

Question 48

What structure (arrow) is shown in Figure 24?

Explanation

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 49

Which of the following findings best describes the acetabular fracture shown in Figure 38?

Explanation

DISCUSSION: 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.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 50

Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Explanation

PHASE V: the crescent sign and articular collapse. The supporting bony architecture may become sufficiently weakened by continued resorption of trabecular bone and subchondral bone plate along the reactive interface that the stress of weight-bearing can result in subchondral bone plate fracture with focal articular cartilage buckling and eventual collapse. This is best seen in the frog-lateral radiograph.

Question 51

The majority of severe cervical spine injuries occurring in contact sports evolve during axial loading and flexion of the cervical spine. At what minimum degree of flexion does axial loading place the cervical spine at risk during contact sports?

Explanation

DISCUSSION: The paravertebral musculature, the intervertebral disks, and the normal lordotic curvature of the cervical spine can absorb much of the imparted energy of collision. However, when the neck is flexed approximately 30 degrees, the normal lordotic curvature is flattened and the forces applied to the vertex of the head are directed at a straight segmented column. In this situation, the cervical spine is less able to absorb the applied force. With mounting axial load, compressive deformation occurs within the intervertebral disks, causing angular deformation and buckling. The spine will fail in flexion, with resultant fracture, subluxation, or dislocation. A rotatory component added to axial compression can cause concomitant extension, rotation, and shear injury patterns. The National Football Head and Neck Injury Registry has made two recommendations to the NCAA Football Rules Committee to minimize the risk of such injuries: (1) No player should intentionally strike an opponent with the crown or top of the helmet; and (2) No player should deliberately use his helmet to butt or ram an opponent.
REFERENCES: Thomas BE, McCullen GM, Yuan HA: Cervical spine injuries in football players. J Am Acad Orthop Surg 1999;7:338-347.
Torg JS, Truex R Jr, Quedenfeld TC, Burstein A, Spealman A, Nichols C III: The National Football Head and Neck Injury Registry: Report and conclusions 1978. JAMA 1979;241:1477-1479.

Question 52

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

Explanation

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

Question 53

Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic

Explanation

Thyroid dysfunction is not one of the clinical entities included in the female athlete triad.
The female athlete triad was coined in 1992 by the American College of Sports Medicine as a complex disorder more prevalent in the adolescent and young female
athlete population including decreased bone mineral density (BMD), menstrual dysfunction, and low energy availability with or without a concomitant eating disorder. Treatment should involve a multidisciplinary approach, including psychological and nutritional counseling for eating behaviors and dietary management, reduction of training intensity to decrease risk of stress fractures, and initiating calcium and vitamin D supplements for osteoporosis.
Nazem et al performed a systematic review of articles containing the female athlete triad, reviewing diagnosis via screening during physical examinations as well as laboratory and imaging evaluation for menstrual dysfunction, low energy availability, and low bone mineral density. They state that potential complications including possible infertility, decreased immune function, cardiovascular disease, and irreversible loss of bone mineral density. They concluded that prevention, early recognition, and a multidisciplinary treatment team with a focus on proper nutrition and natural return of menses is vital.
Nattiv et al review the position of the American College of Sports Medicine regarding the female athlete triad, including screening for the triad at the pre-participation physical, discouragement of unhealthy weight loss practices. Essential members of the multidisciplinary treatment team include a health-care professional, a registered dietitian, and a mental health practitioner. They endorse that the first aim of treatment for any triad component is to increase energy availability by increasing energy intake and reducing exercise energy expenditure.

Question 54

Which of the following findings is more suggestive of neurogenic rather than vascular claudication in the differential diagnosis of leg pain?

Explanation

All of the answers except answer 3 are suggestive of vascular claudication. Additional signs and symptoms of vascular claudication include diffuse aching/cramping/tired pain that is worse with exertion, is usually in the calves (also may be in feet, thighs, hips, and buttocks). Neurogenic claudication, on the other hand, usually is sharply painful, occurs in the back, buttocks, thighs, calves; is worse with spine extension and walking; is better/less with spine flexion and lying recumbent; pulses and skin are unaffected.

Question 55

A 14-year-old gymnast presents after a fall from the balance beam with a hyperextension injury to her left knee. She could ambulate with pain but was unable to continue exercise due to pain. On examination she has a swollen knee with painful

Explanation

The patient has a mild to moderately displaced tibial eminence fracture, which can be treated with closed reduction, casting, and supportive care provided successful closed reduction is achieved.
Tibial eminence fractures are rare but occur more often in pediatric populations, often in the setting of sports-related injuries. Debate continues over operative vs nonoperative treatment, as well as fixation type (screw vs suture) for openly treated fractures. Past evidence suggested closed treatment was adequate but there has been an increase in operative management. Closed treatment is suggested for minimally displaced fractures (Type I and reducible Type II) and open treatment for completely displaced fractures (non-reducible Type II and Type III).
Wilfinger et al provide the results of a closed reduction protocol at their institution including 38 patients with long term followup. All patients underwent aspiration and closed reduction in the OR under fluoroscopic guidance followed by long leg casting in hyperextension and graduated weight bearing over weeks. No patients complained of persistent pain, swelling, giving way, or disability at follow up.
However, Edmonds et al in a retrospective review compare open reduction internal fixation (ORIF), arthroscopic-assisted internal fixation (AAIF), and closed reduction with casting (CRC) for pediatric patients with displaced tibial spine fractures. They report improved reduction but also increased arthrofibrosis in ORIF and AAIF groups
compared to CRC, but of the 24% of patients with long term followup results, there was no difference in functional outcomes across all 3 groups. There was a 17% rate of later operation for the CRC group patients. They suggest closed treatment for fractures with <5mm displacement, otherwise ORIF or AAIF.
Gans et al conducted a systematic review focused on the questions of open vs closed reduction, and screw vs suture fixation. The 26-article review found insufficient evidence to have any clear recommendations. They did find reduced laxity and improved range of motion for minimally displaced fractures that had an open reduction, and that completely displaced fractures treated nonoperative had higher rates of nonunion.
Figures A and B are AP and lateral knee radiographs demonstrating a moderately displaced (Meyers and McKeever Type II) tibial spine fracture in a skeletally immature patient.
Incorrect Responses

Question 56

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Explanation

Closed treatment of humeral shaft fractures with functional bracing is indicated in the vast majority of isolated injuries. An ipsilateral brachial plexus injury, however, is a contraindication to nonoperative management in a functional brace.
Indications for operative management of humeral shaft fractures are limited given the high rates of union and ability of adjacent joints to compensate for deformity. Intact muscular tone is necessary to effect bony apposition in closed treatment with a functional brace. The absence of neurologic and muscle function in patients with a flail extremity leads to increased rates of nonunion and malunion.
Rutgers and Ring conducted a retrospective review of patients managed with functional bracing of humeral shaft fractures at a single institution. The authors found a 90% overall union rate, with maintenance of shoulder and elbow motion. They caution though, that 29% of their proximal third fractures went on to nonunion.
Figure A demonstrates an AP radiograph of a comminuted humeral shaft fracture with varus alignment.
Incorrect Answers:

Question 57

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Explanation

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899. View Abstract at PubMed Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053. View Abstract at PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 58

A previously healthy 65-year-old woman has a closed fracture of the right clavicle after falling down the basement stairs. Examination reveals good capillary refill in the digits of her right hand. Radial and ulnar pulses are 1+ at the right wrist compared with 2+ on the opposite side. In the arteriogram shown in Figure 36, the arrow is pointing at which of the following arteries?

Explanation

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 59

Split posterior tibial tendon transfer is used in the treatment of children with cerebral palsy. Which of the following patients is considered the most appropriate candidate for this procedure?

Explanation

DISCUSSION: Split posterior tibial tendon transfers are best performed in patients with spastic cerebral palsy who are between the ages of 4 and 7 years and have flexible equinovarus deformities. Rigid deformities typically require bony reconstruction procedures. Tendon transfers in patients with athetosis are unpredictable.
REFERENCES: Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 1983;65:748-754.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 1142-1152.

Question 60

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. Radiographs show an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. What is the most appropriate treatment?

Explanation

OCD is an acquired lesion of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged and the normal articular surface restored whenever possible.

Question 61

Figures A and B are axial and coronal MRI images of a 21-year-old male athlete. He injured his left leg during a hurdling race approximately 1 week ago. What would be the next best step in the management of this injury? Review Topic

Explanation

Figures A and B show an acute proximal hamstring tendon avulsion. The next best step in management would be open surgical repair of all tendons to their origin at the ischial tuberosity.
Athletes participating in sports that require sprinting, jumping, acceleration and deceleration are at increased risk of sustaining a proximal hamstring tendon avulsion. The greatest predictor of this injury is prior hamstring injury. Other risk factors include increasing age, high training demand, increased body mass index and tight hip flexor muscles. MRI is the gold standard imaging to identify these images. Open hamstring tendon repair is recommended in athletes when all of the hamstring tendons have avulsed off their origin or 2 tendons have avulsed and retracted more than 2 cm.
Cohen et al. wrote a JAAOS article on acute proximal hamstring rupture. They point out that testing the peroneal branch of the sciatic nerve function is important in the physical examination, as injury to this branch will cause weakness of the short head of the biceps femoris and may slow potential postoperative rehabilitation.
Lefevre et al. reviewed the return to sports after surgical repair of acute proximal hamstring ruptures. They performed a prospective observational study that included 34 patients. Patients returned to sports within a mean 5.7 ± 1.6 months, at the same level in 27 patients (79.4 %) and at a lower level in 7 patients (20.6 %). They conclude that surgical repair of acute proximal hamstring ruptures has the potential to significantly improve the functional prognosis of patients with these injuries.
Figures A and B shows a significant amount of swelling and hematoma around the hamstring tendon. The whole ischial tuberosity is denuded of tendon, which is consistent with a complete rupture. Illustration A shows a large posterior thigh ecchymosis commonly seen with this injury. The ecchymosis presents approximately 1 week following injury, which is know as latent ecchymosis. Illustration B shows a
schematic and intraoperative image of the open tendon repair of an acute injury.
Incorrect

Question 62

A 33-year old man sustains a posterior elbow dislocation after a fall. Attempts at closed reduction result in recurrent instability. What is the most common ligamentous injury found at the time of surgical stabilization?

Explanation

Classic posterior elbow dislocations result from a posterolateral rotatory mechanism, whereby the hand is fixed (typically on the ground) while the weight of the body creates a valgus and external rotation moment on the elbow. This results first in tearing of the lateral collateral ligament that proceeds medially through the anterior and posterior joint capsules, ending with potential involvement of the ulnar collateral ligament (but this is not universal). McKee and associates assessed the lateral soft-tissue injury pattern of elbow dislocations
with and without associated fractures at the time of surgery. Injury to the lateral collateral ligament complex was seen in every case, with avulsion from the distal humerus as the most common finding. Midsubstance
tears, proximal avulsions, and distal bony avulsions of the ulnar collateral ligament are less common.

Question 63

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

Explanation

Internal impingement is characterized by articular-sided partial-thickness rotator cuff tears and superior glenoid labral tears. The capsule is characterized by laxity anteriorly and tightness posteriorly.

Question 64

A 30-year-old man has had a 3-day history of severe, incapacitating lower back pain without radiation. He reports improvement with rest. He denies any history of trauma, has no constitutional symptoms, and his neurologic examination is normal. What is the best course of action?

Explanation

DISCUSSION: There are no red flags in the history or examination to warrant MRI. Limited bed rest (less than 3 days) has been shown to be more beneficial to early recovery compared with prolonged bed rest (more than 7 days). No data support the use of epidural or facet steroid injections for acute low back pain.
REFERENCE: Deyo RA, Diehl AK, Rosenthal M: How many days of bed rest for acute low back pain? A randomized clinical trial. N Engl J Med 1986;315:1064-1070.

Question 65

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Explanation

Minimally invasive methods used for stabilizing complex periarticular fractures continue to evolve. Encouraging results suggest a diminished threat to the soft tissues and enhanced preservation of osseous blood supply. Contemporary locking implants combined with indirect reduction lead to desirable biomechanical and biologic environments for osseous and soft-tissue healing. Deangelis and associates, in a cadaveric tibial study, demonstrated the superficial peroneal nerve to be at significant risk during percutaneous screw placement in very distal targeted holes (within laterally applied tibial locking plates). Use of a larger incision and cautious dissection to the plate in this region were encouraged to minimize risk to this structure.

Question 66

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Explanation

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.

High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 67

Figures 150a through 150d are the radiographs and MR images of a 37-year-old woman who has a 3-month history of severe right hip pain. She does not recall any trauma prior to the pain onset and denies any past steroid exposure. She has 3 children and is not currently pregnant. The pain is located in her groin and the onset was sudden. The pain is refractory to anti-inflammatory medications. What is the most appropriate treatment?

Explanation

DISCUSSION
The patient’s MR images are consistent with transient hip osteoporosis. No signs suggest avascular necrosis. She has no joint narrowing. Transient osteoporosis of the hip is characterized by bone marrow edema in the femoral head and neck. This condition affects more men than women and is sometimes seen in the third trimester of pregnancy but can be seen in women who are not pregnant as well. This is a self-limiting condition, and the treatment is limited weight-bearing activity until the symptoms resolve. Core decompression is rarely used in these cases. There is no indication for arthroplasty or osteotomy in this scenario.

Question 68

A 55-year-old woman is referred for evaluation of a painful knee replacement. She underwent total knee arthroplasty (TKA) more than 1 year ago without perioperative complications but has had consistent pain since the surgery. The patient’s preoperative radiographs and postoperative radiographs are shown in Figures below. Examination reveals medial laxity during valgus stress testing and range of motion of 0° to 70°. Her erythrocyte sedimentation rate and C-reactive protein level are normal. What is the best next step?

Explanation

DISCUSSION:
The radiographs show substantial valgus malalignment of the femoral component, with lateral mechanical axis deviation. Clinically, by examination she displays instability and stiffness as a result. Revision knee replacement is appropriate and should consist of total revision to stemmed femoral and tibial components with a varus-valgus constrained insert, given the likely attenuation of the medial collateral ligament. Open debridement with ligament balancing and polyethylene exchange do not address the underlying cause and are inappropriate. Distal femoral osteotomy is not useful in the setting of previous total knee replacement.
Nonsurgical treatment with an unloader brace would be ineffective in correcting the alignment.

Question 69

A 75-year-old man presents with worsening low back and bilateral leg pain. The pain worsens with ambulation and improves with sitting. On exam, he has strong DP and PT pulses. Straight leg raise is negative. A MRI of the lumbar spine is performed and is pictured in Figure A. On further questioning, which of the following is the patient also likely to report? Review Topic

Explanation

The patient has lumbar spinal stenosis with neurogenic claudication and therefore is likely to experience worsening pain with activities that result in lumbar extension, such as walking down stairs.
Lumbar spinal stenosis often results from degenerative changes of the intervertebral disc and facet joints which ultimately narrows the space available for the thecal sac and exiting nerve roots. Patients can present with neurogenic claudication, reported as worsening leg and/or back pain with ambulation and diminished walking capacity. MRI may demonstrate disc degeneration/bulging, hypertrophy of the ligamentum flavum and facet capsule, and narrowing of the central canal. Nonoperative management includes NSAIDs, PT and epidural steroid injections (ESI). Surgery is reserved for patients who have failed nonoperative measures and includes decompressive laminectomy with or without fusion depending on presence of instability.
Issack et al reviewed degenerative lumbar spinal stenosis. Unlike patients with vascular claudication, patients with neurogenic claudication are able to improve walking tolerance with postural changes, specifically with flexed-forward posture (such as leaning forward on a shopping cart). They are unable to improve their symptoms simply by cessation of walking. Patients with neurogenic claudication tend to lack the trophic changes of the skin on the legs/feet as well as diminished pulses characteristic of vascular disease.
Young et al reviewed the utilization of lumbar ESI for low back and leg pain. The authors concluded that lumbar ESI are a reasonable nonsurgical option to provide temporary symptomatic relief. Fluoroscopic guidance facilitates accurate placement of the injection into the epidural space, while its nonuse may lead to higher percentage of technical failures. Lastly, the transforaminal approach is more selective
than the interlaminar approach and can provide diagnostic information as well as symptom relief.
Figures A and B are T1 sagittal and T2 axial MR images, respectively, of the lumbar spine demonstrating significant central canal stenosis most notable at L4-L5 with broad disc protrusion, facet degeneration and infolding of the ligamentum flavum.
Incorrect
Responses:

Question 70

The posterior approach to the proximal radius uses what intermuscular interval?

Explanation

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 71

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Explanation

Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.

Question 72

A coach of 3 football teams—the B team, junior varsity team, and varsity team—wants to study the average times in the 40-yard dash for his players. Which test would help him determine if the mean 40-yard dash times for the athletes on 1 team are different from those on the other teams?

Explanation

DISCUSSION
Data collected in research studies fall into 1 of 2 categories—continuous or discrete. Continuous data can be displayed on a curve. Examples include height, weight, and time recorded in a 40-yard dash. Discrete data represent data that fall into specific categories such as gender or the presence or absence of a risk factor.
ANOVA is used to determine statistical significance in mean values of continuous data when there are more than 2 independent samples. The 2-sample t test compares mean values of continuous data between 2 independent groups. The Chi-square test and Fisher's exact tests are tests used to analyze discrete data.
RESPONSES FOR QUESTIONS 58 THROUGH 61
Paresthesias in the fourth and fifth digits
Numbness on the lateral side of the forearm
Heterotopic ossification
Posterolateral rotatory instability of the elbow
Medial antebrachial cutaneous neuroma
For each surgical case described below, match the most likely related complication listed above.

Question 73

The patient undergoes hip arthroscopy and the image of the right hip is shown in Figure 39. Repair of the injured structure would be expected to improve

Explanation

DISCUSSION
The radiographic studies reveal both acetabular dysplasia and cam-type femoroacetabular impingement. The MR image shows an acetabular labral tear. Structural abnormalities of the hip, including femoroacetabular impingement, have commonly been identified in association with labral tears. Disruption of the ligamentum teres is not associated with impingement conditions in the absence of trauma.
The patient has acetabular dysplasia with a decreased lateral center-edge angle and also has visible cam-type femoroacetabular impingement. The common pathway for joint degeneration in hips with cam-type femoral head anatomy includes the development of cartilage damage in the anterior or superolateral aspects of the acetabular cartilage. Paralabral cysts may be seen more commonly in association with acetabular dysplasia, although the patient’s radiographs did not demonstrate substantial cystic changes. Osteochondral loose bodies and ligamentum teres ruptures can be seen at arthroscopy in a small number of cases.
There are several proposed roles of the acetabular labrum. It can increase the depth of the acetabular socket by as much as 21% to 28%. Roles of the acetabular labrum include joint lubrication, shock absorption, and pressure distribution. Recent studies assessing the effects of loading on joint stability for both normal and dysplastic hips did not demonstrate a substantial role of the labrum in differences in loading. Although joint stability might be improved following surgical repair, acetabular dysplasia is not likely to be resolved with acetabular labral repair alone.
RECOMMENDED READINGS
Tibor LM, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular impingement. Bone Joint Res. 2012 Oct 1;1(10):245-57. doi: 10.1302/2046-3758.110.2000105.PubMed: 23610655. View Abstract at PubMed
Peelle MW, Della Rocca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clin Orthop Relat Res. 2005 Dec;441:327-33. PubMed PMID: 16331022. View Abstract at PubMed
Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011 Jul;39 Suppl:72S-8S. doi: 10.1177/0363546511412320.
PubMed PMID: 21709035. View Abstract at PubMed
James SL, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of 37
femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec;187(6):1412-9. PubMed PMID: 17114529. View Abstract at PubMed
Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun;2(2):105-17. doi: 10.1007/s12178-009-9052-9. Epub 2009 Apr 7. PubMed PMID: 19468871. View Abstract at PubMed
Henak CR, Ellis BJ, Harris MD, Anderson AE, Peters CL, Weiss JA. Role of the acetabular labrum in load support across the hip joint. J Biomech. 2011 Aug 11;44(12):2201-6. doi: 10.1016/j.jbiomech.2011.06.011. Epub 2011 Jul 14. PubMed PMID: 21757198. View Abstract at PubMed

Question 74

CLINICAL SITUATION Figure 1 is the radiograph taken 6 weeks ago of a 41-year-old woman with persistent pain in her right leg after sustaining a tibia fracture 12 months ago in a motor vehicle collision. On examination, she has well-healed scars and a well-healed flap on the medial aspect at the level of the fracture. She reports having an infection after the initial surgery, which resulted in debridement of the soft tissue and need for the local rotational flap. There are no changes at the fracture site as shown in the most recent radiograph (Figure 2). She is healthy and has no comorbidities. Assuming her workup is negative for any other causes, what is the best treatment option?

Explanation

Discussion: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-unions, especially in the femur.

Question 75

A patient competing in a professional motocross race sustained a direct blow to the knee after falling off his bike at high speed. He sustained several lacerations as shown in Figure 60. He is able to actively extend his knee painlessly and his Lachman examination is negative. What is the most likely injury? Review Topic

Explanation

It is important to recognize the injury pattern sustained by this motocross rider by inspection of his traumatic scars present anteriorly over the proximal tibia and the dorsum of the ankle and dorsum of the forefoot, indicating that his foot was in a plantar flexed position with a concomitant blow to the anterior tibia. This is a classic mechanism for a posterior cruciate ligament injury, and external clues (the scars) should not be overlooked when examining the knee. Occasionally, a posterior cruciate ligament injury is overlooked; however, putting together the patient's history, the examination (especially the posterior drawer and quadriceps active tests) provide a reliable diagnosis. Additional pathology should also be ruled out, such as a posterolateral corner injury and intra-articular pathology. Patella fracture, tibial tubercle avulsion, and patella tendon tears are unlikely because the patient can actively extend the knee. An anterior cruciate ligament tear is unlikely with a negative Lachman examination.

Question 76

At the level of the midcalf, the plantaris tendon is found at which of the following locations?

Explanation

DISCUSSION: The plantaris tendon is often harvested to augment a tendon reconstruction. The origin of the plantaris muscle is on the posterolateral aspect of the distal femur, and the muscle lies lateral to the tibial nerve and the posterior tibial artery. The tendon then courses posteriorly between the soleus and the medial head of the gastrocnemius.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 475.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 491.

Question 77

03 Figure 72 shows the radiograph of a 4 y/o girl who has a painless right Trendelenburg limp. Management should consist of

Explanation

Many high dislocations in children with DDH may remain mobile and pain free for decades despite an inefficient gait. Unilateral dislocations usually create difficulties with limb-length discrepancies and spinal malalignment
(unlike their bilateral counterparts which generally do not need to be reduced). Open reduction is used to obtain absolute concentric reduction. In the dislocated hip reduced at age 15 mths or older, there is usually enough associated bony deformity, either femoral, acetabular, or both to require stabilizing osteotomy to maintain the concentric reduction. Femoral shortening is often necessary to relax soft tissues before a perfect reduction is possible in children > 2 y/o.
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Question 78

In hip arthroplasty, the location of the medial femoral circumflex artery is best described as

Explanation

DISCUSSION: The obturator artery lies closest to the transverse acetabular ligament. The femoral artery is closest to the anterior rim of the acetabulum. No named vessel lies within the substance of the gluteus minimus or superior to the piriformis tendon. The medial femoral circumflex artery lies medial or deep to the quadratus femoris muscle.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 1. Philadelphia, PA, JB Lippincott, 1984, Figure 7-53, p 346.
Callaghan JJ, Rosenberg AG, Rubash HE: The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, p 705.

Question 79

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Explanation

DISCUSSION: Nonsurgical management is considered for proximal tears as well as partial tears in some individuals. Surgical management is often not appropriate in older or sedentary patients. However, patients treated nonsurgically will have a significant cosmetic defect, as well as weakness in adduction and internal rotation.
REFERENCES: Schepsis AA, Grafe MW, Jones HP, et al: Rupture of the pectoralis major muscle: Outcome or repair of acute and chronic injuries: Am J Sports Med 2000;28:9-15.
Petilon J, Carr DR, Sekiya JK, et al: Pectoralis major muscle injuries: Evaluation and management. J Am Acad Orthop Surg 2005;13:59-68.

Question 80

A 40-year-old man sustains a fall while mountain biking and presents with a posterior elbow fracture-dislocation. The elbow is reduced in the ER and noted to be grossly unstable with varus and valgus stress. Imaging demonstrates a two part radial head fracture involving 40% of the articular surface and a fracture involving less than 10% of the coronoid tip. He is taken to the OR for surgical reconstruction. After fixation of the radial head and repair of the LCL complex, the elbow is fluoroscopically examined and noted to be unstable with valgus stress. The elbow is ranged and dislocates at less than 45 degrees of flexion with the forearm in full supination. What is the next best step in management?

Explanation

OrthoCash 2020

Question 81

A 24-year-old runner who underwent an allograft reconstruction of the anterior cruciate ligament (ACL) 3 years ago now reports anterior knee pain. Examination reveals no swelling or effusion, and the patient has full motion. A Lachman test and a pivot-shift test are negative. Palpation reveals tenderness on the patellar tendon and at the inferior pole of the patella. AP and lateral radiographs are shown in Figures 41a and 41b. Management should consist of

Explanation

DISCUSSION: The radiographs show tunnel enlargement, which is seen after ACL reconstruction, particularly with allografts. Occasionally, there will be formation of an associated subcutaneous pretibial cyst. It has been proposed that the tunnel enlargement and cyst are the result of incomplete incorporation of allograft tissues within the bone tunnels. There may be residual graft necrosis, allowing synovial fluid to be transmitted through the tunnel to collect in the pretibial area, manifesting as a synovial cyst. In the absence of cyst formation, the presence of tunnel enlargement does not appear to adversely affect the clinical outcome. Based on studies by Fahey and associates, continued tunnel expansion does not occur. Victoroff and associates report good results with curettage and bone grafting of the tibial tunnel if a pretibial cyst is present. Because this patient does not have a pretibial cyst, observation with activity modification is the preferred treatment.
REFERENCES: Fahey M, Indelicato PA: Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 1994;22:410-414.
Victoroff BN, Paulos L, Beck C, Goodfellow DB: Subcutaneous pretibial cyst formation associated with anterior cruciate ligament allografts: A report of four cases and literature review. Arthroscopy 1995;11:486-494.

Question 82

Figures 51a and 51b show the radiographs of a 12-year-old boy obtained after an attempted closed reduction of an elbow injury in the emergency department. His motor examination is intact but he reports decreased sensation along the palmar aspect of his ring and little finger. What is the best treatment plan? Review Topic

Explanation

Angle A, ilium and cartilaginous acetabulum
Angle A, ilium and bony acetabulum
Angle B, ilium and cartilaginous acetabulum
Angle B, ilium and bony acetabulum
Angle B, bony acetabulum and acetabular labrum
The alpha angle is subtended by (1) a line drawn down the ilium to a point where it intersects with the bony and cartilaginous confluence of the acetabulum and (2) a line drawn along the roof of the bony acetabulum.
The coronal flexion view (as depicted in figure A) of the infant hip is perhaps more familiar if rotated 90 degrees to view as one would view an anterior posterior radiograph of the pelvis. Acetabular development is evaluated primarily by the alpha angle, indicating the morphology of the developing acetabulum, and the percentage of the femoral head that is covered by the bony acetabulum. These are each readily apparent on ultrasound. Normal hips should have an alpha angle of at least 60 degrees by 6-8 weeks of age.
Harcke et al. provide a current concepts review on the state of ultrasound in the diagnosis and management of developmental dysplasia of the hip (as of 1991). They report, since that time, ultrasound has become the mainstay for diagnostic confirmation and management of DDH.
LeBa et al. performed a study to look at whether ultrasound screening would increase in effectiveness if targeted toward infants with established risk factors for developmental dysplasia of the hip and normal findings on physical examination. They found dynamic ultrasound evaluation showed developmental dysplasia in 7.8% of patients who had normal physical exams and led to a change in treatment in 8%. They conclude selective ultrasound screening in infants with risk factors and normal
findings on physical examination is effective and leads to more effective treatment.
Figure A shows an ultrasound exam of a 2 week old infant. The alpha angle is labeled 'B'. The beta angle is lableled 'A'. Illustration A is a diagram from Tachdjian's illustrating diagrammatically the elements of these angles.
Incorrect answers.

Question 83

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following?

Explanation

DISCUSSION: The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Kohles SS, Kohles JD, Karp AP, et al: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: Comments on meta-analysis. Spine 2004;29:1281-1287.

Question 84

A 14-year-old boy sustains a twisting injury to his right shoulder and recalls feeling a snap during a wrestling match. Examination shows hesitancy to raise the arm away from the side, diffuse tenderness and swelling of the upper arm, and no evidence of neurovascular compromise. Figures 6a and 6b show an AP radiograph and MRI scan. What is the most likely diagnosis?

Explanation

DISCUSSION: While difficult to appreciate on the AP radiograph of the shoulder, the increased physeal signal demonstrated on the axial MRI scan is consistent with a nondisplaced growth plate fracture. A comparison radiograph of the left shoulder also could be considered and the injured shoulder evaluated for physeal widening.
Proximal humeral fractures in children are somewhat unusual, representing less than 1% of all fractures seen in children and only 3% to 6% of all epiphyseal fractures. Physeal injuries are classified according to the Salter-Harris classification scheme. Salter-Harris type I fractures represent approximately 25% of physeal injuries to the proximal humerus in adolescents.
The proximal humeral physis is responsible for 80% of the longitudinal growth of the humerus; therefore, there is tremendous potential for remodeling of fractures in this region. Management for nondisplaced Salter-Harris type I fractures is limited to a short period of immobilization followed by a gradual return to activities as clinical symptoms resolve.
REFERENCES: Curtis RJ, Rockwood CA Jr: Fractures and dislocations of the shoulder in children, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 991-1007.
Salter RB, Harris WR: Injuries involving the epiphyseal plate. J Bone Joint Surg Am 1963;45:587-622.

Question 85

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following? Review Topic

Explanation

The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.

Question 86

Explanation

Question 87

1 shows the radiograph obtained from a year-old man recently diagnosed with osteoarthritis, 8 years after receiving a left metal-on-metal total hip arthroplasty (THA). The acetabular component has a modular cobalt alloy acetabular liner. The patient states that he did very well postoperatively, but for the last 6 months has noted worsening pain and swelling in his left hip. Serum metal ion testing reveals a chromium level of 4 ng/mL, compared with a normal level of less than 3 ng/mL, and a cobalt level of 8 ng/mL, compared with a normal level less than 7 ng/mL. An MRI with metal artefact reduction sequence (MARS) was performed and is shown in What is the most appropriate management at this time?

Explanation

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

Question 88

Figure 25 shows an arthroscopic thermal capsular shrinkage device being used in the anterior inferior quadrant of a patient with a subluxating shoulder. Which of the following neurologic complications is most frequently reported with this technique?

Explanation

DISCUSSION: The axillary nerve lies within millimeters of the anterior inferior capsule. The inferior capsule is of varying thickness, and thermal energy used in shortening the ligament can cause damage to the sensory fibers of the axillary nerve. Clinically, this is manifested as a burnt skin sensation in the axillary nerve distribution area. The motor branch of the axillary nerve is usually spared. The suprascapular nerve and the radial nerve are far from the shrinkage zone. The musculocutaneous nerve, frequently at risk with open procedures, lies well anterior.
REFERENCES: Fanton GS: Arthroscopic electrothermal surgery of the shoulder. Op Tech Sports Med 1998;6:157-160.
David TS, Drez DJ Jr: Electrothermally-assisted capsular shift. IEEE Eng Med Biol Mag 1998;17:102-104.

Question 89

Regarding the role of the orthopaedic surgeon in addressing domestic and family violence, all of the following statements are true EXCEPT:

Explanation

DISCUSSION: Reporting requirements for adult spousal or intimate partner abuse is not standardized among states and it is the responsibility of the orthopaedic surgeon to understand the laws of his or her
state. The AAOS Advisory statement gives information to assist in meeting the ethical and legal obligations on Domestic and Family Violence and Abuse.
Domestic and family violence affects over 10% of the US population (approximately 32 million Americans). Child abuse and neglect contributed to 1,400 fatalities in 2002 and there was 565,747 reports of suspected elder abuse.
Reporting of suspected child abuse is required in all states. The orthopaedic surgeon should hospitalize elderly victims who are in immediate danger and help develop a plan to insure their safety.

Question 90

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

Explanation

DISCUSSION: Passive stretching is contraindicated during rehabilitation as it may potentiate the severity of the myositis ossificans. Electrical stimulation, iontophoresis, isometric exercise, and ice/heat contrast are not known to exacerbate this process.
REFERENCES: Brunet ME, Hontas RB: The thigh, in DeLee JC, Drez D (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.
Cushner FD, Morwessel RM: Myositis ossificans traumatica. Orthop Rev 1992;21:1319-1326.

Question 91

A 6-year-old boy sustained a fracture of the medial malleolus as a result of twisting his ankle. The fracture line extends from the joint surface proximally and medially to include a small fragment of the metaphysis, with a displacement of 3 mm. Management should consist of

Explanation

Salter-Harris III and IV fractures of the medial aspect of the distal tibia commonly cause growth disturbances, such as shortening and varus angulation, unless an anatomical reduction of the physis is obtained. The authors of the reference (Drs Kling, Bright, and Hensinger) felt that these fractures needed to be “perfectly reduced” to minimize any gap, primarily to prevent a bone bridge from forming. According to Spiegel, any of these fractures with 2 mm or more should be openly reduced.
The authors felt that “anatomical reduction” must include closure of the physeal gap and restoration of rotational alignment of the fracture fragment. They recommended that these fractures be treated with ORIF, consisting of small, smooth Kirschner wires from one epiphyseal fragment to the other. The pins should diverge or converge to prevent any slippage or rotation. They do not recommend crossing the physis with fixation devices, for this may lead to further injury.

Question 92

Heat transfer from the skin to the environment when the ambient temperature exceeds 35°C primarily is attributable to

Explanation

DISCUSSION
Heat transfer from the skin to the environment occurs through conduction, convection, evaporation, and radiation. Evaporation of sweat is the primary mechanism by which core body temperature is regulated when the ambient temperature exceeds 35°C. High humidity can inhibit the evaporation of sweat, placing athletes at increased risk for heat-related illness, which is defined as a core temperature above 40°C. Symptoms include dizziness, confusion, irritability, hyperventilation, nausea, vomiting, fatigue, and collapse. Initial treatment involves rapid cooling through immersion in cold or ice water to prevent end-stage organ failure.

Question 93

A 7-year-old boy has had low back pain for the past 3 weeks. Radiographs reveal apparent disk space narrowing at L4-5. The patient is afebrile. Laboratory studies show a WBC count of 9,000/mmP3P and a C-reactive protein level of 10 mg/L. A lumbar MRI scan confirms the loss of disk height at L4-5 and reveals a small perivertebral abscess at that level. To achieve the most rapid improvement and to lessen the chances of recurrence, management should consist of Review Topic

Explanation

Strict bedrest for six weeks then progressive weightbearing
Ambulation as tolerated with or without a TLSO
Surgical decompression and anterior stabilization
Surgical decompression and posterior stabilization
Surgical decompression and combined anterior/posterior stabilization
The patient has a L1 burst fracture with minimal retropulsion of bony fragments in the spinal canal. In the absence of neurological deficits and injury to the PLC, the most appropriate treatment is ambulation as tolerated with or without a thoracolumbrosacral orthosis (TLSO).
Thoracolumbar burst fractures are typically caused by an axial load with flexion and commonly found in this location due to increased motion at these segments. With an intact posterior ligamentous complex (PLC) and no neural compromise, TLSO is the mainstay of treatment. If there is evidence of neurological deficit and/or PLC injury, decompression and fusion are indicated. The degree of acceptable kyphosis is controversial. The choice of anterior versus posterior approach is based on ease of decompression.
Vaccaro et al. introduced a new classification system for thoracolumbar injuries, TLICS, based on morphological appearance, integrity of the posterior ligamentous complex, and neurological status. They advocate use of the system for nonoperative versus operative decision making and communication between surgeons.
Bailey et al. completed a randomized, nonblinded controlled trial to determine the
efficacy of bracing for AO type A0-A3 thoracolumbar burst fractures. Both groups were encouraged to ambulate as tolerated and the no brace group had bending restrictions for 8 weeks. They found no difference in the Roland Morris Disability Questionnaire (RMDQ) score at 3 months after injury.
Figure A is sagittal CT scan of the lumbar spine showing a burst fracture of L1 with minimal retropulsion. Illustration A is the TLICS classification with score of 4 being the branch point for nonoperative versus operative management.
Incorrect Answers:

Question 94

Figures 16a and 16b show the radiographs of an otherwise healthy 3 1/2-year-old boy who has an isolated deformity of the left leg. Definitive primary treatment of this condition should consist of

Explanation

DISCUSSION: Treatment of congenital pseudarthrosis of the tibia is problematic. To achieve union, a resection of the pseudarthrosis, stabilization, and bone grafting must be performed. Simple cast immobilization does not yield union. There are various options for the resection, immobilization, and grafting. On the first surgical attempt, retrograde intramedullary nailing offers the best chance for success by transfixing the ankle and subtalar joints with abundant autogenous bone grafting. Distraction osteogenesis and vascularized free fibular graft are reserved as salvage procedures.
REFERENCES: Gilbert A, Brockman R: Congenital pseudarthrosis of the tibia: Long-term follow-up of 29 cases treated by microvascular bone transfer. Clin Orthop 1995;314:37-44.
Boero S, Catagni M, Donzelli O, Facchini R, Frediani PV: Congenital pseudarthrosis of the tibia associated with neurofibromatosis - 1: Treatment with Ilizarov’s device. J Pediatr Orthop 1997;17:675-684.
Anderson DJ, Schoenecker PL, Sheridan JJ, Rich MM: Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am 1992;74:161-168.

Question 95

Following an episode of transient quadriplegia in contact sports, an athlete’s return to play is absolutely contraindicated when

Explanation

DISCUSSION: Return to play decisions after traumatic spinal or spinal cord injury are not always clear-cut and often must be made on a patient-by-patient basis. The Torg ratio has been found to have low sensitivity in patients with large vertebral bodies. Abnormal electromyographic studies can persist in the face of normal function and do not define spinal injury. Duration of quadriplegia is not related to anatomic pathology. Findings on MRI scans or contrast-enhanced CT scans consistent with stenosis include lack of a significant cerebrospinal fluid signal around the cord, bony or ligament hypertrophy, or disk encroachment. Based on these findings, return to play should be avoided.
REFERENCES: Cantu RC, Bailes JE, Wilberger JE Jr: Guidelines for return to contact or collision sport after a cervical spine injury. Clin Sports Med 1998;17:137-146.
Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ: Normal cervical spine morphometry and cervical stenosis in asymptomatic professional football players: Plain film radiography, multiplanar computer tomography, and magnetic resonance imaging. Spine 1991;16:178-186.
Bailes JE, Hadley MN, Quigley MR, Sonntag VK, Cerullo LJ: Management of athletic injuries of the cervical spine and spinal cord. Neurosurgery 1991;29:491-497.

Question 96

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Explanation

DISCUSSION: The radiographic findings show 30 degrees of talar tilt (severe) and 10 mm of anterior translation that typically involves laxity of both of the major lateral ligaments of the ankle (anterior talofibular and calcaneofibular). There is no evidence of deltoid laxity.
REFERENCES: Harper MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle 1992;13:435-438.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.

Question 97

Patients with patellar clunk syndrome are best managed by which of the following methods?

Explanation

DISCUSSION: Patellar clunk syndrome is usually the result of a fibrous nodule that forms on the undersurface of the distal quadriceps tendon. It may get entrapped in the intercondylar notch of the femoral component during flexion, and lead to a sudden snap as the nodule is pulled out of the notch during active extension. Nonsurgical management is rarely successful. Surgical debridement is usually curative, with only rare recurrence. More aggressive procedures such as realignment, revision, or patellectomy are usually not necessary, and are reserved for cases resistant to soft-tissue debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:

Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 329.
Diduch DR, Scuderi GR, Scott WN, et al: The efficacy of arthroscopy following total knee replacement. Arthroscopy 1997;13:166-171.
Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

Question 98

A study is proposed in which 50 patients with osteonecrosis of the knee are compared with 23 patients without osteonecrosis in terms of their alcohol consumption levels. This is an example of what type of study?

Explanation

In a case control study, all the subjects are selected based on whether they have (cases) or do not have (controls) the disease or outcome of interest. Case control studies are retrospective as they always look back to see how a certain risk factor may be different between the two groups. The main aspect of a cross-sectional study is that it is designed to look at a representative sample of the entire population of interest at a single point in time. Longitudinal studies follow groups of subjects over a period of time. A cohort study follows a particular group in relation to an event, studying them at intervals in time and uses objective outcome criteria. In a randomized controlled study, subjects are divided randomly into control and experimental groups to balance both the known and unknown differences between the groups.

Question 99

Figures 1 and 2 show the intraoperative photographs obtained during surgical treatment for de Quervain tendonitis. For orientation purposes, dorsal is at the top. Figure 1 is obtained just after the initial first extensor compartment release, and Figure 2 shows the floor of the first extensor compartment. If the structure marked by the black dot is not addressed, the most common postoperative problem would be

Explanation

EXPLANATION:
The black dot identifies an accessory compartment of the extensor pollicis brevis (EPB) tendon. The incidence of accessory EPB compartment in patients undergoing surgical treatment for de Quervain syndrome ranges from 46% to 60%. Failure to release this compartment at the time of initial surgery can cause persistent postoperative pain. The patient would not experience altered sensation if this compartment were not released. Altered sensation would most commonly occur following injury to the dorsal radial sensory nerve branch during surgery. EPB tendon subluxation also would not occur should the accessory compartment not be released. For EPB tendon subluxation to occur, its own compartment would need to be released first. Finally, EPB tendon rupture would be an extremely uncommon complication of failure to release the accessory compartment.

Question 100

Which of the following activities can improve posterior capsular contractures?

Explanation

DISCUSSION: Posterior capsule stretching is performed in the cross-chest and behind the back positions. Stretching in internal rotation in the abducted shoulder will further stretch the posterior capsule. Wide grip stretch, and anterior capsule and strengthening exercises will not necessarily stretch the capsule.
REFERENCES: Ellenbacher TS: Shoulder internal and external rotation strength and range of motion of highly-skilled junior tennis players. Isokinetic Exercise Sci 1992;2:1-8.
Kibler WB, McMullen J, Uhl J: Shoulder rehabilitation strategies, guidelines, and practice. Op Tech Sports Med 2000;8:258-267.

Full Question & Answer Text (for Search Engines)

Question 1:

The stiffness of a 16-mm femoral stem is mostly influenced by the

Options:

elastic modulus of the material.
surface coating or treatment.
diameter of the femoral stem.
length of the femoral stem.
ultimate tensile strength.

Correct Answer: diameter of the femoral stem.

Explanation:

Question 2:

A 35-year-old woman began to train for a half marathon. After 8 weeks of increasing her mileage, what changes can you expect in her Achilles tendon?

Options:

Net decrease of type I collagen
Net increase of type I collagen
Increased diameter of collagen fibrils
Increased cross-sectional area of the tendon

Correct Answer: Net increase of type I collagen

Explanation:

Question 3:

In the most common condition causing a winged scapula, which of the following nerves is affected? Review Topic

Options:

Long thoracic nerve
Spinal accessory nerve
Suprascapular nerve
Dorsal scapular nerve
Thoracodorsal nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 4:

Options:

Galvanic
Pitting
Fretting
Crevice

Correct Answer: Fretting

Explanation:

Question 5:

Options:

The surgical intern must be present because he brought the patient to the operating room
The timeout cannot begin without the implant representative
If both the orthopaedic and plastic surgical teams are present, a single timeout is sufficient for the entire procedure
The timeout may be completed as long as the attending is in an adjacent operating room
The pre-surgical timeout has not been shown to decrease complication rates

Correct Answer: The surgical intern must be present because he brought the patient to the operating room

Explanation:

Question 6:

Options:

Arthroscopic labral debridement and biceps tenodesis
Shoulder arthroscopy with undersurface cuff debridement and acromioplasty
Cyst decompression at the spinoglenoid notch with possible labral repair
Cyst decompression at the suprascapular notch with possible labral repair This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

Correct Answer: Shoulder arthroscopy with undersurface cuff debridement and acromioplasty

Explanation:

Question 7:

Which component position is associated with poor patellar tracking during total knee arthroplasty (TKA)?

Options:

Lateral placement of the femoral component
Medial placement of the patellar component
Internal rotation of the tibial component
Varus alignment of the proximal tibia

Correct Answer: Internal rotation of the tibial component

Explanation:

DISCUSSION
Internal malrotation of the femoral or tibial component is associated with lateral tracking of the patella in TKA. Lateral placement of the femoral component and medial placement of the patella component can aid in preventing lateral tracking of the patella. Varus alignment of the proximal tibia has not been associated with patella maltracking.
RESPONSES FOR QUESTIONS 106 THROUGH 109
Immobilization/nonsurgical management
Irrigation and debridement
stage reimplantation total knee arthroplasty (TKA)
Increased constraint/polyethylene exchange
Revision of the femoral component only
Revision of the tibial component only
Revision of both components
Revision of the patellar component
Select the treatment listed above that most appropriately addresses each scenario described below.

Question 8:

Options:

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

Correct Answer: closed reduction under general anesthesia.

Explanation:

Question 9:

A 72-year-old man has had persistent pain after undergoing a hemiarthroplasty 18 months ago. Radiographs are shown in Figures 50a and 50b. What is the most likely cause of his problem?

Options:

Suboptimal cement technique
Excessive activity level
Oversized bipolar component
Infection
Osteoporosis

Correct Answer: Infection

Explanation:

DISCUSSION: The radiographs demonstrate a rapid erosion of the bipolar component into the acetabulum. Although acetabular erosion is more common with unipolar hip arthroplasties, it can occur with bipolar components. Haidukewych and associates noted a very low erosion rate but none in the first 2 years. The second finding on the radiographs is the linear radiolucency progressing from the joint toward the end of the stem at the cement-bone interface suggesting chronic infection or diffuse loosening. The persistent pain since implantation also suggests chronic infection. High activity levels and osteoporosis do not lead to acetabular erosion in the first 2 years after hemiarthroplasty. While the cement technique is suboptimal, loosening and erosion should not be expected from this alone. An oversized bipolar head would extrude and not erode.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Long-term survivorship of cemented bipolar hemiarthroplasty for fracture of the femoral neck. Clin Orthop Relat Res 2002;403:118-126.
Lestrange NR: Bipolar hemiarthroplasty for 496 hip fractures. Clin Orthop Relat Res 1990;251:7-19.
Callaghan JJ, Dennis DA, Paprosky WG, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, p 158.

Question 10:

Options:

Excision of the damaged portion of the peroneus longus with possible transfer of the proximal peroneus longus into the peroneus brevis
Excision of the damaged portion of the peroneus brevis with possible transfer of the peroneus brevis into the peroneus longus
Excision of the bony fragments of the calcaneus with planing down of the lateral wall of the calcaneus to avoid irritation of the peroneal tendons
Casting to allow the avulsed portion of the base of the fifth metatarsal to heal
Debridement of the posterior tibial tendon, transfer of the flexor digitorum longus tendon into the navicular, and medial translational osteotomy of the calcaneus

Correct Answer: Excision of the damaged portion of the peroneus longus with possible transfer of the proximal peroneus longus into the peroneus brevis

Explanation:

DISCUSSION: The radiograph and MRI scan show elongation and fragmentation of the os peroneum. Although casting, orthoses, and steroid injection may relieve symptoms, excision of the os peroneum and primary repair when necessary, with or without tenodesis of the peroneus longus to the peroneus brevis, have been shown to produce excellent results.
REFERENCES: Haddad SL: Disorders of tendons: Peroneal tendon dysfunction, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999,
pp 812-817.
MacDonald BD, Wertheimer SJ: Bilateral os peroneum fractures: Comparison of conservative and surgical treatment and outcomes. J Foot Ankle Surg 1997;36:220-225.

Question 11:

Options:

Range of motion
Infraspinatus strength
Activity level
Quality of the subscapularis

Correct Answer: Quality of the subscapularis

Explanation:

Question 12:

Figures 5a and 5b show the radiographs of a 45-year-old patient. What is the most likely diagnosis?

Options:

Glenoid dysplasia
Rheumatoid arthritis with centralization
Osteoarthritis with posterior glenoid wear
Posterior scapular fracture deformity
Traumatic posterior subluxation of the shoulder

Correct Answer: Glenoid dysplasia

Explanation:

Question 13:

What is the incidence and significance of anterior cruciate ligament laxity following tibial eminence fractures in skeletally immature individuals?

Options:

Common and frequently symptomatic
Common and infrequently symptomatic
Common but generally resolves spontaneously
Rare but when present, usually symptomatic
Rare and if present, infrequently symptomatic

Correct Answer: Common and infrequently symptomatic

Explanation:

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior
eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.
J Pediatr Orthop 1984;4:462-464.

Question 14:

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

Options:

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

Correct Answer: Transient radicular leg pain

Explanation:

Question 15:

The medial collateral ligament complex of the elbow originates on what portion of the medial epicondyle?

Options:

Anterior and inferior
Anterior and superior
Anterior and central
Posterior and superior
Posterior and inferior

Correct Answer: Anterior and inferior

Explanation:

Question 16:

Which of the following is most associated with local recurrence of the lesion seen in the radiograph and MRI scan shown in Figures 27a and 27b?

Options:

Effectiveness of chemotherapy
Effect of local adjuvant
Open physes
Presence of giant cells
Effectiveness of embolization

Correct Answer: Open physes

Explanation:

DISCUSSION: The lesion is an aneurysmal bone cyst. These lesions are known to have a local recurrence rate of 5% to 50%. Young age, open physes, stage, and type of surgical removal and resulting margin have all been shown to affect the recurrence rate. Chemotherapy is not used in the treatment of aneurysmal bone cysts.
REFERENCES: Gibbs CP Jr, Hefele MC, Peabody TD, et al: Aneurysmal bone cyst of the extremities: Factors related to local recurrence after curettage with a high-speed burr. J Bone Joint Surg Am 1999;81:1671-1678.
Vergel De Dios AM, Bond JR, Shives TC, et al: Aneurysmal bone cyst: A clinicopathologic study of 238 cases. Cancer 1992;69:2921-2931.

Question 17:

Options:

Clostridium
Acinetobacter
Pseudomonas
Mycobacterium
Staphylococcus aureus

Correct Answer: Clostridium

Explanation:

Question 18:

Options:

Metatarsophalangeal joint arthrodesis
Medial capsular release with lengthening of the abductor hallucis
Medial capsular release with lateral sesamoid excision
Proximal phalangeal lateral closing wedge osteotomy
Medial capsular lengthening and split extensor hallucis longus tendon transfer

Correct Answer: Medial capsular lengthening and split extensor hallucis longus tendon transfer

Explanation:

DISCUSSION: The patient has a flexible hallux varus that is a complication of the bunion surgery. With joints that are not arthritic and still flexible, a medial release is necessary to realign the joint. The extensor hallucis longus split transfer helps maintain position and still preserve motion at the interphalangeal joint level. Arthrodesis is a salvage procedure. Soft-tissue releases alone are most likely inadequate. Excision of the lateral sesamoid is contraindicated because that further compromises the forces resisting hallux varus. Phalangeal osteotomy would not address the medial subluxation at the metatarsophalangeal joint.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 27-32.
Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby, 2007, pp 345-351.

Question 19:

Options:

Plain radiographs of the lumbar spine
Anteroposterior radiograph of the pelvis
CT scan of the thoracic spine
MRI of the brain

Correct Answer: CT scan of the thoracic spine

Explanation:

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult vertebral fractures that are not readily detectable on radiographs. The treating surgeon must have a high suspicion for fractures in these patients and pursue further imaging of the spine with CT and (often) MRI. Even among patients who are neurologically intact, fracture displacement and neurologic deterioration can occur if fractures are not recognized early and appropriately stabilized. Fractures in patients with ankylosing spondylitis are extremely unstable and are associated with high risk for delayed neurological deterioration. Although plain film imaging of the entire spine should be considered, occult fractures can easily be missed. Imaging of the sacroiliac joints can be helpful to establish the diagnosis of ankylosing spondylitis but would not identify an occult fracture of the vertebra in this patient.
RECOMMENDED READINGS
Finkelstein JA, Chapman JR, Mirza S. Occult vertebral fractures in ankylosing spondylitis. Spinal Cord. 1999 Jun;37(6):444-7. PubMed PMID: 10432265.
View Abstract at PubMed
Harrop JS, Sharan A, Anderson G, Hillibrand AS, Albert TJ, Flanders A, Vaccaro AR. Failure of standard imaging to detect a cervical fracture in a patient with ankylosing spondylitis. Spine (Phila Pa 1976). 2005 Jul 15;30(14):E417-9. PubMed PMID: 16025019.
View Abstract at
PubMed
Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and
complications. Eur Spine J. 2009 Feb;18(2):145-56. doi: 10.1007/s00586-008-0764-0. Epub 2008 Sep 13. Review. PubMed PMID: 18791749.
View Abstract at PubMed

Question 20:

Options:

Rotator cuff repair and biceps tenodesis
Rotator cuff repair and loose body removal
Latissimus dorsi transfer
Bankart repair

Correct Answer: Rotator cuff repair and biceps tenodesis

Explanation:

The MR image shows medial subluxation of the biceps tendon, which can be confused with an articular loose body. In the clinical scenario of biceps instability/subluxation, the rationale regarding tenodesis is to address the painful dislocation and subluxation of the biceps tendon from the bicipital groove. Biceps tendon subluxation is most frequently associated with subscapularis tendon pathology, which is indicated by the MRI and by a positive lift-off test. The MR image does not show a loose body or Bankart lesion. Patients with irreparable rotator cuff tears with a severe external rotation deficit and a deficient teres minor
may experience a better functional result with latissimus dorsi transfer.

Question 21:

Options:

UCL repair and nighttime elbow extension splinting
UCL repair with ulnar nerve decompression in situ
Allograft UCL reconstruction with interference screws
Autograft UCL reconstruction with ulnar nerve transposition
Autograft UCL reconstruction using a docking technique

Correct Answer: Autograft UCL reconstruction with ulnar nerve transposition

Explanation:

DISCUSSION: High-level pitchers with symptomatic UCL tears require reconstruction, with autograft being the best studied graft selection. With concomitant ulnar nerve symptoms, a simultaneous ulnar nerve transposition provides good results. Ligament “repairs” and allograft reconstructions have not shown good long-term results.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Ciccotti MG, Jobe FW: Medial collateral ligament instability and ulnar neuritis in the athlete’s elbow. Instr Course Lect 1999;48:383-391.

Question 22:

Following insertion of a cementless femoral component into the total hip arthroplasty construct, the amount of femoral stress shielding is most associated with

Options:

presurgical bone mineral density.
material modulus.
characteristics of the ingrowth/ongrowth surface.
extent of the ingrowth/ongrowth surface.

Correct Answer: presurgical bone mineral density.

Explanation:

Question 23:

Options:

Debridement of the labral tear plus bony resection of the pincer lesion
Debridement of the labral tear and no bony resection of the pincer lesion
Femoral neck osteoplasty plus labral repair using suture anchor
Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer: Resection of the bony pincer lesion plus labral repair using suture anchor

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 24:

Options:

The local Keyhole representative has invited you and your spouse out to dinner at a local restaurant to discuss your interest in their new minimally invasive total knee system, the Keyhole Genuflex knee.
Keyhole has offered to pay your tuition to attend a CME course sponsored by the American Association of Hip & Knee Surgeons where both the Genuflex and the competing Styph total knee are discussed and demonstrated.
Keyhole will pay your expenses to attend a workshop, in Phoenix at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.
Keyhole will pay you $500 for each knee that you implant if you switch from your current total knee system.
After you have implanted 25 Genuflex knees, Keyhole will list you on their website as a consultant, pay you a consulting fee of $5,000 per year, and invite you to a golf tournament for their consultants at a resort.

Correct Answer: Keyhole will pay your expenses to attend a workshop, in Phoenix at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.

Explanation:

Question 25:

Options:

Refrain from exercise.
Exercise muscles to exhaustion, but allow 1 day in between exercise sessions to allow the muscles to recover.
Exercise muscles to exhaustion, but allow 2 days in between exercise sessions to allow the muscles to recover.
Exercise daily at a subexhaustion level.
Exercise should be limited to postural and antigravity muscles.

Correct Answer: Exercise daily at a subexhaustion level.

Explanation:

Question 26:

Options:

vigorous physical therapy for passive range of motion.
manipulation of the shoulder under anesthesia.
an intra-articular steroid injection.
an axillary radiograph.
MRI.

Correct Answer: an axillary radiograph.

Explanation:

Question 27:

Options:

Gender
Age
Race
Environment

Correct Answer: Race

Explanation:

Question 28:

What is the most important preoperative factor predicting conversion to total hip arthroplasty after arthroscopic surgery of the hip?

Options:

Age over 60 years
Morbid obesity
Diagnosis of osteoarthritis
Tobacco use

Correct Answer: Morbid obesity

Explanation:

Question 29:

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

Options:

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

Correct Answer: Sling immobilization

Explanation:

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

Question 30:

Total hip arthroplasty is most appropriate for the injury shown in Figure A for which of the following patients?

Options:

year-old female golf instructor
year-old female with Parkinsons dementia
year-old male household ambulator
year-old male alcoholic with hepatic encephalopathy
year-old male laborer

Correct Answer: year-old female with Parkinsons dementia

Explanation:

Question 31:

Options:

Suture anchor repair of the labral tear and no bony resection
Suture anchor repair of the labral tear and bony resection of the pincer lesion
Debridement of the labral tear and bony resection of the pincer lesion
Debridement of the labral tear with no bony resection of the pincer lesion

Correct Answer: Suture anchor repair of the labral tear and bony resection of the pincer lesion

Explanation:

DISCUSSION FOR QUESTIONS 26 THROUGH 29
The clinical scenario, examination, and MRI scans are consistent with a pincer-type FAI. The decreased range of motion is secondary to the pain produced by the continued abutment of the femoral head against the anterosuperior acetabulum. Flexing the hip while internally rotating and adducting the leg recreates this contact and is typically painful. No clinical signs suggest sacroiliac joint arthritis, an intra-articular loose body, or trochanteric bursitis, although these are all diagnoses that should be considered in a patient with a painful hip. The most sensitive and specific study to detect an acetabular labral tear is an MRI arthrogram of the hip. This study should be obtained in this patient to evaluate the labrum as well as the status of the articular cartilage. An MRI scan without intra-articular contrast is not as sensitive as an arthrogram. An ultrasound can provide a dynamic assessment of the hip and help in the setting of a snapping hip; however, this study is not reliable to determine the presence of a labral tear. In the setting of pincer FAI, the forced leverage of the anterosuperior femoral head upon the anterior acetabulum results in abnormal forces against the posteroinferior acetabulum. This continued force can lead to a chondral lesion in this location know as a “counter-coup” injury. Chondral lesions of the femoral head are rare in the setting of pincer FAI. The posterosuperior quadrant does not experience increased force and rarely sustains chondral injuries. The patient is a young, active individual with no pre-existing degenerative changes, so repair of the tear with bony resection of the pincer lesion is the most appropriate treatment.A capsulolabral detachment should be repaired because these tears can heal and the labrum functions as a seal, preventing egress of synovial fluid from the joint space. If the pincer lesion is not resected, the patient will continue to experience abnormal contact and the repair will likely fail. There is no evidence that the patient has a cam impingement, and recontouring of the femoral head/neck junction is not appropriate. Simple debridement should be reserved for intrasubstance tears of the labrum, which would not be expected to heal with repair.
CLINICAL SITUATION FOR QUESTIONS 30 THROUGH 32
Figures 30a and 30b 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.

Question 32:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 33:

Figure 25 shows the CT scan of an adult patient who has neck pain following a motor vehicle accident. What is the most likely diagnosis?

Options:

Jefferson’s fracture
C1-C2 rotational instability
Transverse ligament rupture
Normal finding
Basilar invagination

Correct Answer: Transverse ligament rupture

Explanation:

Question 34:

Options:

MRI of the spinal axis
Physical therapy
A brace for scoliosis
Observation, with reevaluation in 6 to 12 months
Posterior spinal fusion from T6 to T12

Correct Answer: MRI of the spinal axis

Explanation:

Question 35:

Options:

classic dysplasia with volume deficient acetabula.
acetabular retroversion with positive crossover signs and ischial spine signs.
no substantial dysplasia, with normal acetabular volume and anteversion.
inadequate radiographic evidence to assess for hip dysplasia.

Correct Answer: inadequate radiographic evidence to assess for hip dysplasia.

Explanation:

Question 36:

Options:

Anterior shoulder dislocation
Humeral component loosening
Glenoid component loosening
Glenoid component catastrophic fracture
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

Question 37:

Options:

Continue wet-to-dry dressing changes until the wound heals by secondary intention.
Perform a volar advancement flap (ie, Moberg flap).
Perform a V-Y advancement flap.
Perform a thenar flap.
Perform a cross-finger flap to the ring finger.

Correct Answer: Continue wet-to-dry dressing changes until the wound heals by secondary intention.

Explanation:

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 38:

Options:

MRI scan
Bone scan
Arthrogram
Axillary lateral radiograph
CT arthrogram

Correct Answer: Axillary lateral radiograph

Explanation:

Question 39:

- A right-handed, 53 year old man reports pain in the left shoulder following a fall on an abducted externally rotated shoulder 3 months ago. Examination reveals pain on elevation and tenderness localized to the anterior aspect of the shoulder. Results of the lift-off test are inconclusive due to limited internal rotation. Figure 2 shows the T1-weighted axial image from an MRI-arthrogram. Treatment should include

Options:

Labral repair
acromioplasty
excision of the coracoid process
an arthroscopic Bankart procedure
subscapularis repair

Correct Answer: subscapularis repair

Explanation:

Question 40:

Options:

Resolution by age 3 or 4 years without active treatment in most patients
Resolution by age 8 or 9 years without active treatment in most patients
Resolution with casting as the most effective treatment
Resolution with bracing and shoe modification as the most effective treatment
Resolution with surgery as the most effective treatment

Correct Answer: Resolution by age 3 or 4 years without active treatment in most patients

Explanation:

DISCUSSION: Excessive internal tibial torsion is a common cause of intoeing in toddlers. In most children, this resolves spontaneously by 3 to 4 years of age. Intoeing in elementary age children is usually the result of excessive femoral anteversion. Studies have shown that active intervention (casting, splinting, and shoe modifications) has no demonstrable effect on the natural history or resolution of tibial torsion. Surgery is rarely indicated in adolescents with severe internal tibial torsion that has not resolved and is resulting in cosmetic and functional problems.
REFERENCES: Canale ST, Beaty JH: Operative Pediatric Orthopaedics. St Louis, MO, Mosby Year Book, 1991, pp 357-385.
Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.

Question 41:

Which of the following choices best describes the fracture pattern shown in Figures 2a through 2c?

Options:

Anterior column
Anterior wall
Posterior column
Both column
Transverse

Correct Answer: Posterior column

Explanation:

DISCUSSION: The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1009-1149.

Question 42:

When performing a gastrocnemius recession, what structure should be protected?

Options:

Tibial nerve
Sural artery
Plantaris
Posterior tibial artery
Sural nerve

Correct Answer: Sural nerve

Explanation:

DISCUSSION: When performing a gastrocnemius slide at the tendinous portion of the gastrocnemius insertion, the sural nerve and saphenous vein, which tend to run midline posterior at this level, must be protected and retracted laterally. An anatomic study of the sural nerve at this level localized the nerve superficial to the deep fascia overlying the gastrocnemius in 42.5% of the cases; deep to the superficial fascia in 57.5% of the cases, and directly applied to the gastrocnemius tendon in 12.5% of cases.
REFERENCES: Pinney SJ, Sangeorzan BJ, Hanen ST Jr: Surgical anatomy of the gastrocnemius resection (Strayer procedure). Foot Ankle Int 2004;25:247-250.
Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 415-417.

Question 43:

Options:

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

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

Explanation:

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

Question 44:

Options:

Nonsteroidal medication and follow up as needed
Repeat radiographs in 1 week
MR imaging of the thoracic spine
Flexion-extension radiographs

Correct Answer: MR imaging of the thoracic spine

Explanation:

DISCUSSION
Ankylosing spinal disorders, including ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are conditions that make the spine rigid and at risk for 3-column unstable fractures. Spinal fractures in these patients pose high risk for complications and death and patients should be counseled and observed closely. Mortality strongly correlates with older age and increased number of comorbidities.
These spine fractures often are not seen at the time of initial evaluation, and a delay in diagnosis can occur in up to 19% of cases. This is particularly common in the setting of non- or minimally displaced fractures following minor injuries. A delayed diagnosis can lead to displacement of a previously nondisplaced fracture that can incur a high neurologic injury risk. Advanced imaging with a CT scan or MRI should be obtained for patients with ankylosing spinal disorders even when minor injuries occur. Although bracing and observation can be used, posterior multilevel spinal instrumentation is typically required to obtain adequate spinal stabilization.
The radiographs show an osteopenic ankylosed thoracic spine; the anteroposterior radiograph clearly shows fusion of the sacroiliac joints. Recognition of these radiographic findings is important when evaluating patients after an injury.
RECOMMENDED READINGS
Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010 May 15;35(11):E458-64. doi: 10.1097/BRS.0b013e3181cc764f. PubMed PMID: 20421858.
View Abstract at PubMed
Hendrix RW, Melany M, Miller F, Rogers LF. Fracture of the spine in patients with ankylosis due to diffuse skeletal hyperostosis: clinical and imaging findings. AJR Am J Roentgenol. 1994 Apr;162(4):899-904. PubMed PMID: 8141015.
View Abstract at PubMed

Question 45:

Options:

Strong
Moderate
Limited
Inconclusive

Correct Answer: Moderate

Explanation:

Question 46:

Options:

Becker muscular dystrophy
Spinal muscular atrophy, type III
Emery-Dreifuss dystrophy
Limb girdle dystrophy
Guillain-Barre syndrome

Correct Answer: Becker muscular dystrophy

Explanation:

Question 47:

Options:

Long arm cast immobilization
Total elbow arthroplasty
Open reduction and internal fixation
Osteoarticular allograft
Resection arthroplasty

Correct Answer: Total elbow arthroplasty

Explanation:

DISCUSSION: Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.
REFERENCES: Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement. J Bone Joint Surg Am 2004;86:940-947.
Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Garcia JA, Mykula R, Stanley D: Complex fractures of the distal humerus in the elderly: The role of total elbow replacement as primary treatment. J Bone Joint Surg Br 2002;84:812-816.

Question 48:

What structure (arrow) is shown in Figure 24?

Options:

Ilioinguinal nerve
Sympathetic chain
Ureter
Iliac vein
L5 nerve

Correct Answer: Sympathetic chain

Explanation:

DISCUSSION: The structure illustrated is the sympathetic chain viewed from an anterolateral view of the lower lumbar spine. It descends along the anterolateral aspect of the spine into the pelvis closely adherent to the vertebral column. The spinal nerves, including L5, can be seen exiting from the foramen. The ureters descend from the kidneys and cross anterior to the iliac vessels to the bladder.
REFERENCES: Onibokun A, Khoo LT, Holly L: Anterior retroperitoneal approach to the lumbar spine, in Kim DH, Henn JS, Vaccaro AR, et al (eds): Surgical Anatomy and Techniques to the Spine. Philadelphia, PA, Saunders Elsevier, 2006, pp 101-105.
Netter GH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy Corporation, 1989.

Question 49:

Which of the following findings best describes the acetabular fracture shown in Figure 38?

Options:

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

Correct Answer: Posterior wall with articular impaction and a free intra-articular fragment

Explanation:

DISCUSSION: 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.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 50:

- Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Options:

traumatic femoral head fracture
osteonecrosis
osteoarthritis
neuropathic joint
rheumatoid arthritis

Correct Answer: osteonecrosis

Explanation:

Question 51:

Options:

15 degrees
30 degrees
45 degrees
60 degrees
75 degrees

Correct Answer: 30 degrees

Explanation:

Question 52:

Options:

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

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

Explanation:

Question 53:

Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic

Options:

Decreased bone mineral density
Menstrual dysfunction
Low energy availability with an eating disorder
Low energy availability without an eating disorder
Thyroid dysfunction

Correct Answer: Decreased bone mineral density

Explanation:

Question 54:

Which of the following findings is more suggestive of neurogenic rather than vascular claudication in the differential diagnosis of leg pain?

Options:

Loss of skin hair on the feet
Absent pulses on vascular examination
Pain that originates proximally and spreads distally
Pain that is relieved by stopping and standing
Pain that is worse when the patient walks uphill rather downhill

Correct Answer: Pain that originates proximally and spreads distally

Explanation:

Question 55:

Options:

Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees
Transphyseal ACL reconstruction with hamstring autograft
Physeal spearing ACL reconstruction with hamstring autograft
Application of long leg cast following successful fluoroscopic closed reduction
Application of long leg cast for 1-2 weeks with transition to hinged knee brace 0-90 degrees, progressive weight-bearing, and physical therapy for quadriceps strengthening

Correct Answer: Immediate weight-bearing as tolerated with hinged knee brace 0-90 degrees

Explanation:

Question 56:

A 25 year-old-male presents with the injury seen in Figure A. Which of the following would be a contraindication to closed management with a functional brace?

Options:

Radial nerve injury
1 cm shortening
20 degree varus deformity
Brachial plexus injury
Comminuted fracture pattern

Correct Answer: Radial nerve injury

Explanation:

Question 57:

What is the advantage of percutaneous pedicle screw fixation over open instrumentation and fusion for a thoracolumbar burst fracture without neurologic deficit?

Options:

Better clinical outcomes
Less blood loss
Less pseudarthrosis risk
Lower revision surgery rate

Correct Answer: Less blood loss

Explanation:

DISCUSSION
A prospective randomized study on short-segment treatment of burst fractures with and without fusion demonstrated similar outcomes at 5 years with lower blood loss in the nonfusion group. There is by definition no fusion performed with percutaneous stabilization, so patients often develop hardware failure. Some surgeons routinely remove instrumentation following percutaneous stabilization, thus revision surgery is common. Clinical outcomes are not improved compared to open methods.
RECOMMENDED READINGS
Koreckij T, Park DK, Fischgrund J. Minimally invasive spine surgery in the treatment of thoracolumbar and lumbar spine trauma. Neurosurg Focus. 2014;37(1):E11. doi: 10.3171/2014.5.FOCUS1494. Review. PubMed PMID: 24981899.
View Abstract at PubMed
Jindal N, Sankhala SS, Bachhal V. The role of fusion in the management of burst fractures of the thoracolumbar spine treated by short segment pedicle screw fixation: a prospective randomised trial. J Bone Joint Surg Br. 2012 Aug;94(8):1101-6. doi: 10.1302/0301-620X.94B8.28311. PubMed PMID: 22844053.
View Abstract at
PubMed
Dai LY, Jiang LS, Jiang SD. Posterior short-segment fixation with or without fusion for thoracolumbar burst fractures. a five to seven-year prospective randomized study. J Bone
Joint Surg Am. 2009 May;91(5):1033-41. doi: 10.2106/JBJS.H.00510. PubMed PMID:

Question 58:

Options:

Brachiocephalic
Innominate
Subclavian
Axillary
Circumflex scapular

Correct Answer: Axillary

Explanation:

DISCUSSION: The axillary artery commences at the first rib as a direct continuation of the subclavian artery and becomes the brachial artery at the lower border of the teres major. The arteriogram reveals a nonfilling defect in the third portion of the artery just distal to the subscapular artery. The complex arterial collateral circulation in this region often permits distal perfusion of the extremity despite injury.
REFERENCE: Radke HM: Arterial circulation of the upper extremity, in Strandness DE Jr (ed): Collateral Circulation in Clinical Surgery. Philadelphia, PA, WB Saunders, 1969, pp 294-307.

Question 59:

Split posterior tibial tendon transfer is used in the treatment of children with cerebral palsy. Which of the following patients is considered the most appropriate candidate for this procedure?

Options:

A 6-year-old child with athetosis and a flexible equinovarus deformity of the foot
A 6-year-old child with spastic hemiplegia and a rigid equinovarus deformity of the foot
A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot
A 10-year-old child with spastic quadriplegia and rigid valgus deformities of the feet
A 15-year-old child with spastic diplegia and rigid equinovalgus deformities of the feet

Correct Answer: A 6-year-old child with spastic hemiplegia and a flexible equinovarus deformity of the foot

Explanation:

DISCUSSION: Split posterior tibial tendon transfers are best performed in patients with spastic cerebral palsy who are between the ages of 4 and 7 years and have flexible equinovarus deformities. Rigid deformities typically require bony reconstruction procedures. Tendon transfers in patients with athetosis are unpredictable.
REFERENCES: Green NE, Griffin PP, Shiavi R: Split posterior tibial-tendon transfer in spastic cerebral palsy. J Bone Joint Surg Am 1983;65:748-754.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 1142-1152.

Question 60:

Options:

Arthroscopic or open reduction and internal fixation
Arthroscopic loose body removal
Activity restriction for up to 9 months
Subchondral drilling

Correct Answer: Arthroscopic or open reduction and internal fixation

Explanation:

Question 61:

Options:

Anti-inflammatory medication and non-weightbearing for 6 weeks
Urgent CT scan
Hip arthroscopy
Open surgical repair
Dynamic stretching and progressive mobilization

Correct Answer: Urgent CT scan

Explanation:

Question 62:

Options:

Midsubstance tear of the lateral ulnar collateral ligament
Proximal avulsion of the ulnar collateral ligament
Proximal avulsion of the lateral ulnar collateral ligament
Distal bony avulsion of the ulnar collateral ligament from the sublime tubercle

Correct Answer: Proximal avulsion of the lateral ulnar collateral ligament

Explanation:

Question 63:

Internal impingement is characterized by which of the following anatomic lesions? Review Topic

Options:

Subscapularis tear
Bursal-sided rotator cuff tear
Articular-sided rotator cuff tear
Tight anterior capsule
Laxity of the posterior capsule

Correct Answer: Articular-sided rotator cuff tear

Explanation:

Question 64:

Options:

Facet injections
Epidural steroid injection
MRI of the lumbar spine
Bed rest for 2 weeks with continued restrictions
Early return to activities as his symptoms allow

Correct Answer: Early return to activities as his symptoms allow

Explanation:

Question 65:

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

Options:

Sural
Saphenous
Superficial peroneal
Deep peroneal
Posterior tibial

Correct Answer: Superficial peroneal

Explanation:

Question 66:

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Options:

Using commercially available antibiotic-loaded bone cement
Adding 0.5 g vancomycin to commercially available antibiotic-loaded bone cement
Adding 0.5 g tobramycin and 0.5 g vancomycin/unit of standard bone cement
Adding either 1.0 g vancomycin or 1.2 g tobramycin per 40 g of standard bone cement
Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Correct Answer: Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Explanation:

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.
High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 67:

Options:

Toe-touch weight-bearing activity and supportive care
Core decompression and femoral head grafting
Periacetabular osteotomy
Hemiarthroplasty

Correct Answer: Toe-touch weight-bearing activity and supportive care

Explanation:

Question 68:

Options:

Unloader brace
Distal femoral osteotomy
Open arthrofibrosis debridement with lateral ligament balancing and polyethylene exchange
Revision TKA of both the femoral and tibial components

Correct Answer: Revision TKA of both the femoral and tibial components

Explanation:

Question 69:

Options:

Increased pain walking down stairs
Increased pain while using a stationary bike
Increased pain with coughing or sneezing
Increased pain after driving a car for a long distance
Pain that is worst first thing in the morning and gradually improves as the day goes on

Correct Answer: Increased pain while using a stationary bike

Explanation:

Question 70:

The posterior approach to the proximal radius uses what intermuscular interval?

Options:

Extensor carpi radialis brevis and extensor digitorum communis
Extensor carpi radialis longus and extensor digitorum communis
Extensor digitorum communis and extensor pollicis brevis
Brachioradialis and flexor carpi radialis
Anconeus and extensor carpi ulnaris

Correct Answer: Extensor carpi radialis brevis and extensor digitorum communis

Explanation:

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 71:

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern? Review Topic

Options:

Extending down the spine into the lumbosacral region
Down the inner aspect of either upper extremity
Cephalad up to the cervicothoracic junction
Around or through the chest to the anterior wall
Down the contralateral lower extremity

Correct Answer: Around or through the chest to the anterior wall

Explanation:

Question 72:

Options:

Independent 2-sample t test
Analysis of variance (ANOVA)
Chi-square test
Fisher’s exact test

Correct Answer: Analysis of variance (ANOVA)

Explanation:

Question 73:

The patient undergoes hip arthroscopy and the image of the right hip is shown in Figure 39. Repair of the injured structure would be expected to improve

Options:

hip joint survival.
hip joint lubrication.
hip joint motion. 36
hip joint stability.

Correct Answer: hip joint lubrication.

Explanation:

DISCUSSION
The radiographic studies reveal both acetabular dysplasia and cam-type femoroacetabular impingement. The MR image shows an acetabular labral tear. Structural abnormalities of the hip, including femoroacetabular impingement, have commonly been identified in association with labral tears. Disruption of the ligamentum teres is not associated with impingement conditions in the absence of trauma.
The patient has acetabular dysplasia with a decreased lateral center-edge angle and also has visible cam-type femoroacetabular impingement. The common pathway for joint degeneration in hips with cam-type femoral head anatomy includes the development of cartilage damage in the anterior or superolateral aspects of the acetabular cartilage. Paralabral cysts may be seen more commonly in association with acetabular dysplasia, although the patient’s radiographs did not demonstrate substantial cystic changes. Osteochondral loose bodies and ligamentum teres ruptures can be seen at arthroscopy in a small number of cases.
There are several proposed roles of the acetabular labrum. It can increase the depth of the acetabular socket by as much as 21% to 28%. Roles of the acetabular labrum include joint lubrication, shock absorption, and pressure distribution. Recent studies assessing the effects of loading on joint stability for both normal and dysplastic hips did not demonstrate a substantial role of the labrum in differences in loading. Although joint stability might be improved following surgical repair, acetabular dysplasia is not likely to be resolved with acetabular labral repair alone.
RECOMMENDED READINGS
Tibor LM, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular impingement. Bone Joint Res. 2012 Oct 1;1(10):245-57. doi: 10.1302/2046-3758.110.2000105.PubMed: 23610655.
View Abstract at PubMed
Peelle MW, Della Rocca GJ, Maloney WJ, Curry MC, Clohisy JC. Acetabular and femoral radiographic abnormalities associated with labral tears. Clin Orthop Relat Res. 2005 Dec;441:327-33. PubMed PMID: 16331022.
View Abstract at PubMed
Ross JR, Zaltz I, Nepple JJ, Schoenecker PL, Clohisy JC. Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia. Am J Sports Med. 2011 Jul;39 Suppl:72S-8S. doi: 10.1177/0363546511412320.
PubMed PMID: 21709035.
View Abstract at PubMed
James SL, Ali K, Malara F, Young D, O'Donnell J, Connell DA. MRI findings of
37
femoroacetabular impingement. AJR Am J Roentgenol. 2006 Dec;187(6):1412-9. PubMed PMID: 17114529.
View Abstract at PubMed
Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009 Jun;2(2):105-17. doi: 10.1007/s12178-009-9052-9. Epub 2009 Apr 7. PubMed PMID: 19468871.
View Abstract at PubMed
Henak CR, Ellis BJ, Harris MD, Anderson AE, Peters CL, Weiss JA. Role of the acetabular labrum in load support across the hip joint. J Biomech. 2011 Aug 11;44(12):2201-6. doi: 10.1016/j.jbiomech.2011.06.011. Epub 2011 Jul 14. PubMed PMID: 21757198.
View Abstract at PubMed

Question 74:

Options:

Observation for a month
Plate the tibia after removing the nail
Autogenous bone graft to the tibia
Exchange nailing of the tibia

Correct Answer: Exchange nailing of the tibia

Explanation:

Question 75:

Options:

Anterior cruciate ligament tear
Patella fracture
Patellar tendon tear
Tibial tubercle avulsion
Posterior cruciate ligament tear

Correct Answer: Posterior cruciate ligament tear

Explanation:

Question 76:

At the level of the midcalf, the plantaris tendon is found at which of the following locations?

Options:

Superficial to the fascia of the gastrocnemius
Between the medial and lateral heads of the gastrocnemius
Between the soleus and lateral head of the gastrocnemius
Between the soleus and medial head of the gastrocnemius
Between the soleus and posterior tibialis muscle

Correct Answer: Between the soleus and medial head of the gastrocnemius

Explanation:

DISCUSSION: The plantaris tendon is often harvested to augment a tendon reconstruction. The origin of the plantaris muscle is on the posterolateral aspect of the distal femur, and the muscle lies lateral to the tibial nerve and the posterior tibial artery. The tendon then courses posteriorly between the soleus and the medial head of the gastrocnemius.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 475.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 491.

Question 77:

03 Figure 72 shows the radiograph of a 4 y/o girl who has a painless right Trendelenburg limp. Management should consist of

Options:

– closed reduction
– open reduction with femoral shortening and pelvic osteotomy
– traction followed by closed reduction
– medial soft tissue release, traction, and closed reduction
– pelvic osteotomy without reduction of the joint back answer Question 201.03

Correct Answer: – open reduction with femoral shortening and pelvic osteotomy

Explanation:

Question 78:

In hip arthroplasty, the location of the medial femoral circumflex artery is best described as

Options:

superior to the piriformis tendon.
superior to the anterior rim of the acetabulum.
deep to the transverse acetabular ligament.
deep to the quadratus femoris muscle.
within the substance of the gluteus minimus.

Correct Answer: deep to the quadratus femoris muscle.

Explanation:

Question 79:

Nonsurgical management of pectoralis major tears is likely to result in weakness of glenohumeral

Options:

abduction and external rotation.
abduction and internal rotation.
adduction and external rotation.
adduction and internal rotation.
external rotation and forward flexion.

Correct Answer: adduction and internal rotation.

Explanation:

Question 80:

Options:

Application of a hinged external fixator
Conversion to radial head arthroplasty
Open reduction internal fixation of the coronoid fragment
Repair of the medial collateral ligament
Splint at 90 degree flexion and full pronation Corrent answer: 4 This patient has persistent elbow instability likely secondary to medial collateral ligament (MCL) rupture and therefore should undergo repair of the MCL, followed by repeat fluoroscopic examination. Small coronoid fractures involving less than or equal to 10% of the coronoid tip do not confer major elbow instability and do not necessitate repair. Terrible triad injuries of the elbow are characterized by: 1. Radial head fracture, 2. Coronoid fracture, and 3. Elbow dislocation. Whether to surgically address the coronoid fracture depends on the size of the fragment (Reagan-Morrey types I-III; Illustration A) as well as elbow stability. Reagan and Morrey suggested that small fractures of the coronoid tip (type I) involving less than 10% of the coronoid may represent anterior capsule avulsions; however, recent cadaveric studies demonstrate that the capsule inserts more distally on the tip and that small fractures often do not contain capsule insertion. Gross elbow instability in the presence of a type I fracture is most likely due to an independent MCL injury and NOT the coronoid avulsion. Surgical repair of type I fractures has not been shown to affect stability and may detrimentally affect elbow range of motion. Matthew et al reviewed the terrible triad injury of the elbow. While the coronoid process provides substantial resistance to posterior subluxation, small fractures involving 10% of the coronoid process have been shown to have little effect on elbow stability. In a cadaveric study of a simulated terrible triad injury, when residual instability was present after radial head repair or arthroplasty and lateral ulnar collateral ligament (LUCL) repair, repair of the MCL was more effective than fixation of small coronoid fractures in restoring elbow stability. However, the authors note that in clinical series of terrible triad injuries, most coronoid fragments were larger than 10%, suggesting that fixation of the coronoid process is usually part of the treatment of terrible triad injuries. Papatheodorou et al performed a retrospective analysis of 14 patients with acute terrible triad injuries and type I or type II coronoid fractures who underwent radial head fixation or arthroplasty and LUCL repair without coronoid fixation. Intraoperative stability was confirmed under fluoroscopy. At 2 year follow up, none of the patients demonstrated elbow instability. Mean elbow flexion-extension was 123 and forearm rotation 145. The authors concluded that terrible triad injuries with type I or II coronoid fractures can be treated without coronoid fixation when intraoperative stability is restored with radial head repair or arthroplasty and LUCL repair. Illustration A demonstrates the Regan-Morrey classification of coronoid fractures. Type I fractures involve < 10% of the coronoid tip and do not result in significant elbow instability. Type II fractures involve < 50% of the coronoid and may result in elbow instability secondary to loss of the anterior bony buttress that resists posterior displacement of the ulna, as well as loss of the anterior capsule insertion. These fractures are often repaired, particularly when associated with elbow instability. Type III fractures involve > 50% of the coronoid and often contain the insertion of the anterior band of the MCL (red arrow). The insertion of the brachialis (red triangle) may also be involved resulting in proximal displacement of the fracture fragment. Surgical repair of type III fractures is necessary to reconstitute the MCL and restore elbow stability. Illustration B is a CT scan of a type I coronoid fracture. Illustration C is a CT scan of a type II coronoid fracture. Illustration D is a CT scan of a type III coronoid fracture. Incorrect Answers:

Correct Answer: Splint at 90 degree flexion and full pronation Corrent answer: 4 This patient has persistent elbow instability likely secondary to medial collateral ligament (MCL) rupture and therefore should undergo repair of the MCL, followed by repeat fluoroscopic examination. Small coronoid fractures involving less than or equal to 10% of the coronoid tip do not confer major elbow instability and do not necessitate repair. Terrible triad injuries of the elbow are characterized by: 1. Radial head fracture, 2. Coronoid fracture, and 3. Elbow dislocation. Whether to surgically address the coronoid fracture depends on the size of the fragment (Reagan-Morrey types I-III; Illustration A) as well as elbow stability. Reagan and Morrey suggested that small fractures of the coronoid tip (type I) involving less than 10% of the coronoid may represent anterior capsule avulsions; however, recent cadaveric studies demonstrate that the capsule inserts more distally on the tip and that small fractures often do not contain capsule insertion. Gross elbow instability in the presence of a type I fracture is most likely due to an independent MCL injury and NOT the coronoid avulsion. Surgical repair of type I fractures has not been shown to affect stability and may detrimentally affect elbow range of motion. Matthew et al reviewed the terrible triad injury of the elbow. While the coronoid process provides substantial resistance to posterior subluxation, small fractures involving 10% of the coronoid process have been shown to have little effect on elbow stability. In a cadaveric study of a simulated terrible triad injury, when residual instability was present after radial head repair or arthroplasty and lateral ulnar collateral ligament (LUCL) repair, repair of the MCL was more effective than fixation of small coronoid fractures in restoring elbow stability. However, the authors note that in clinical series of terrible triad injuries, most coronoid fragments were larger than 10%, suggesting that fixation of the coronoid process is usually part of the treatment of terrible triad injuries. Papatheodorou et al performed a retrospective analysis of 14 patients with acute terrible triad injuries and type I or type II coronoid fractures who underwent radial head fixation or arthroplasty and LUCL repair without coronoid fixation. Intraoperative stability was confirmed under fluoroscopy. At 2 year follow up, none of the patients demonstrated elbow instability. Mean elbow flexion-extension was 123 and forearm rotation 145. The authors concluded that terrible triad injuries with type I or II coronoid fractures can be treated without coronoid fixation when intraoperative stability is restored with radial head repair or arthroplasty and LUCL repair. Illustration A demonstrates the Regan-Morrey classification of coronoid fractures. Type I fractures involve < 10% of the coronoid tip and do not result in significant elbow instability. Type II fractures involve < 50% of the coronoid and may result in elbow instability secondary to loss of the anterior bony buttress that resists posterior displacement of the ulna, as well as loss of the anterior capsule insertion. These fractures are often repaired, particularly when associated with elbow instability. Type III fractures involve > 50% of the coronoid and often contain the insertion of the anterior band of the MCL (red arrow). The insertion of the brachialis (red triangle) may also be involved resulting in proximal displacement of the fracture fragment. Surgical repair of type III fractures is necessary to reconstitute the MCL and restore elbow stability. Illustration B is a CT scan of a type I coronoid fracture. Illustration C is a CT scan of a type II coronoid fracture. Illustration D is a CT scan of a type III coronoid fracture. Incorrect Answers:

Explanation:

OrthoCash 2020

Question 81:

Options:

immediate biopsy of the proximal tibia.
aspiration and culture of the knee.
observation with activity modification.
a white blood cell scan.
revision of the ACL reconstruction.

Correct Answer: observation with activity modification.

Explanation:

Question 82:

Options:

Closed reduction and percutaneous pinning
Reconstruction of the ulnar collateral ligament using palmaris tendon autograft
Open reduction and internal fixation
Splinting for 1 week and observation of the nerve injury
Ulnar nerve exploration and transposition

Correct Answer: Closed reduction and percutaneous pinning

Explanation:

The radiographs reveal an incarcerated medial epicondyle fracture apparently associated with an elbow dislocation. The incarcerated position of the fragment warrants open reduction and internal fixation. Due to the close proximity of the ulnar nerve, percutaneous pinning of a medial epicondyle fracture is not recommended. Ulnar nerve symptoms secondary to this fracture usually do not require a formal transposition.
(SBQ13PE.97) A 3-year-old boy presents to your office for evaluation. On physical examination, the patient has large calves and uses his hands to assist in rising from the floor. Laboratory results from the pediatrician reports notably high creatinine kinase of 43000 IU/L. What is the most likely inheritance pattern?
Review Topic
Autosomal recessive
Autosomal dominant
X-linked recessive
X-linked dominant
Mitochondrial inheritance
Duchenne's muscular dystrophy (DMD) has an X-linked recessive inheritance pattern.
Duchenne's muscular dystrophy is characterized by a lack of dystrophin on muscle biopsy. Gower's sign is a typical physical exam finding (child uses hands to assist in rising from sitting), along with pseudohypertrophy of the calves. Notable laboratory values include elevated creatinine kinase (CK), typically above 25,000 IU/L.
Sussman et al. provide a comprehensive review of DMD, highlighting characteristic findings, including pseudohypertrophy of the calves (due to replacement of skeletal muscle with adipose tissue), Gower's sign, as well as CK levels typically above 25,000 IU/L. CK levels can aid in distinguishing between Becker's dystrophy which has levels less than 25,000 IU/L.
Figure A exhibits a muscle biopsy (calf) at low power of DMD; note the replacement of muscle with adipose tissue.
Incorrect answers:
(SBQ13PE.47) Figure A shows an ultrasound of a 2 week old infant being evaluated for developmental dysplasia of the hip. Which of the labels depict the alpha angle, and what anatomic landmarks define this angle?
Review Topic
Angle A, ilium and cartilaginous acetabulum
Angle A, ilium and bony acetabulum
Angle B, ilium and cartilaginous acetabulum
Angle B, ilium and bony acetabulum
Angle B, bony acetabulum and acetabular labrum
The alpha angle is subtended by (1) a line drawn down the ilium to a point where it intersects with the bony and cartilaginous confluence of the acetabulum and (2) a line drawn along the roof of the bony acetabulum.
The coronal flexion view (as depicted in figure A) of the infant hip is perhaps more familiar if rotated 90 degrees to view as one would view an anterior posterior radiograph of the pelvis. Acetabular development is evaluated primarily by the alpha angle, indicating the morphology of the developing acetabulum, and the percentage of the femoral head that is covered by the bony acetabulum. These are each readily apparent on ultrasound. Normal hips should have an alpha angle of at least 60 degrees by 6-8 weeks of age.
Harcke et al. provide a current concepts review on the state of ultrasound in the diagnosis and management of developmental dysplasia of the hip (as of 1991). They report, since that time, ultrasound has become the mainstay for diagnostic confirmation and management of DDH.
LeBa et al. performed a study to look at whether ultrasound screening would increase in effectiveness if targeted toward infants with established risk factors for developmental dysplasia of the hip and normal findings on physical examination. They found dynamic ultrasound evaluation showed developmental dysplasia in 7.8% of patients who had normal physical exams and led to a change in treatment in 8%. They conclude selective ultrasound screening in infants with risk factors and normal
findings on physical examination is effective and leads to more effective treatment.
Figure A shows an ultrasound exam of a 2 week old infant. The alpha angle is labeled 'B'. The beta angle is lableled 'A'. Illustration A is a diagram from Tachdjian's illustrating diagrammatically the elements of these angles.
Incorrect answers.

Question 83:

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following?

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

DISCUSSION: The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Kohles SS, Kohles JD, Karp AP, et al: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: Comments on meta-analysis. Spine 2004;29:1281-1287.

Question 84:

Options:

Anterior dislocation of the shoulder
Salter-Harris type I fracture of the proximal humeral physis
Rupture of the subscapularis tendon
Sprain of the acromioclavicular joint
Fracture of the glenoid neck

Correct Answer: Salter-Harris type I fracture of the proximal humeral physis

Explanation:

Question 85:

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

Question 86:

Options:

Femoroacetabular impingement (FAI)
Osteoarthritis of the sacroiliac joint
Intra-articular loose body
Trochanteric bursitis

Correct Answer: Femoroacetabular impingement (FAI)

Explanation:

This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown. The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography is not commonly used to diagnose labral pathology. Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result in a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has
important functions for hip stability and maintenance of the suction seal of the joint.

Question 87:

Options:

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

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

Explanation:

Question 88:

Options:

Axillary nerve dysesthesia
Axillary nerve motor partial paralysis
Suprascapular nerve neurapraxia
Musculocutaneous nerve neurapraxia
Radial nerve sensory dysesthesia

Correct Answer: Axillary nerve dysesthesia

Explanation:

Question 89:

Regarding the role of the orthopaedic surgeon in addressing domestic and family violence, all of the following statements are true EXCEPT:

Options:

Report all cases of child abuse, as this is required by all states
Report all cases of adult spousal or intimate partner abuse, as this is required by all states
Hospitalize elderly victims who are in immediate danger and help develop a plan to ensure their safety
Advocate for appropriate legislation and public policy on violence and abuse related to health care
Orthopedic surgeons are responsible for knowing the reporting laws and procedures for suspected abuse

Correct Answer: Report all cases of child abuse, as this is required by all states

Explanation:

Question 90:

Myositis ossificans is a recognized complication of contusion to the quadriceps muscle. During early rehabilitation, this condition is most likely to be exacerbated by

Options:

electrical stimulation.
iontophoresis.
isometric exercise.
ice/heat contrast.
passive stretching.

Correct Answer: passive stretching.

Explanation:

Question 91:

- A 6-year-old boy sustained a fracture of the medial malleolus as a result of twisting his ankle. The fracture line extends from the joint surface proximally and medially to include a small fragment of the metaphysis, with a displacement of 3 mm. Management should consist of

Options:

Acceptance of the current position of the ankle
Open reduction and fixation in the epiphysis only
ORIF with a small-fragment T-plate from the malleolus up to the metaphysis
Closed reduction by eversion of the ankle and application of a bivalved long leg cast
CRUGA and fixation with a malleolar screw from the malleolus into the metaphysis

Correct Answer: Open reduction and fixation in the epiphysis only

Explanation:

Question 92:

Heat transfer from the skin to the environment when the ambient temperature exceeds 35°C primarily is attributable to

Options:

evaporation.
conduction.
convection.
radiation.

Correct Answer: evaporation.

Explanation:

Question 93:

Options:

oral antibiotics.
IV antibiotics.
surgical drainage of the perivertebral abscess and IV antibiotics.
bed rest.
cast immobilization.

Correct Answer: oral antibiotics.

Explanation:

The patient has diskitis. Administration of IV antibiotics speeds resolution and minimizes recurrence. Bed rest and cast immobilization have been successfully used to treat this disorder but can be associated with prolonged recovery and frequent recurrence, even when oral antibiotics are administered. A perivertebral abscess seen in association with this condition usually resolves without surgery.
(SBQ12SP.92) A 36-year-old man presents to the emergency department after being involved in a motor vehicle collision. He is complaining of back pain and imaging shows the findings in Figure A. On neurological examination, he does not have any deficits. MRI shows approximately 25% canal encroachment and no evidence of injury to the posterior ligamentous complex. Which of the following is the most appropriate course in management?
Review Topic
Strict bedrest for six weeks then progressive weightbearing
Ambulation as tolerated with or without a TLSO
Surgical decompression and anterior stabilization
Surgical decompression and posterior stabilization
Surgical decompression and combined anterior/posterior stabilization
The patient has a L1 burst fracture with minimal retropulsion of bony fragments in the spinal canal. In the absence of neurological deficits and injury to the PLC, the most appropriate treatment is ambulation as tolerated with or without a thoracolumbrosacral orthosis (TLSO).
Thoracolumbar burst fractures are typically caused by an axial load with flexion and commonly found in this location due to increased motion at these segments. With an intact posterior ligamentous complex (PLC) and no neural compromise, TLSO is the mainstay of treatment. If there is evidence of neurological deficit and/or PLC injury, decompression and fusion are indicated. The degree of acceptable kyphosis is controversial. The choice of anterior versus posterior approach is based on ease of decompression.
Vaccaro et al. introduced a new classification system for thoracolumbar injuries, TLICS, based on morphological appearance, integrity of the posterior ligamentous complex, and neurological status. They advocate use of the system for nonoperative versus operative decision making and communication between surgeons.
Bailey et al. completed a randomized, nonblinded controlled trial to determine the
efficacy of bracing for AO type A0-A3 thoracolumbar burst fractures. Both groups were encouraged to ambulate as tolerated and the no brace group had bending restrictions for 8 weeks. They found no difference in the Roland Morris Disability Questionnaire (RMDQ) score at 3 months after injury.
Figure A is sagittal CT scan of the lumbar spine showing a burst fracture of L1 with minimal retropulsion. Illustration A is the TLICS classification with score of 4 being the branch point for nonoperative versus operative management.
Incorrect Answers:

Question 94:

Figures 16a and 16b show the radiographs of an otherwise healthy 3 1/2-year-old boy who has an isolated deformity of the left leg. Definitive primary treatment of this condition should consist of

Options:

distraction osteogenesis.
an intramedullary nail and onlay bone graft.
a short leg cast.
a vascularized free fibular graft.
plate fixation and an autogenous bone graft.

Correct Answer: an intramedullary nail and onlay bone graft.

Explanation:

Question 95:

Following an episode of transient quadriplegia in contact sports, an athlete’s return to play is absolutely contraindicated when

Options:

the spinal canal to vertebral body ratio (Torg ratio) is less than or equal to 0.8.
electromyelographic studies are abnormal.
MRI scans or contrast-enhanced CT scans show severe spinal stenosis.
unilateral burning pain persists.
the episode of quadriplegia lasts 5 minutes.

Correct Answer: MRI scans or contrast-enhanced CT scans show severe spinal stenosis.

Explanation:

Question 96:

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Options:

Calcaneofibular alone
Posterior talofibular alone
Posterior talofibular and deltoid
Anterior talofibular and deltoid
Anterior talofibular and calcaneofibular

Correct Answer: Anterior talofibular and calcaneofibular

Explanation:

Question 97:

Patients with patellar clunk syndrome are best managed by which of the following methods?

Options:

Rest and nonsteroidal anti-inflammatory drugs
Surgical debridement
Patellectomy
Patellar revision
Lateral release/patellar realignment

Correct Answer: Surgical debridement

Explanation:

DISCUSSION: Patellar clunk syndrome is usually the result of a fibrous nodule that forms on the undersurface of the distal quadriceps tendon. It may get entrapped in the intercondylar notch of the femoral component during flexion, and lead to a sudden snap as the nodule is pulled out of the notch during active extension. Nonsurgical management is rarely successful. Surgical debridement is usually curative, with only rare recurrence. More aggressive procedures such as realignment, revision, or patellectomy are usually not necessary, and are reserved for cases resistant to soft-tissue debridement.
REFERENCES: Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update:
Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 329.
Diduch DR, Scuderi GR, Scott WN, et al: The efficacy of arthroscopy following total knee replacement. Arthroscopy 1997;13:166-171.
Lucas TS, DeLuca PF, Nazarian DG, et al: Arthroscopic treatment of patellar clunk. Clin Orthop 1999;367:226-229.

Question 98:

Options:

Case control
Cohort
Cross-sectional
Randomized
Longitudinal

Correct Answer: Case control

Explanation:

Question 99:

Options:

persistent pain.
tendon subluxation.
altered sensation.
tendon rupture.

Correct Answer: persistent pain.

Explanation:

Question 100:

Which of the following activities can improve posterior capsular contractures?

Options:

Theraband exercises to strengthen the external rotator
Latissimus pull-down exercises to the chest
Seated rows
Internal rotation stretch at 90 degrees abduction with scapular stabilization
Bench press with wide grip

Correct Answer: Internal rotation stretch at 90 degrees abduction with scapular stabilization

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

Orthopedic Board Prep MCQs: Arthroplasty, Trauma, Hip, Peripheral Nerve & Tendon – Part 138

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 138

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index