Orthopedic MCQs: Hip, Sports Medicine, Oncology - Part 148

About This Board Review Set

This is Part 148 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.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 148

This module focuses heavily on: Hip.

Sample Questions from This Set

Sample Question 1: Which of the following abnormalities has been observed in a higher than expected frequency in patients with metal-on-metal hip bearings?...

Sample Question 2: What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?...

Sample Question 3: 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...

Sample Question 4: Which of the following factors are considered prognostic of survival in patients with soft-tissue sarcomas?...

Sample Question 5: What is the most appropriate way to communicate instructions to a family when there is a language barrier?...

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

Which of the following abnormalities has been observed in a higher than expected frequency in patients with metal-on-metal hip bearings?

Explanation

DISCUSSION: Metal-on-metal hip bearings have been associated with very low rates of wear and are commonly used in North America and Europe. Patients with these bearings have higher levels of metal ions (particularly cobalt and chromium) in the bloodstream than patients with bearings made of other materials. Although many researchers have been concerned that these ions may predispose to cancer, there has been no evidence that patients with metal-on-metal bearings are developing sarcomas or carcinomas with higher frequency than the general population. However, there has been mixed data as to whether hematopoietic malignancies are slightly more prevalent in patients with metal-on-metal bearings. Two recent reports have found chromosomal abnormalities, such as translocations and aneuploidy, to be increased in patients with metal-on-metal hip bearings. The clinical consequences of these changes, if any, remain unknown.
REFERENCES: Dunstan E, Ladon D, Whittingham-Jones P, et al: Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings. J Bone Joint Surg Am 2008;90:517-522. Ladon D, Doherty A, Newson R, et al: Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metal-on-metal hip arthroplasty. J Arthroplasty 2004:19:78-83.
Visuri T, Pukkala E, Paavolainen P, et al: Cancer risk after metal on metal and polyethylene on metal total hip
arthroplasty. Clin Orthop Relat Res 1996:329:S280-S289. Question 61
A 73-year-old woman with a history of type II diabetes mellitus undergoes a total hip arthroplasty for osteoarthritis. She continues to have serosanguinous wound drainage from the midportion of the incision 12 days after surgery. What is the most appropriate treatment at this time?
Return to the operating room for debridement and irrigation with removal of all implants and immediate reimplantation
Return to the operating room for open debridement and irrigation, exchange of the polyethylene
insert, followed by appropriate antibiotics based on intraoperative culture results
Hip spica pressure dressing and a 2-week course of oral antibiotics
Hip aspiration for culture, followed by a 2-week course of appropriate IV antibiotics based on
culture results
Hip aspiration for culture, followed by a 6-week course of appropriate IV antibiotics based on culture results
DISCUSSION: This patient has an acute postoperative deep infection, with prolonged drainage at 12 days postoperatively. Even without other signs or symptoms of infection, the prolonged drainage this far out after surgery is concerning for an acute postoperative infection. The most appropriate treatment at this point is open debridement with retention of the implants. Modular parts, if present, are exchanged. Oral or IV antibiotics alone are generally inadequate to treat the infection, and this form of management alone would result in a missed opportunity to potentially cure the infection. Removal of all implants at this point is not required because early aggressive debridement within the first 2 weeks after surgery offers a reasonable outcome. After 4 to 6 weeks of symptoms, results of debridement are less favorable and removal of the implants is usually required.
REFERENCES: Crockarell JR, Hanssen AD, Osmon DR, et al: Treatment of infection with debridement and retention of the components following hip arthroplasty. J Bone Joint Surg Am 1998;80:1306-1313. Hanssen AD, Osmon DR: Assessment of patient selection criteria for treatment of the infected hip arthroplasty. Clin Orthop Relat Res 2000;381:91 -100.

Question 2

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Explanation

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 3

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 4

Which of the following factors are considered prognostic of survival in patients with soft-tissue sarcomas?

Explanation

DISCUSSION: The factors that are independently prognostic of patient survival are tumor size, tumor grade, and tumor depth (ie, subfascial versus superficial). These factors are the basis for the American Joint Committee on Cancer staging criteria. Patient age and neurovascular invasion are not prognostic. Surgical margin is prognostic for local recurrence but not conclusively for patient survival or metastasis. Metastatic disease is also predictive of survival.
REFERENCES: Cheng EY, Thompson RC Jr: New developments in the staging and imaging of soft-tissue sarcomas. Instr Course Lect 2000;49:443-451.
Fleming ID, et al: Manual for Staging of Cancer/American Joint Committee on Cancer, ed 5. Philadelphia, PA, Lippincott Raven, 1997, pp 149-156.

Question 5

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Explanation

RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 6

In a patient with vertebral tuberculosis, which of the following characteristics is most predictive of progression of the kyphosis?

Explanation

DISCUSSION: In patients with vertebral tuberculosis, involvement of the anterior and posterior elements creates an instability and severe kyphotic collapse can occur. This characteristic has been shown to have a stronger association than level of involvement, age, or pretreatment degree of deformity. In the absence of instability, anterior growth can resume after treatment, leading to a decrease in the deformity.
REFERENCES: Rajasekaran S: The natural history of post-tubercular kyphosis in children: Radiological signs which predict late increase in deformity. J Bone Joint Surg Br

2001;83:954-962.
Rajasekaran S, Shanmagasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty DK: Tuberculous lesions of the lumbosacral region: A 15-year follow-up of patients treated by ambulant chemotherapy. Spine 1998;23:1163-1167.

Question 7

A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?

Explanation

The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle. The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60° and 70° and is lowest at
full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the MCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the two functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion. Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response C incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses B and D are incorrect. The posterior bundle of the MCL also demonstrates the most change in
length from extension to flexion of all the elbow ligaments.

Question 8

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 9

A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of

Explanation

DISCUSSION: Atraumatic subluxation or dislocation of the sternoclavicular joint typically occurs in individuals with generalized ligamentous laxity. It is generally not painful, has no long-term sequelae, and needs no treatment. In fact, it is more likely to be painful following surgery than if managed nonsurgically.
REFERENCES: Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.
Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998,

p 583.

Question 10

A 40-year-old man with a history of Legg-Calve-Perthes disease underwent a right hip resurfacing 3 years ago with no perioperative complications. Hip pain has developed gradually during the last 4 months. Radiographs show no evidence of fixation loosening or any adverse changes at the femoral neck. No periarticular osteolysis is evident. A large intra-articular and intrapelvic pseudotumor has developed. What predominant histological feature(s) is/are present in such a lesion?

Explanation

DISCUSSION:
Controversy persists over what exactly is the best approach to managing patients with metal-on-metal (MOM) hip arthroplasties. All patients with painful MOM hip arthroplasties should be examined for fixation loosening, wear/osteolysis, and infection—no differently than patients without MOM hip arthroplasties. It is recommended to obtain serum trace element levels. If the levels are high, cross-sectional imaging should be obtained to determine whether any pseudotumor or tissue necrosis is present around the hip arthroplasty. Hip aspiration should be considered if concern for infection exists. Adverse tissue reaction has been identified to occur around MOM hip arthroplasties. The predominant histologic feature is tissue necrosis with infiltration of lymphocytes and plasma cells.

Question 11

A 46-year-old male is involved in a motor vehicle accident and suffers a proximal humerus fracture. Operative treatment is recommended, and plate fixation is performed through an extended anterolateral acromial approach. Which of the following structures is at increased risk of injury using this surgical exposure compared to the deltopectoral approach?

Explanation

DISCUSSION: The anterolateral acromial approach was developed to allow less invasive treatment of proximal humerus fractures. The plane of the avascular anterior deltoid raphe is utilized, and the axillary nerve is at particular risk of injury and must be identified and protected. With this approach, anterior dissection near the critical blood supply is avoided, substantial muscle retraction is minimized, and the lateral plating zone is directly accessed.
Gardner et al evaluated 23 patients who had acute displaced fractures of the proximal humerus treated with the anterolateral acromial approach and either a locking plate or an intramedullary nail. At one year post-op, there were no axillary nerve deficits, and they found that the approach allowed direct access to the lateral fracture planes for fracture reduction and plate placement or safe nail and interlocking screw placement.
Gardner et al, in another study, performed cadveric dissection using the extended anterolateral acromial approach and measured multiple parameters regarding the axillary nerve. The nerve was predictably found approximately 35 mm from the prominence of the greater tuberosity.
Morgan et al performed a cadaveric study to describe the anatomic insertion point of the deltoid onto the proximal humerus. They found that the deltoid insertion is long and broad, and that placement of 4.5-mm plate would result in detaching 13.5 mm of its insertional footprint. This would leave half of the insertion still attached to the humerus.
Illustration A identifies the location of the incision for the anterolateral acromial exposure , and Illustration B shows the position of the axillary nerve in relation to the approach.

Question 12

A 62-year-old man with a long history of ankylosing spondylitis has neck pain after lightly bumping his head on the wall. Examination reveals neck pain with any attempted motion; the neurologic examination is normal. Plain radiographs show extensive ankylosis of the cervical spine and kyphosis but no fracture. What is the next most appropriate step in management?

Explanation

DISCUSSION: A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine.
REFERENCES: Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998,

pp 724-727.
McDowell GS, Cammisa FP, Eismont FJ: Hyperextension injuries of the cervical spine, in Levine AM, Eismont FJ, Garfin SR, Zigler JE (eds): Spine Trauma. Philadelphia, PA,

WB Saunders, 1998, pp 372-374.

Question 13

Lymphatic metastasis is a common feature of which of the following lesions?

Explanation

Rhabdomyosarcoma is a high grade malignancy with a rapid growth pattern. Local recurrence and distant metastasis after inadequate excision occurs in almost all instances and is uniformly fatal. The primary site of metastasis is the lung. Lymph node metastasis occurs in about > 10% of the patients, (synovial cell sarcoma = 25%). Whereas M.F.H. only occasionally metastasizes to regional LN, and liposarcoma is slow growing & recurrences or local metastasis is < 10%.

Question 14

A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Explanation

Neurogenic shock is defined as vascular hypotension with bradycardia as a result of spinal injury. The first few minutes after spinal cord injury are associated with hypertension and tachycardia, with a subsequent drop in pressure and pulse rate.

Question 15

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Explanation

DISCUSSION: All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray.
REFERENCES: Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.
Myerson MS, Schon LC, McGuigan FX, et al: Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int

2000;21:297-306.

Question 16

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?

Explanation

DISCUSSION: A knock-out mouse to the Vitamin D receptor would cause loss of vitamin D function, resulting in rickets. Renal failure would not occur; although Vitamin D is converted from 25 (OH) D to 1,25 (OH) D in the kidney, the active hormone acts on the gut and bone. Osteopetrosis can be seen as the phenotype for the c fos knock-out mouse; the Jansen-type metaphyseal dysplasia phenotype results from overactivation of the PTH/PTHrp receptor. Although compensatory hyperparathyroidism would occur, excessive PTH would not be able to rescue the skeletal loss and instead phosphoturia and phosphotasia would result.
REFERENCES: Glowacki J, Hurwitz S, Thornhill TS, et al: Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis undergoing total hip arthroplasty. J Bone Joint Surg Am 2003;85:2371-2377.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 51.

Question 17

Among the ankle arthroscopy portals described below, which portal is at highest risk for serious complications?

Explanation

Extensor digiti minimi
Flexor digitorum superficialis (FDS) to the index finger 77
Abductor pollicis brevis
First dorsal interossei
DISCUSSION
The intraoperative image shows a piece of glass splitting the ulnar nerve in the cubital tunnel. The extensor digiti minimi is innervated by the radial nerve. The FDS to the index finger and the abductor pollicis brevis are innervated by the median nerve. The first dorsal interossei is the last muscle innervated by the ulnar nerve.
RECOMMENDED READINGS
Miller MD. Review of Orthopaedics. 3rd ed. New York, NY: Saunders; 2000.
Anderson JE. Grant’s Atlas of Anatomy. 8th ed. Baltimore, MD: Williams & Wilkins; 1983.

Question 18

A 32-year-old male presents with left leg pain and weakness. An axial image from his MRI is shown in Figure A. Which of the following physical exam findings would be most consistent with this MRI finding. Review Topic

Explanation

A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 19

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Explanation

The annulus fibrosis has a multilayer lamellar architecture mode of type I collagen fibers. Each successive layer is oriented at 30 degrees to the horizontal in the opposite direction, leading to a “criss-cross” type pattern. This composition allows the annulus, which has the highest tensile modulus, to resist torsional, axial, and tensile loads.

Question 20

Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of

Explanation

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 21

A 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph is shown in Figure 14. Initial management should consist of

Explanation

DISCUSSION: The presence of the relatively long second metatarsal, along with the close approximation of the second and third metatarsal heads, are consistent with second metatarsophalangeal tenosynovitis. The hallmark of initial management is conservative. Modalities include taping, nonsteroidal anti-inflammatory drugs, metatarsal pads, and cortisone injections. Trepman and Yeo combined the use of a cortisone injection with a rocker bottom sole. Mizel and Michelson reported their results using an extended rigid steel shank shoe along with a cortisone injection.
REFERENCES: Trepman E, Yeo SJ: Nonoperative treatment of metatarsophalangeal joint synovitis. Foot Ankle Int 1995;16:771-777.
Mizel MS, Michelson JD: Nonsurgical treatment of monarticular nontraumatic synovitis of the second metatarsophalangeal joint. Foot Ankle Int 1997;18:424-426.

Question 22

A 75-year-old female with a longstanding history of brachial plexus palsy 2 . A 63-year-old male with a 6 month history of shoulder pain and inability to abduct past 30 degrees

Explanation

Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?

Immobilization in external rotation for 6 weeks Arthroscopic bony Bankart repair

Arthroscopic Remplissage procedure

Glenoid augmentation using coracoid transfer Glenoid augmentation using tricortical iliac crest graft
This patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.
Older (>20 years old), recreational athletes with minor glenoid bone loss (<20 % of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid.
Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.
Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.
Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.
Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.
Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss. Incorrect Answers:
A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?

Nonsynergistic action of the transferred muscle Fatty atrophy of the supraspinatus and infraspinatus Deficiency of the subscapularis

Absence of the coracoacromial ligament Deltoid weakness
A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer.
The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.
An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure?

Anchor fatigue and breakage Anchor pull out from bone

Suture rupture secondary to anchor eyelet abrasion Suture pull out from the repaired tissue

Infection
Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).
George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.
Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include highstrength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.
Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, singlerow configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 1215 mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing. Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.
Incorrect Responses
Biocomposite anchors exhibit high load-to-failure and result in fatigue failure less commonly than metal anchors.

A 32-year-old cross-training athlete awakens with severe left neck and shoulder pain after a day of intense upper body training. Aside from a recent viral illness, he is otherwise healthy. His pain improves, but two weeks later he notes significant left shoulder weakness. Examination reveals weakness of shoulder abduction, forward elevation and external rotation with the arm at his side. Radiographs are normal. Electromyography demonstrates 2+ positive sharp waves and fibrillations. Sensory nerve conduction studies show reduced amplitudes. MRI of the brain, cervical spine and shoulder are shown in Figures A-D, respectively. Which of the following is true of his prognosis?

Decompression will result in improved muscle strength and function.

The patient can expect a gradual return of muscle strength without long term functional deficits. Immunomodulators may decrease the number and severity of his relapses. 4 . Arthroscopic repair will result in the best functional outcomes given the patient's high activity level.

Question 23

Figures 10a and 10b show the radiographs of a 47-year-old man who reports pain in both shoulders. He has a history of leukemia that was treated with chemotherapy and high-dose cortisone. What is the most reliable treatment option for pain relief in this patient? Review Topic

Explanation

The radiographs reveal osteonecrosis with collapse. The most reliable and durable treatment for osteonecrosis of the humeral head remains prosthetic shoulder arthroplasty. Osteonecrosis of the humeral head may be seen after the use of steroids, and there is an increasing demand for shoulder arthroplasty in young people because of the use of high-dose steroids in chemotherapy regimes for the treatment of malignant tumors. The indications for most shoulder arthrodeses today include posttraumatic brachial plexus injury, paralytic disorders in infancy, insufficiency of the deltoid muscle and rotator cuff, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following resection of a tumor in the proximal aspect of the humerus. Clearly, the role of arthroscopy and related minimally invasive techniques in the treatment of humeral head osteonecrosis remains unknown.

Question 24

What is the most appropriate treatment?

Explanation

DISCUSSION
A common postsurgical problem after TKA is a sudden increase of pain that typically occurs about 2 to 3 weeks after surgery. ESR findings are not reliable during the acute postsurgical period. A CRP level exceeding 100 mg/L during the acute postsurgical period is a joint aspiration indication. If the patient does not have sepsis, there is no emergency. This pain is likely attributable to too much activity during physical therapy. Observation is recommended for this patient.

Question 25

Figure 83a shows an axillary radiograph and Figures 83b and 83c show axial MR arthrograms of a 20-year-old collegiate offensive lineman who has shoulder pain while pass-blocking. He sustained a shoulder injury 3 months earlier when he "jammed it." Prior to this injury, he denies any pain or instability in either shoulder. Despite undergoing rehabilitation with a physical therapist and trainer and abstaining from playing for 6 weeks, he is currently unable to play because of his symptoms. Examination reveals full active range of motion, a positive jerk test which reproduces his symptoms, and a grade 2 posterior translation of the humeral head with load and shift testing which also reproduces his symptoms. What is the best management option to allow him to return to his pre-injury function next season? Review Topic

Explanation

Arthroscopic posterior capsulolabral repair is most likely to return him to competitive athletics. The patient has symptomatic posterior instability that is preventing him from performing high-level athletic activities. Posterior subluxation of the humeral head is seen on the axillary radiograph and a posterior labral tear is seen on the axial MR arthrograms. Because nonsurgical management has failed to provide relief, treatment should consist of posterior capsulolabral repair. This can be performed either arthroscopically or open with similar excellent results. An intra-articular injection may help his pain but will not likely allow him to return to his pre-injury functional level. Thermal capsulorrhaphy has limited use in the shoulder because of the high rate of complications reported, and anterior capsulorrhaphy will not correct the posterior instability. Whereas a trial of immobilization in external rotation may have benefitted him with the acute injury, it is unlike to help with this recurrent instability.

Question 26

Figures 1 through 4 show the radiographs and MRI obtained from a 40-year-old man who has a 6-week history of ring finger pain, redness, and swelling after puncturing the finger with a toothpick. Purulent drainage from the puncture wound site grew Eikenella corrodens . The patient was initially treated with oral antibiotics for 10 days and then intravenous (IV) antibiotics for 3 weeks. What is the best next step in treatment?

Explanation

EXPLANATION:
This patient has a septic distal interphalangeal joint, which was treated with antibiotics alone. As a result, the patient developed osteomyelitis with bone destruction and abscess. The best way to treat this problem is to perform surgical débridement of bone and soft tissue, along with abscess drainage and an appropriate antibiotic regimen. Antibiotic treatment without surgery would not be successful in eliminating this particular infection. Bone scan with biopsy is not the correct option, because this problem is an infection and not a tumor, and MRI already has provided enough diagnostic information.

Question 27

A 37-year-old man who works in a factory has isolated, lateral unicompartmental pain about his knee with activities. Nonsurgical management has failed to provide relief. The radiograph shown in Figure 45 reveals a tibiofemoral angle of approximately 15 degrees which is clinically correctable to neutral. What is the best surgical option in this patient?

Explanation

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 28

A 32-year-old man who sustained a tarsometatarsal (Lisfranc) injury 3 years ago now reports increasing pain in the left foot. Orthotics, nonsteroidal anti-inflammatory drugs, and injections have provided only temporary relief. Examination reveals swelling and tenderness over the tarsometatarsal joints. Radiographs show advanced arthrosis of the first and second tarsometatarsal joints. Management should now include

Explanation

DISCUSSION: The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief. Therefore, the treatment of choice is midfoot arthrodesis. Shock wave treatment has not been shown to be beneficial for arthritis. An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint. Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury.
REFERENCES: Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis. Foot Ankle 1990;10:193-200.
Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Question 29

A 30-year-old woman has had pain in her right leg for the past 6 months. A lytic lesion is noted in the anterior cortex of the midtibia, extending 5 cm in length without a soft-tissue mass. A radiograph and a biopsy specimen are shown in Figures 35a and 35b. What is the preferred treatment?

Explanation

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 30

He reports that he had no problems with the knee until 6 weeks ago when he noted the gradual onset of pain following a colonoscopy. Examination reveals a painful, swollen knee. Knee aspiration reveals a WBC count of 40,000/mm3. Management should consist of

Explanation

The treatment of choice for a late hematogenous infection is two-stage resection arthroplasty and reimplantation, with parenteral antibiotics prior to reimplantation. This is particularly true when septic loosening has occurred as in this patient. Open irrigation and debridement with polyethylene exchange
has been used successfully when the duration of symptoms is 3 weeks or less. Long-term suppressive antibiotics are most commonly used when the patient’s medical condition precludes further surgery. Delayed reimplantation has been shown to be superior to immediate reimplantation in multiple studies. Little data support the use of arthroscopic irrigation and debridement.

Question 31

A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 3. What is the most likely diagnosis?

Explanation

DISCUSSION: Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization.
REFERENCES: Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.
Lee JK, Yao L: Stress fractures: MR imaging. Radiology 1988;169:217-220.

Question 32

A 30-year-old patient has acetabular dysplasia and moderate secondary osteoarthrosis. Which of the following studies will best help predict the success of periacetabular osteotomy?

Explanation

DISCUSSION: Improvement in the appearance of the hip joint on functional radiographic evaluation (abduction/adduction views) has been shown to be predictive of outcome following joint preserving surgery. CT and MRI findings have not been shown to be predictive of outcome.
REFERENCE: Murphy S, Deshmukh R: Periacetabular osteotomy: Preoperative radiographic predictors of outcome. Clin Orthop 2002;405:168-174.

Question 33

Autosomal dominant

Explanation

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

Question 34

An active, right-handed 71-year-old woman fell on her left shoulder and sustained the injury shown in the radiographs in 52a and 52b and the CT scan in 52c. Management should consist of

Explanation

Prosthetic hemiarthroplasty is the accepted form of treatment for badly displaced fractures and fracture dislocations, including 4-part fractures, head splitting fractures and fractures with impression defects involving more than 45 % of the humeral head. Displacement is classified as >1cm or angulated > 45 degrees. About 15% of all shoulder fx’s are considered displaced.

Question 35

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

Explanation

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

Question 36

Figures below represent the radiographs obtained from a 37-year-old man with severe right knee pain. He has a history of prior tibial osteotomy for adolescent tibia vara but notes residual bowing of his legs. On examination, he is 5'8" tall and weighs 322 pounds. He has a waddling gait with a bilateral varus thrust and 20° varus deformity of both legs. His right knee range of motion is 0° to 120° with a fixed varus deformity. What is the best next step?

Explanation

DISCUSSION:
This patient has severe, uncorrectable varus deformity and pain from end-stage osteoarthritis secondary to prior adolescent tibia vara. Although he is young to consider arthroplasty, this option is likely to give him the most functional limb, compared with arthrodesis with a long antegrade nail. During arthroplasty surgery, his knee will likely require extensive medial release to achieve anatomic limb alignment. Standard components in total knee arthroplasty likely would result in lateral instability, so this option is
not the best answer. The best choice is total knee arthroplasty with a constrained device, which adds constraint to the knee to provide balance.

Question 37

What is the current 5-year survival rate for patients with classic nonmetastatic, high-grade osteosarcoma of the extremity?

Explanation

DISCUSSION: Multidisciplinary treatment combining systemic chemotherapy and adequate surgical resection has resulted in a 5-year survival rate of 70% in patients with nonmetastatic osteosarcoma of the extremity . The advent of effective chemotherapy has increased the overall survival rate from 20% to 70% in current studies.
REFERENCES: Arndt CA, Crist WM: Common musculoskeletal tumors of childhood and adolescence. N Engl J Med 1999;341:342-352.
Glasser DB, Lane JM, Huvos AG, Marcove RC, Rosen G: Survival, prognosis, and therapeutic response in osteogenic sarcoma: The Memorial Hospital experience. Cancer 1992;69:698-708.

Question 38

Figures 1a and 1b are the MR images of a 69-year-old woman with bilateral leg pain that is worse with ambulation. She feels better when she is sitting down or leaning on a grocery cart. Which condition or structure is indicated by the arrows?

Explanation

DISCUSSION
This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable.
A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion.
RECOMMENDED READINGS
Epstein NE, Baisden J. The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration. Surg Neurol Int. 2012;3(Suppl 3):S157-66. doi: 10.4103/2152-7806.98576. Epub 2012 Jul 17. PubMed PMID: 22905322. View Abstract at PubMed
Xu R, McGirt MJ, Parker SL, Bydon M, Olivi A, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine (Phila Pa 1976). 2010 May 1;35(10):1044-53. PubMed PMID: 20173680. View Abstract at PubMed

Question 39

A 29-year-old woman is seen in the emergency department with a 24-hour history of severe back and leg pain precipitated by weight-lifting. The patient reports bilateral leg pain and is unable to urinate. She has dense anesthesia in the perineal region on examination. A MRI scan is shown in Figure 38. The patient is taken to surgery urgently. What is her prognosis for recovery? Review Topic

Explanation

The patient with cauda equina syndrome should be taken to surgery urgently to provide the best chance of symptom resolution. However, many studies indicate that patients with cauda equina syndrome do not return to a completely normal status even following urgent surgery. Whereas pain is typically relieved after surgery, other deficits, especially bladder and sexual dysfunction, may persist. Particularly in light of the patient's severe saddle anesthesia, she may have a poor prognosis for recovery of normal bladder function.

Question 40

A 46-year-old man with a sacral chordoma is treated with sacrectomy.

Explanation

DISCUSSION
Complications frequently occur following treatment for spinal disorders. Postsurgical morbidity may range from minor complications such as urinary tract infection to death. Wound infections are among the most commonly encountered complications following any surgical intervention; however, their incidence after spine surgery has been reported to be in the range of only 1% to 6%. Meanwhile, risk for adjacent segment degeneration, particularly following a fusion procedure performed with an interbody device, has been documented as high as 30%. Pressure ulcers can occur when spinal injuries are treated with rigid orthoses, especially in individuals who are immobile. Risk for pressure sores and decubiti is further elevated in patients who are obtunded and cannot communicate regarding pain levels and their need to mobilize. Hardware failure may occur following any instrumented spine procedure, but risk for this complication is elevated in the event of pseudarthrosis or in settings in which no fusion is performed.
In the recent work of Lee and associates, hardware failure was the only complication encountered among patients who were treated with percutaneous stabilization without fusion for thoracolumbar burst fractures. Similarly, iatrogenic neurologic injury may transpire in the setting of any spinal intervention (its incidence is rare). For example, in a large cohort of
more than 10000 patients undergoing surgical treatment for spondylolisthesis, acute neurologic injury was reported in only 0.8% of cases. Postsurgical wound infection, although relatively rare in cases of elective spine surgery, is common following large tumor resection such as sacrectomy performed for treatment of chordomas.
RECOMMENDED READINGS
Eismont FJ, Norton RP, Hirsch BP. Surgical management of lumbar degenerative spondylolisthesis. J Am Acad Orthop Surg. 2014 Apr;22(4):203-13. doi: 10.5435/JAAOS-22-04-203. Review. PubMed PMID: 24668350. View Abstract at PubMed
Bransford RJ, Morgan RA. Thoracolumbar trauma. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:373-385.
Lee JK, Jang JW, Kim TW, Kim TS, Kim SH, Moon SJ. Percutaneous short-segment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective? comparative study with open short-segment pedicle screw fixation with posterolateral fusion. Acta Neurochir (Wien). 2013 Dec;155(12):2305-12; discussion 2312. doi: 10.1007/s00701-013-1859-x. Epub 2013 Sep 10. PubMed PMID: 24018981. View
Abstract at PubMed
Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 41

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Explanation

DISCUSSION: There is a negative change of calcium balance with a decrease

in intestinal absorption and an increase in urinary calcium loss. The reduction of

intestinal absorption is accompanied by reduced circulating concentrations of total, but

not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 42

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Explanation

The recent experience of a large clinical cohort revealed the most likely risk factors as being female gender, age younger than 40, small components, and a diagnosis of hip dysplasia causing osteoarthritis. Failure was least likely among men and after procedures involving larger components. These data have prompted some authors to caution against using metal-on-metal hip resurfacing in women and to primarily target candidates who are men younger than age 50. Small components may be more prone to failure because of malpositioning and edge loading, which have been noted to be more common in dysplasia cases.

Question 43

What is the primary sign/symptom with unidirectional posterior instability of the shoulder? Review Topic

Explanation

Posterior labral tears and pathology are usually associated with recurrent chronic injury to the shoulder. Situations such as blocking in football load the humeral head posteriorly, and may predispose to posterior labral injury. Unlike anterior and superior labral pathology, symptoms of posterior labral tears are often vague, though pain with activity is most common. Instability is usually associated with anterior labral pathology. Dead arm symptoms are associated with anterior and superior pathology, especially in throwers. Mechanical locking and catching are less common for any labral pathology. Range of motion with posterior labral pathology is usually unaffected.

Question 44

Figure 19 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Explanation

DISCUSSION: The radiograph reveals a reverse obliquely subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.
REFERENCES: Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Koval KJ, Zuckerman JD: Intertrochanteric fractures, in Rockwood & Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1635-1681.

Question 45

What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery?

Explanation

The current recommendation for antibiotic prophylaxis for major orthopaedic surgical procedures is to administer intravenous antibiotics within 1 hour of surgical incision. Redosing of antibiotics should occur 3 to 4 hours after the initial dose for procedures that extend beyond 3 to 4 hours. Little evidence supports postsurgical antibiotic use beyond 24 hours. As you move beyond 1 hour from time of administration of antibiotics, risk for infection increases and rates of bacterial cell death decline. It is not acceptable to administer presurgical antibiotics after incision.

Question 46

The force generated by a muscle is most highly dependent on its

Explanation

The cross-sectional area of a muscle determines to a great extent the force generated by the muscle. The force of a muscle contraction is controlled by the amount of myofibrils that contract; the greater the amount of contracting myofibrils, the greater the force of contraction. Fiber types have less to do with the force of contraction and more to do with the duration and speed of contraction. Muscle length affects contraction force through the Blix curve. The morphology of a muscle can affect the cross-sectional area by varying the angle of the fibers in relation to the force vector. Conditioning mostly affects duration and fatigability.

Question 47

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future?

Explanation

DISCUSSION: For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.
REFERENCES: Bleck EE: Orthopaedic Management in Cerebral Palsy. Lavenham, Suffolk, The Lavenham Press, 1987, pp 121-139.
Tachdjian MO: The neuromuscular system: Cerebral palsy, in Wickland EH Jr (ed): Pediatric Orthopaedics, ed 2. Philadelphia, PA, WB Saunders, 1990, vol 2, p 1621.

Question 48

The radiographic finding in Figure 58 is indicative of what type of acetabular fracture?

Explanation

Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:

Question 49

A 10-year-old girl sustained a Gartland type III supracondylar fracture after falling off a trampoline 1 hour ago. She has a well perfused hand but no palpable pulses. The remainder of her examination is otherwise normal. What is the next step in treatment? Review Topic

Explanation

Most supracondylar fractures are extension type and a Gartland type III is defined as a fracture that is completely displaced (ie, no posterior cortical hinge). Treatment consists of closed reduction and pinning. Controversy exists over the use of a medial and lateral pin versus multiple lateral pins. Although uncommonly needed, the surgeon should be prepared to open the fracture to achieve adequate reduction. A careful preoperative examination should be performed and documented. There is a growing body of evidence that patients with a normal neurovascular examination can be treated in a delayed fashion; nevertheless, the initial evaluation cannot be delayed.
If there is evidence of vascular compromise, the fracture should be reduced and pinned urgently and the limb reevaluated.

Question 50

A 9-year-old girl has had bilateral knee and leg pain for the past 2 years. The family has noted increasing deformity in both lower extremities. She is less than the fifth percentile for height. Examination reveals bilateral femoral bowing, mild medial-lateral laxity of the knees, and the deformities shown in the radiograph seen in Figure 3. What is the most likely diagnosis? Review Topic

Explanation

The widening, bowing, and cupping of the physes indicate some form of metabolic bone disease; therefore, the most likely diagnosis is renal osteodystrophy. The age of onset makes X-linked hypophosphatemic rickets less likely. The ground glass lesions and widening of the medullary canal characteristic of fibrous dysplasia are not present. There are no fractures creating the deformities indicating osteogenesis imperfecta. There is an asymmetry of the deformities that makes diastrophic dysplasia less likely.

Question 51

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Explanation

DISCUSSION: The lesion is typical of a subungual exostosis, which is most often found on the medial aspect of the great toe in children and young adults. The diagnosis is confirmed on radiographs and usually requires excision for relief.
REFERENCES: Lokiec F, Ezra E, Krasin E, Keret D, Wientraub S: A simple and efficient surgical technique for subungual exostosis. J Pediatr Orthop 2001;21:76-79.
Letts M, Davidson D, Nizalik E: Subungual exostosis: Diagnosis and treatment in children. J Trauma 1998;44:346-349.
Davis DA, Cohen PR: Subungual exostosis: Case report and review of the literature. Pediatr Dermatol 1996;13:212-218.

Question 52

A patient has a C6-7 herniated nucleus pulposus. What is the most likely distribution of symptoms? Review Topic

Explanation

Hyperextension
Flexion-distraction
Flexion-compression
Rotational
Pure axial load
Figure A shows a quadrangular fracture pattern of C5. These injuries are observed with flexion-compression loads.
Quadrangular fractures of the cervical spine are considered flexion teardrop fractures. However, they present with a larger anterior lip fragment compared to the classic teardrop fracture pattern. The radiographic findings include a quadrangular-shaped fragment from the anterior one-third of the vertebral body with significant posterior vertebral subluxation, angular kyphosis, and an increased interspinous space with facet subluxation due to disruption of the posterior elements. These are unstable fractures, and almost always require anterior and posterior stabilization.
Moore et al. studied the reliability of Cervical Spine Injury Severity Score to measure stability after cervical spine trauma. The classification system is based on morphologic descriptions and, secondly, on stability based on a quantifiable value. They showed that the Cervical Spine Injury Severity Score had excellent reliability with intra-observer intraclass correlation coefficients (ICC) >0.97 and inter-observer ICC >0.88.
Vaccaro et al. published the subaxial cervical spine injury classification system (SLIC). This systems involves 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status). The overall injury severity score is obtained by summing the scores from each category. They propose that SLIC < 4 can be treated non-operatively.
Allen et al. published a classification system of cervical spine injuries which breaks injuries of the subaxial spine into six phylogenic groups based on mechanism of injury. These include: 1) flexion-compression 2) vertical-compression 3) flexion-
distraction 4) extension-compression 5) extension-distraction 6) lateral flexion. Facet
dislocation
is
caused
by
flexion-distraction
force.
Figure A shows a lateral radiograph of the cervical spine demonstrating a typical flexion-compression fracture with anteriorly displaced quadrangular fragment. Illustration A shows a flexion-compression injury. Illustration B shows the mechanism of injury for a quadrangular fracture of the cervical spine. This unstable fracture pattern is characterized by anterior column failure in flexion/compression and posterior column failure in tension. Illustration C shows an illustration of the fracture morphology according to the Allen and Ferguson classification.
Incorrect Answer 1:
Hyperextension injuries
Flexion-distraction injuries usually result in facet dislocations.

Question 53

What is the most commonly reported complication following elbow arthroscopy?

Explanation

DISCUSSION: The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy.

J Bone Joint Surg Am 2001;83:25-34.
Morrey BF: Elbow complication, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 519-522.

Question 54

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Explanation

DISCUSSION: Radiographic fusion success rates are best described as slightly rather than substantially improved. Hospital stay and time to fusion also are not substantially decreased. Use of BMP does eliminate the need for autograft harvest for anterior lumbar interbody fusion/cage. The need for postoperative bracing is not altered based on graft choice. Early studies of posterolateral fusion applications appear to show a greater potential benefit of rhBMP-2 over autograft. Not all BMP formulations perform the same with regard to safety and effectiveness. Other osteoinductive proteins in clinical trials (BMP-7, GDF-5) will require individual analysis of these properties.
REFERENCE: Burkus JK, Gornet MF, Dickman CA, et al: Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech 2002;15:337-349.

Question 55

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Explanation

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
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, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 56

Primary arthrodesis is associated with which outcome when compared to outcomes associated with open reduction and internal fixation (ORIF) without arthrodesis?

Explanation

DISCUSSION
There are longitudinal, oblique, and transverse ligaments at the TMT complex that are further defined by their location as dorsal, interosseous, or plantar. There are 3 ligaments between the medial cuneiform and the second MT base, the most important of which is the oblique interosseous ligament, which is also known as the Lisfranc ligament. Plantar and dorsal oblique ligaments contribute to stability to a lesser degree. The dorsal ligaments are weakest and may be the first to fail in a Lisfranc injury.
The second MT base should be aligned with the middle cuneiform at the medial borders, and the fourth MT base should be aligned with the cuboid at the medial borders on the oblique view. The dorsal and plantar aspects of the MTs
should align with the cuneiforms/cuboid on the lateral view. Any malalignment should raise the suspicion of a Lisfranc injury. Diastasis between the second MT and the first MT/medial cuneiform complex of more than 2 mm indicates injury, as does TMT joint subluxation of 2 mm more than seen on the uninjured contralateral side. Diastasis between the first and second MT up to 2.7 mm can be normal. Another radiographic sign of injury includes avulsion fracture of the second MT base or medial cuneiform. Additional imaging studies that may be helpful in identifying subtle injuries include weight-bearing radiographs and CT or MRI images.
Two prospective randomized studies compared primary fusion with ORIF Lisfranc injuries. The second study included fracture-dislocations, whereas the first looked at primarily ligamentous injuries. Results conflicted with an earlier study demonstrating improved results (less pain, better function) with primary fusion, while a more recent study showed no difference. Neither study showed worse results with primary fusion, and the rate of secondary surgery was more common in the ORIF group (salvage arthrodesis or hardware removal).
RECOMMENDED READINGS
Solan MC, Moorman CT 3rd, Miyamoto RG, Jasper LE, Belkoff SM. Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation. Foot Ankle Int. 2001 Aug;22(8):637-41. PubMed PMID: 11527024.View Abstract at PubMed
Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28. Review. PubMed PMID: 21119138.View Abstract at PubMed
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. 1990 Dec;72(10):1519-22. PubMed PMID: 2254360.View Abstract at PubMed
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.View Abstract at PubMed
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583. View
Abstract at PubMed

Question 57

Which of the following is included in safety checks on the World Health Organization Safe Surgery Guidelines Checklist?

Explanation

The WHO Safe Surgery guidelines checklist requires that antibiotic prophylaxis be given within 60 minutes prior to skin incision. This check is performed between nurse, anesthetist and surgeon.
Preoperative checks are necessary for patient safety. On the WHO checklist, critical preoperative check points for the surgeon include: site marking, patient consent, allergies, blood loss, antibiotic prophylaxis, critical and non-routine steps, case duration, and whether preoperative imaging is readily visible.
The WHO Surgical Safety Checklist (see below) has 3 checkpoints: before induction of anesthesia, before skin incision, and before leaving the operating room.
Haynes et al. prospectively collected data on the outcomes of 3733 patients before, and 3955 patients after introduction of the Surgical Safety Checklist in 8 hospitals in 8 cities. They found an improvement in death rate (1.5% before, 0.8% after) and inpatient complication rate (11.0% before, 7.0% after). They concluded that implementation of the checklist led to reduction in death and complication rates.
Illustration A shows the WHO Surgical Safety Checklist. Incorrect Answers:

Question 58

Retrograde ejaculation is most commonly associated with what surgical approach?

Explanation

DISCUSSION: Retrograde ejaculation is the sequela of an injury to the superior hypogastric plexus. This structure needs protection, especially during anterior exposure of the lumbosacral junction. Although the superior hypogastric plexus can be injured with anterior or anterolateral spine surgery at any lumbar level, it is most at risk with anterior transperitoneal approaches to the lumbosacral junction. To avoid this complication, the use of monopolar electrocautery should be avoided during deep dissection in this region. The ideal anterior exposure starts with blunt dissection just to the medial aspect of the left common iliac vein sweeping the prevertebral tissues toward the patient’s right side.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983,

p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 59

Figure 93 is the radiograph of 3½-year-old girl who was evaluated for a progressive increase in tibia vara and complains that her feet are turning in. What is the most appropriate course of action?

Explanation

The radiograph shows advanced changes in the medial tibial growth plates. The metaphyseal-diaphyseal angle is more than 20 degrees. With these advanced changes, an osteotomy is indicated. Waiting will allow the problem to increase. Bracing (KAFO or night bar) has not been shown effective in advanced Blount disease.

Question 60

A 19-year-old college student reports a 1-week history of wrist pain following an intramural rugby match. A PA radiograph is shown in Figure 6. He denies any prior wrist injury. What is the best course of action?

Explanation

DISCUSSION: The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79.
Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.
McCallister WV, Knight J, Kaliappan R, et al: Central placement of the screw in simulated fractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 2003;85:72-77.

Question 61

Figure 8 shows the radiograph of a 76-year-old man who has knee pain and swelling. History reveals that he underwent total knee arthroplasty 18 years ago. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiograph reveals complete loss of joint space with particulate metal debris consistent with total polyethylene failure and metal-on-metal articulation. The components appear to be well fixed and minimal osteolysis is evident.
REFERENCES: Kilgus DJ, Moreland JR, Finerman GA, et al: Catastrophic wear of tibial polyethylene inserts. Clin Orthop Relat Res 1991;273:223-231.
Vince KG: Why knees fail. J Arthroplasty 2003;18:39-44.

Question 62

4 mg/kg for 48 hours

Explanation

The standard practice in the pharmacologic treatment of a spinal cord injury in the United States has been the administration of methylprednisolone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours, in accordance with the findings of the second and third National Acute Spinal Cord Injury Studies (NASCIS). Although the studies have subsequently drawn criticism for their methodology and outcomes, it has been generally accepted that beneficial neurologic outcomes were anticipated in patients who were able to start the protocol within 8 hours of their initial injury. Further improvement was noted in patients receiving the methylprednisolone within 3 hours of their injury and continuing an infusion for 48 hours. In this patient, who is outside the 8-hour treatment window, no studies have supported starting the methylprednisolone protocol at this time.

Question 63

A 38-year-old woman with metastatic thyroid carcinoma has had increasing pain in the left hip for the past 3 months. An AP radiograph and coronal T 1 -weighted MRI scan are shown in Figures 28a and 28b. Management should consist of

Explanation

DISCUSSION: The radiograph and MRI scan reveal a lytic lesion in the left femoral neck region that extends to the lesser trochanter. Although external beam radiation and radioactive iodine infusion may be helpful in controlling the local disease, the patient is at high risk for femoral neck fracture given the location of the lesion. Prophylactic surgery is indicated; therefore, the treatment of choice is a cemented bipolar hemiarthroplasty. The use of a compression hip screw and side plate or an intramedullary nail has a high likelihood of failure with disease progression. Postoperative treatment with radiation therapy and bisphosphonates is also indicated.
REFERENCES: Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.
Swanson KC, Pritchard DJ, Sim FH: Surgical treatment of metastatic disease of the femur. J Am Acad Orthop Surg 2000;8:56-65.
Clarke HD, Damron TA, Sim FH: Head and neck replacement endoprosthesis for pathologic proximal femoral lesions. Clin Orthop 1998;353:210-217.

Question 64

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

Explanation

DISCUSSION: The radiographs reveal osteoarthritis and proximal humeral head migration. Integrity of the rotator cuff must be questioned based on these radiographic changes. The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty. The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear. The radiographs do not indicate significant humeral head or glenoid erosion. Acromioclavicular arthritis is often asymptomatic.
REFERENCES: Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.
Hettrich CM, Weldon E III, Boorman RS, et al: Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg Am 2004;86:1446-1451.

Question 65

The images reveal T2-weighted MRI sequences with edema isolated to the infraspinatus. In the absence of a tear in the infraspinatus tendon, the edema is most likely due to compression of the suprascapular nerve in the spinoglenoid notch. As this pathology persists, progressive muscle atrophy and fatty infiltration can result. Compression of the suprascapular nerve in the suprascapular notch would have resulted in edema and weakness in both the supra- and infraspinatus muscles. Compression is commonly caused by cysts from the joint secondary to labral tears. A rotator cuff tear of the infraspinatus is not identified on these images, and there is no history of trauma provided. There is no evidence of an anteroinferior labral tear, nor would this be expected to result in external rotation weakness or MRI abnormality of the infraspinatus. Quadrilateral space syndrome results in compression of the axillary nerve, which supplies the teres minor. Correcr answer : C

Explanation

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?

Elbow arthroscopy with debridement

Immobilization and rest for 6 weeks

Corticosteroid injection

Open osteochondral autograft transfer

Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients

with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.

Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 66

A lower chance of failure when using an extensor mechanism allograft to address a chronic disruption of an extensor tendon is associated with

Explanation

DISCUSSION
Disruption of the extensor mechanism is a rare but devastating complication of knee arthroplasty. Primary repair is associated with a high rate of failure. The results associated with using an extensor mechanism allograft are still variable overall, but the literature on the subject supports tensioning of the allograft in full extension. In studies conducted by Burnett and associates and Nazarian and Booth, the patellar remnant is excised. The use of a fresh-frozen nonirradiated allograft is recommended, and patellar resurfacing of the insensate patella is unnecessary and potentially weakens the allograft.
CLINICAL SITUATION FOR QUESTIONS 133 THROUGH 135
A middle-age man who had an anterior cruciate ligament (ACL) reconstruction with a carbon fiber ligament as a teenager also had a debridement, synovectomy, and a medial unicompartmental arthroplasty. Fourteen years later, he has a painful knee (mainly laterally and anteriorly) that swells with activity. His range of motion is 0 to 120 degrees.

Question 67

An active 47-year-old woman with rheumatoid arthritis reports forefoot pain and deformity and has difficulty with shoe wear. Examination reveals hallux valgus and claw toes. A radiograph is shown in Figure 10. What is the most appropriate surgical treatment?

Explanation

DISCUSSION: Rheumatoid arthritis commonly affects the metatarsophalangeal joints, which become destabilized with time resulting in hallux valgus and dislocated lesser claw toes. The result is metatarsalgia as the dislocated claw toes “pull” the fat pad distally. Severe hallux valgus reduces first ray load, which compounds the metatarsalgia because the load is transferred to the lesser metatarsal heads. First metatarsophalangeal arthrodesis restores weight bearing medially and corrects the painful bunion. Metatarsal head resection slackens the toe tendons to allow correction of the claw toes by whatever means necessary and decreases plantar load over the forefoot. Rheumatoid arthritis in the first metatarsophalangeal joint will continue to progress if osteotomies or a Lapidus procedure are performed. Keller resection arthroplasty increases transfer metatarsalgia and reduces push-off power during gait. Flexor-to-extensor tendon transfer of the lesser toes does not address the metatarsalgia and does not correct the dislocation of the metatarsophalangeal joint.
REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 572.
Abdo RV, Iorio LJ: Rheumatoid arthritis of the foot and ankle. J Am Acad Orthop Surg 1994;2:326-332.

Question 68

A 7-year-old child is unresponsive, tachycardic, and has a systolic blood pressure of 50 mm Hg after being struck by a car. The patient is intubated and venous access is obtained. The secondary survey reveals an unstable pelvis. Despite adequate resuscitation, the patient continues to be hemodynamically unstable. What is the best course of action?

Explanation

DISCUSSION: The patient is hemodynamically unstable, so any treatment should be aimed at stabilization. Airway, breathing, and circulation are the most important areas to control initially; the patient has been intubated and has adequate venous access. Despite fluid resuscitation, the child remains hypotensive, indicating continued blood loss. With an unstable pelvic fracture there can be significant hemorrhage. Decreasing the pelvic volume can decrease blood loss related to the pelvic fracture. This can be done in the emergency department by applying a pelvic sling. Other means of decreasing pelvic volume include a pelvic clamp, a simple anterior frame pelvic external fixator, or a simple sheet tied around the pelvis. These maneuvers may stabilize the patient so that further evaluation and treatment can be undertaken. All of the other choices will delay stabilization and should be postponed until the patient is stabilized.
REFERENCES: Torode I, Zieg D: Pelvic fractures in children. J Pediatr Orthop 1985;5:76-84.
Eichelberger MR, Randolph JG: Pediatric trauma-initial resuscitation, in Moore EE, Eisman B, Van Way CE (eds): Critical Decisions in Trauma. St Louis, MO, CV Mosby, 1984, p 344.
Ganz R, Krushell RJ, Jacob RP, Kuffer J: The antishock pelvic clamp. Clin Orthop 1991;267:71-78.

Question 69

Which of the following structures is predominantly composed of Type 1 collagen? Review Topic

Explanation

The most common fiber type in the Anterior cruciate ligament is Type 1 collagen.
Type 1 collagen accounts for more than 90% of the total collagen content in the body. Type 1 collagen is found in bone, ligament, tendon, meniscus, annulus of intervertebral discs, skin, healed cartilage, scar tissue, and nerves.
Duthon et al present a review of the ACL and its histologic and mechanical properties. The ACL has a mean length of 32 mm and a width of 7-12 mm. They state that the ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans with multiple functional interactions.
Incorrect
1: Epithelial
2: L4 disc
Basement
Membrane is made up of Type
nucleus pulposus is composed of mostly Type
4 collagen.
2 collagen
4: Medial femoral condyle articular cartilage is comprised mostly of Type 2 collagen. 5: Dupuytren's contracture tissue is mostly Type 3 collagen.

Question 70

A 58-year-old man underwent distal radius ORIF with a volar locking plate yesterday. Preoperatively, he reported some mild sensory disturbances in the volar thumb and index finger, but had 2-point discrimination of 6mm in each finger. Now, he complains of worsening hand pain and sensory disturbances in his volar thumb and index finger. Two-point discrimination is now >10mm in these fingers. Radiographs show a well-fixed fracture in good alignment. What is the most appropriate treatment at this time?

Explanation

DISCUSSION: This patient had mild median parasthesias preoperatively that have significantly worsened postoperatively. Immediate carpal tunnel release is the most appropriate next step in treatment.
Mack et al reported on ten cases of acute carpal tunnel syndrome (ACTS) and six cases of nerve contusion in patients with acute median neuropathy associated with blunt wrist trauma. The patients with ACTS initially had normal sensation and subsequently developed objective sensory loss (2-point discrimination greater than 15 mm) in the median nerve distribution associated with severe wrist pain. In contrast, patients with nerve contusion injuries had immediate sensory loss and symptoms were nonprogressive. Four of five patients with ACTS who underwent carpal tunnel release within 40 hours of the onset of numbness had normal 2-point discrimination within 96 hours. Neuropathy, secondary to nerve contusion without coexisting ACTS, may be treated initially by observation.
Ford et al reported of five cases of ACTS. Four with delayed treatment had poor outcomes while the one patient with early CTR had full recovery. All patients with ACTS had increasing and severe pain in the wrist with parasthesia and impaired sensation in the median distribuation. These symptoms initially weren’t present after wrist trauma, but developed rapidly in the next few hours.

Question 71

A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure addresses which of the following issues?

Explanation

DISCUSSION: The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, fusion, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship. In Carr’s series, pre- and postoperative radiographic analysis for tibiotalar impingement, lateral talocalcaneal angle, and talonavicular subluxation was performed, with improvement to a normal range seen in the cases analyzed. Bednarz did a radiographic analysis and showed an average increase of 8 mm in hindfoot height, 9 degrees in lateral talocalcaneal angle, and 11 degrees in lateral talar declination angle. Rammelt found that compared with the unaffected side, the talocalcaneal height was corrected by 61.8%, the talus-first metatarsal axis by 46.5%, the talar declination angle by 38.5% and the talocalcaneal angle by 35.4%. Based on these three references, this procedure ultimately addresses the lost hindfoot height, subtalar arthritis (joint is fused), ankle impingement (improvement of the talus 1st MT axis), and peroneal impingement. It does not address hindfoot valgus. However, the deformity after a calcaneus fracture is usually from lateral wall blowout and hidfoot varus

Question 72

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Explanation

EXPLANATION:
The ultrasound shows a homogeneous anechoic mass consistent with a ganglion cyst. As a benign lesion, no further workup or biopsy is required prior to a marginal surgical excision other than age-appropriate laboratory studies. An MRI study with contrast would provide no diagnostic benefit.

Question 73

-Four months after injury, the tibia is showing evidence of slow healing on radiographs. What is the optimal treatment for this potential nonunion?

Explanation

DISCUSSION FOR QUESTIONS 108 THROUGH 110:
This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.

Question 74

A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction, internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status?

Explanation

DISCUSSION: Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates. Brumback et al evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred. The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing

Question 75

A 9-year-old boy is injured while playing soccer. His examination reveals painful range of motion between 5° and 75°. There is tenderness on the medial side of his knee. There is no effusion, a grade 1A Lachman test, and severe pain over the medial epicondyle of the knee. Varus stress is negative and pain is elicited with valgus stress. Initial radiographs were negative for abnormality. What is the next diagnostic step?

Explanation

This patient likely has a physeal injury to the distal femoral physis. Stress radiographs or an MRI scan will most reliably reveal this diagnosis. The growth plate, when injured, is most commonly fractured through the hypertrophic zone of cartilage, its weakest point. This patient is optimally treated in a cylindrical or long-leg cast.

Question 76

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

Question 77

Radiographs of a pediatric patient reveal a suspected osteosarcoma of the distal femur. Additional staging studies should consist of

Explanation

DISCUSSION: CT of the abdomen and pelvis is not part of the staging of osteosarcoma. Staging studies should consist of CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan. The MRI should be obtained prior to the biopsy.
REFERENCE: O’Reilly R, Link M, Fletcher B, et al: NCCN pediatric osteosarcoma practice guidelines: The National Comprehensive Cancer Network. Oncology (Huntingt) 1996;10:1799-1806, 1812.

Question 78

A professional baseball player has had intermittent, mild shoulder pain for the past 2 years. Nonsurgical management has consisted of anti-inflammatory drugs. Examination reveals atrophy of the infraspinatus muscle but not the supraspinatus. There is weakness in external rotation with the arm at his side but not at 90 degrees of abduction. He has no weakness or pain with resisted abduction. Electromyography confirms an isolated lesion of the suprascapular nerve branch to the infraspinatus. He is otherwise neurologically intact. An MRI scan of the shoulder shows no cysts but confirms atrophy of the infraspinatus muscle. What is the next most appropriate step in management?

Explanation

DISCUSSION: Suprascapular nerve injuries are more commonly seen in athletes who participate in overhead activities. When a patient is evaluated for posterior shoulder pain and infraspinatus muscle weakness or atrophy, electrodiagnostic studies are an essential part of the evaluation. In addition, imaging studies are indicated to exclude other diagnoses that can mimic a suprascapular nerve injury. Initial management should consist of cessation of the aggravating activity along with an organized shoulder rehabilitation program. If nonsurgical management fails to provide relief within 6 months to 1 year, surgical exploration of the suprascapular nerve should be considered. Release of the spinoglenoid ligament with resultant suprascapular nerve decompression may result in pain relief and a return of normal shoulder function. In this patient, who has a chronic neuropathy and mild symptoms, surgery is indicated only if nonsurgical management fails to provide relief and he is unable to perform at his position.
REFERENCES: Cummins CA, Bowen M, Anderson K, et al: Suprascapular nerve entrapment at the spinoglenoid notch in a professional baseball pitcher. Am J Sports Med 1999;27:810-812.
Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment. J Bone Joint Surg Am 2000;82:415-424.
Ferretti A, De Carli A, Fontana M: Injury of the suprascapular nerve at the spinoglenoid notch: The natural history of infraspinatus atrophy in volleyball players. Am J Sports Med 1998;26:759-763.

Question 79

Which of the following 50-year-old patients with an irreparable rotator cuff tendon is the best candidate for an isolated latissimus dorsi muscle transfer? Review Topic

Explanation

Patients with superior escape or a torn subscapularis (demonstrated by a positive lift-off test) will not benefit from a latissimus dorsi transfer, even if combined with a pectoralis muscle transfer. In the study by Iannotti and associates, women had poorer outcomes than men, and patients with preoperative elevation below shoulder level or 90 degrees also had poorer outcomes. Patients with complete loss of external rotator function have worse function after latissimus dorsi transfer than patients with some external rotation function.

Question 80

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

Explanation

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

Question 81

A 74-year-old patient is seen for follow-up 6 weeks after undergoing a total shoulder arthroplasty for glenohumeral osteoarthritis. The patient missed the 2-week follow-up appointment and is currently wearing a sling. The incision is well healed with no signs of breakdown. Examination reveals that passive range of motion is forward elevation of 90 degrees, external rotation at the side 0 degrees, and internal rotation up the back is to the level of the greater trochanter. A radiograph shows no signs of fracture or dislocation. What is the next most appropriate management for this patient? Review Topic

Explanation

The patient has a postoperative stiff shoulder. The patient missed follow-up appointments and has not been participating in physical therapy for stretching. Based on normal radiographic findings, the shoulder is not dislocated; therefore, physical therapy should begin immediately. Continued sling immobilization will further worsen the stiffness. There is no indication of an infection or rotator cuff tear. Deep venous thrombosis would present with abnormal swelling and pain.

Question 82

A 65-year-old woman who works as a florist has had pain in her right elbow for the past 6 months after lifting a flowerpot. MRI scans are shown in Figures 55a and 55b. The area of increased signal intensity seen in Figure 55b most likely represents which of the following findings?

Explanation

DISCUSSION: The MRI scans reveal a chronic distal biceps tendinitis. The T₁-weighted scan shows the anatomic detail of the biceps tendon, and the T₂-weighted scan shows increased signal caused by edema surrounding the tendon. The T₁-weighted scan is not consistent with an antecubital lipoma. The chronicity of the lesion makes hematoma unlikely. An aneurysm usually appears with blood flow through the region and is dark on T₁- and T₂-weighted scans.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 492-504.
Morrey B: Distal biceps tendon rupture, in Master Techniques in Orthopedic Surgery:

The Elbow, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2002, pp 173-192.

Question 83

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Explanation

This patient has sustained a displaced extension-type supracondylar fracture. The most commonly affected nerve in this setting is the anterior interosseous nerve (AIN). This will affect thumb IP flexion.
The most common neurapraxia after pediatric extension-type supracondylar fractures involve the AIN. It supplies the FPL (thumb IP flexion), the pronator quadratus, and the FDP of the index/long fingers. Subsequently, patients are often unable to make an “a-ok” sign. Most of these neuropraxias resolve without complication. The ulnar nerve is most commonly implicated with flexion-type supracondylar fractures.
Abzug et al. review management of supracondylar fractures. They note that the AIN
is most commonly injured nerve in extension type supracondylar fractures. They note that nerve injuries often resolve within 6-12 weeks.
Babal et al. completed a meta-analysis to determine the risk of neurapraxia associated with pediatric supracondylar fractures. The rate of traumatic neurapraxia was 11.4% amongst 5000 patients. The AIN was affected 34.1% of the time. AIN neurapraxia was most common in extension type injuries.
Figures A and B show an AP and lateral radiographs of a displaced pediatric supracondylar fracture
Incorrect Answers

Question 84

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present.
REFERENCES: McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.
Thometz J: Tarsal coalition. Foot Ankle Clin 2000;5:103-118.

Question 85

Figures 15a through 15c show the radiographs of a 23-year-old football player who was injured when another player fell on his flexed and planted foot. He reports severe pain in the midfoot with a feeling of numbness on the dorsum of the foot, and he is unable to bear weight on the limb. Examination reveals mild swelling. Management should consist of

Explanation

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,

pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 86

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management? Review Topic

Explanation

In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.

Question 87

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of

Explanation

DISCUSSION: The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.
REFERENCES: Ahmad CS, ElAttrache NS: Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 2004;23:665-676.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 101-111.

Question 88

A 55-year-old woman with a 15-year history of systemic lupus erythematosus has had left shoulder pain for the past 3 months. She reports that the pain has grown progressively worse over the past few months, and her shoulder function is severely limited. She is presently being treated with azathioprine and has used corticosteroids in the past. AP and axillary radiographs are shown in Figures 19a and 19b, and MRI scans are shown in Figures 19c and 19d. Which of the following forms of management will yield the most predictable pain relief and return of shoulder function?

Explanation

DISCUSSION: Prosthetic shoulder arthroplasty has been shown to provide predictable results for treating stage III and stage IV osteonecrosis of the humeral head. The decision to resurface the glenoid (total shoulder arthroplasty versus humeral hemiarthroplasty) usually is made based on the radiographic and intraoperative appearance of the glenoid. Core decompression of the humeral head has been reported to be effective for earlier stages (pre collapse) but would not be appropriate for a patient with stage IV disease.
REFERENCES: Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: Results of replacement. J Shoulder Elbow Surg 2000;9:177-182.
L’Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: Clinical course and radiographic predictors of outcome. J Shoulder Elbow Surg 1996;5:355-361.
Cruess RL: Steroid-induced avascular necrosis of the head of the humerus: Natural history and management. J Bone Joint Surg Br 1976;58:313-317.

Question 89

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 90

03 Figure 33 shows the radiograph of a 48-year-old man who sustained a fracturedislocation of his dominant arm and a significant head injury in a fall from a roof. Eight days after injury he is medically cleared for surgery. Treatment should consist of

Explanation

As stated, the radiograph shows a multiple-part fracture dislocation of the
proximal humerus, with what appears to be a head-splitting component. Answer 1
(rotator cuff repair) is certainly not indicated yet – maybe as a secondary procedure
once the bone is healed, or as a subsequent procedure while dealing with the fracture.
Similar to question #109, there is no need to resurface the glenoid unless we have
evidence of significant degenerative changes, which we don’t. ORIF of head-splitting
fractures hasn’t had any promising results, and AVN is always an issue here. Both
articles referenced discuss the outcomes of acute hemiarthroplasty in the
treatment of 3- and 4-part proximal humerus fractures versus late replacement for
failed non-operative treatment, and the benefits of early management in regards
to difficulty of procedure, post-operative pain, and functional ROM/strength outcomes. Arthrodesis is a viable option, but not with the good results of hemiarthroplasty as evidenced here.
Goldman RT, Koval KJ, Cumom F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.
Norris TR, Green A, McGuigan FX: Late prosthetic shoulder arthroplasty for displaced proximal humerus fracture. J Shoulder Elbow Surg 1995;4:271-280.
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Question 91

Which of the following best describes athletic pubalgia?

Explanation

DISCUSSION: Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures.
REFERENCES: Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC: MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270-277.

Question 92

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Explanation

DISCUSSION: Inflammation, overload, or decreased matrix production may lead to cartilage degeneration. During the second stage of articular cartilage degeneration with osteoarthritis, there is increased chondrocyte activity with proliferation and increased production of extracellular matrix. At the same time, there is an increase in catabolic activity with removal of damaged matrix to facilitate matrix remodeling. Chondrocyte repair response decreases with aging. Matrix degradation includes decreased proteoglycan production, less aggregation, and shorter glycosaminoglycan chains.
REFERENCE: Buckwalter JA, Mankin HJ, Grodzinsky AJ: Articular cartilage and osteoarthritis. Instr Course Lect 2005;54:465-480.

Question 93

A 28-year-old woman has left shoulder pain and a tender soft-tissue mass. Based on the MRI scan and biopsy specimens shown in Figures 74a through 74c, what is the most likely diagnosis?

Explanation

DISCUSSION: Schwannomas (neurilemomas) occur at all ages but are most frequently seen in persons between the ages of 20 and 50 years. MRI features of schwannomas are fairly nonspecific, but when they are associated with a large named nerve, the identification of a mass in continuity with that nerve is highly suggestive of a schwannoma. Most have a fairly homogeneous appearance with a high water content and often fusiform shape. Classically, the histology shows alternating Antoni A (dense spindle cell region) areas and Antoni B (loose myxoid tissue) areas. They also demonstrate uniform intense immunostaining with S-100 protein.
REFERENCES: Damron TA, Sim FH: Soft-tissue tumors about the knee. J Am Acad Orthop Surg 1997;5:141-152.
Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 1146-1167.

Question 94

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

Explanation

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

Question 95

A 25-year-old male professional lacrosse player collides with another player, with injury resulting from a knee impacting the athlete’s thigh. He has immediate pain in the mid-thigh area and is unable to return to the game because of difficulty with running. Examination reveals developing swelling in the anterior mid-thigh area. The thigh compartments are soft, and he is able to extend his knee against gravity. Knee flexion at 90° gives him discomfort in the thigh but no knee pain. The knee and hip examinations are otherwise unremarkable. Plain films of the femur are negative. What is the best next step?

Explanation

The lesion seen in the MRI scan in Figure 1 is treated with a marrow stimulation technique. The reparative tissue formed by this technique is predominantly composed of
A. only type 1 collagen.
B. only type 2 collagen.
C. type 1 and type 2 collagen.
D. neither type 1 or type 2 collagen.
The MRI scan shows a full-thickness cartilage defect. When treated with a marrow stimulation technique, such as a microfracture, the reparative tissue is fibrocartilage. Unlike hyaline cartilage, which is composed of only type 2 collagen, fibrocartilage is composed of both type 1 and type 2 collagen.
15- Figures 1 and 2 are the radiographs of a 58-year-old retired laborer who has had many years of right shoulder pain. He initially experienced relief with anti-inflammatory medication over the past year, but this no longer provides him pain relief. He has pain with overhead activities and is dissatisfied with his shoulder function. Examination indicates active and passive forward elevation to 130°, full strength with external rotation, and a negative belly press test. MRI demonstrates an intact rotator cuff. What is the best next step in treatment?
A. Anatomic total shoulder arthroplasty (TSA)
B. Hemiarthroplasty
C. Reverse shoulder arthroplasty
D. Arthroscopy with debridement and biceps tenodesis
The patient has glenohumeral osteoarthritis based on the radiograph. His examination demonstrates limited motion and no significant rotator cuff pathology – full strength with external rotation, negative belly press, and no pseudoparalysis. Of all the answer choices, an anatomic TSA would be the most appropriate treatment option. Hemiarthroplasty does not address glenoid pathology and provides inferior pain relief and function, compared with TSA. A reverse shoulder arthroplasty is utilized for patients with degenerative shoulder changes in conjunction with irreparable rotator cuff pathology. Shoulder arthroscopy with debridement and biceps tenodesis is not appropriate for those with severe degenerative changes of the shoulder.
16- According to the MRI scan shown in Figure 1, which pathologic finding is expected to be encountered during arthroscopy?
A. Figure 2
B. Figure 3
C. Figure 4
D. Figure 5
The sagittal MRI scan is a clear example of a double posterior cruciate ligament (PCL) sign. This sign has a high specificity for a displaced bucket handle tear of the medial meniscus as seen in Figure 4. The other arthroscopic
images show a flap tear of the medial meniscus (Figure 2), anterior cruciate ligament tear (Figure 3), and a full thickness articular cartilage defect (Figure 5). Other less likely causes of a double PCL sign include intermeniscal ligament, meniscofemoral ligaments, loose bodies, osteophytes, and fracture fragments. Correct answer : C 13
17- Figures 1 and 2 are the radiographs of a 21-year-old football player who underwent anterior cruciate ligament (ACL) reconstruction with patellar tendon autograft 1 year ago. He reports mild stiffness in his knee. Upon examination, he has a negative Lachman test, trace effusion, and range of motion from 0 to 85° of knee flexion. Which factor is most contributory to his examination findings?
A. Incorrect graft choice
B. Improper tunnel position
C. Tibial graft-tunnel mismatch
D. Femoral fixation at 80° flexion
Technical failure is the most common reason for ACL reconstruction failure. Tunnel position is the most frequent cause of technical failure. Malpositioning of the tunnel affects the length of the graft, causing either decreased range of motion or increased graft laxity. This patient has anterior and vertical placement of his femoral tunnel, which has been shown to cause stiffness in knee flexion. Although graft choice is an important factor when planning ACL reconstruction, overall outcomes with autograft tissues are fairly similar. Fixation of the graft at the femoral or tibial end is not as important as tunnel position. Fixing the graft in flexion can cause extension loss when isometry is not achieved, but this condition is not touched upon in this scenario.

Question 96

What is the most frequent complication of percutaneous repair of an acute Achilles tendon rupture?

Explanation

DISCUSSION: Sural nerve entrapment is the major risk of percutaneous repair. A small mini-open technique with a suture guide can obviate that issue. Re-rupture rates after surgical repair are approximately 3%. Infection and wound problems are rarely encountered with percutaneous repair; they are issues with open repair.
REFERENCES: Aracil J, Pina A, Lozano JA, et al: Percutaneous suture of Achilles tendon ruptures. Foot Ankle 1992;13:350-351.
Sutherland A, Maffulli N: A modified technique of percutaneous repair of the ruptured Achilles tendon. Oper Orthop Traumatol 1998;10:50-58.
Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am

2002;84:161-170.

Question 97

A polytrauma patient sustains a right bicondylar tibial plateau fracture and a right humeral shaft fracture both treated with open reduction and internal fixation. He also underwent statically locked intramedullary nailing of a left femoral shaft fracture. What is the appropriate weightbearing status?

Explanation

The standard treatment for a bicondylar tibial plateau fractures is a period of post-operative non-weight bearing.
Tingstad et al found favorable results of immediate weightbearing on humeral shaft fractures treated with plating and full weightbearing did not have any effect on the union or malunion rates.
Brumback et al evaluated the feasibility, safety and efficacy of immediate
weightbearing after treatment of femoral shaft fractures with statically locked IM nail. All the patients went on to union and no loss of fixation occurred.
OrthoCash 2020

Question 98

A 34-year-old man underwent open reduction and internal fixation of a closed both bones forearm fracture 11 months ago. The radiographs shown in Figures 32a and 32b reveal a 3-mm gap and loose screws. What is the best treatment option?

Explanation

DISCUSSION: In an atrophic nonunion with a good soft-tissue envelope, adequate plating with cancellous bone graft can be used to span defects of up to 6 cm. Cortical graft from the fibula or iliac crest is not necessary. BMP-7 is a bone graft substitute and should not be used alone in this patient because the hardware is loose.
REFERENCES: Ring D, Allende C, Jafarnia K, et al: Ununited diaphyseal forearm fractures with segmental defects: Plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am 2004;86:2440-2445.

Question 99

Figures 29a and 29b show the radiograph and CT scan of a 48-year-old man who has diffuse spinal pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The studies show marginal syndesmophyte formation characteristic of ankylosing spondylitis. These patients typically have diffuse ossification of the disk space without large osteophyte formation. DISH typically presents with large osteophytes, referred to as nonmarginal syndesmophytes. In this patient, the zygoapophyseal joints are fused rather than degenerative as would be seen in rheumatoid arthritis, and the costovertebral joints are also fused. Osteopetrosis does not normally ankylose the disk space.
REFERENCES: McCullough JA, Transfeldt EE: Macnab’s Backache, ed 3. Baltimore, MD, Williams and Wilkins, 1997, pp 190-194.
Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott, Williams and Wilkins, 2003, pp 141-151.

Question 100

A year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Postreduction CT is shown in 2 through What is the most appropriate definitive surgical treatment?

Explanation

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following abnormalities has been observed in a higher than expected frequency in patients with metal-on-metal hip bearings?

Options:

Renal cell carcinoma
Leukocyte chromosomal aberrations
Carcinomas of the gastrointestinal tract
Soft-tissue sarcomas
Thyroid carcinoma

Correct Answer: Leukocyte chromosomal aberrations

Explanation:

Question 2:

What are the optimal conditions for leaving the acetabular shell in place, replacing the acetabular liner, and grafting the osteolytic defect shown in Figure 39?

Options:

Nonmodular implant
Instability
Well-designed, well-fixed modular implant
Complete radiolucency of the acetabular component
Migration of the acetabular component

Correct Answer: Well-designed, well-fixed modular implant

Explanation:

DISCUSSION: Dense pods of ingrowth into the porous coating of cementless ingrowth sockets are seen. Channels through the non-ingrown portion allow access to the trabecular bone of the ilium. Polyethylene wear debris can enter these areas through screw holes. Expansile, lytic lesions can result, which can become large without compromising implant fixation. Loosening is late and results from catastrophic loss of bone. A well-fixed acetabular component with a modular design, a well-designed locking mechanism, and a good survivorship history is a candidate for exchange of the liner and grafting of the osteolytic lesion.
REFERENCES: Ries MD: Complications in primary total hip arthroplasty: Avoidance and management. Wear. Instr Course Lect 2003;52:257-265.
Dumbleton JH, Manley MT, Edidin AA: A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty 2002;17:649-661.
Pelicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 175-180.

Question 3:

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 4:

Which of the following factors are considered prognostic of survival in patients with soft-tissue sarcomas?

Options:

Patient age, surgical margin, and neurovascular invasion
Tumor grade, patient age, and tumor depth
Tumor grade, tumor depth, and surgical margin
Tumor size, patient age, and tumor depth
Tumor size, tumor grade, and tumor depth

Correct Answer: Tumor size, tumor grade, and tumor depth

Explanation:

Question 5:

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Options:

Use a translation program to print out instructions in the family’s native language and ask if they have questions
Have the patient translate the instructions if his or her English skills are adequate
Use a member of the hospital’s nonmedical staff to translate
Use a professional medical interpreter

Correct Answer: Use a professional medical interpreter

Explanation:

DISCUSSION
Ideally, professional medical interpreters should be used in situations involving language difficulties. Printed instructions are helpful, but, if there is a language barrier, these instructions cannot substitute for conversing and answering questions. Asking the child to translate (no matter how fluent he or she may be) is suboptimal. Nonmedical staff may not be fluent enough to adequately translate medical terms.
RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 6:

In a patient with vertebral tuberculosis, which of the following characteristics is most predictive of progression of the kyphosis?

Options:

Involvement of the vertebral body and posterior elements
Involvement of the thoracic vertebrae
Involvement of the lumbar vertebrae
Age of the patient
Pretreatment degree of kyphosis

Correct Answer: Involvement of the vertebral body and posterior elements

Explanation:

DISCUSSION: In patients with vertebral tuberculosis, involvement of the anterior and posterior elements creates an instability and severe kyphotic collapse can occur. This characteristic has been shown to have a stronger association than level of involvement, age, or pretreatment degree of deformity. In the absence of instability, anterior growth can resume after treatment, leading to a decrease in the deformity.
REFERENCES: Rajasekaran S: The natural history of post-tubercular kyphosis in children: Radiological signs which predict late increase in deformity. J Bone Joint Surg Br
2001;83:954-962.
Rajasekaran S, Shanmagasundaram TK, Prabhakar R, Dheenadhayalan J, Shetty AP, Shetty DK: Tuberculous lesions of the lumbosacral region: A 15-year follow-up of patients treated by ambulant chemotherapy. Spine 1998;23:1163-1167.

Question 7:

Options:

The posterior bundle demonstrates the greatest change in tension from flexion to extension.
The posterior bundle is isometric.
The anterior bundle becomes tight in flexion and lax in extension.
The anterior and posterior bundles are isometric.

Correct Answer: The posterior bundle demonstrates the greatest change in tension from flexion to extension.

Explanation:

Question 8:

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 9:

Options:

figure-of-8 splinting to maintain the clavicle in a reduced position.
an exercise program to stabilize the joint in a reduced position.
elective reconstruction of the sternoclavicular joint ligaments.
reassurance and local symptomatic treatment.
closed reduction and temporary pin fixation to stabilize the joint.

Correct Answer: reassurance and local symptomatic treatment.

Explanation:

Question 10:

Options:

Polymorphonuclear leukocytes
Extracellular metal-wear debris
Cement particles within the macrophages
Lymphocytes and plasma cells

Correct Answer: Lymphocytes and plasma cells

Explanation:

Question 11:

Options:

Musculocutaneous nerve
Posterior humeral circumflex artery
Axillary nerve
Cephalic vein
Anterior humeral circumflex artery

Correct Answer: Musculocutaneous nerve

Explanation:

Question 12:

Options:

Application of a rigid collar and follow-up radiographs in 1 week
Gardner-Wells tongs and in-line traction
Hospital admission and frequent neurologic checks
Immobilization of the neck, followed by CT with reconstruction
Flexion-extension radiographs to evaluate for any occult instability

Correct Answer: Immobilization of the neck, followed by CT with reconstruction

Explanation:

DISCUSSION: A high level of suspicion must be given for a fracture in any patient with ankylosing spondylitis who reports neck pain, even with minimal or no trauma. The neck should be immobilized in its normal position, which is often kyphotic, and plain radiographs should be obtained. If no obvious fracture is seen, CT with reconstruction should be obtained. The placement of in-line traction can have catastrophic effects because it may malalign the spine.
REFERENCES: Brigham CD: Ankylosing spondylitis and seronegative spondyloarthropathies, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998,
pp 724-727.
McDowell GS, Cammisa FP, Eismont FJ: Hyperextension injuries of the cervical spine, in Levine AM, Eismont FJ, Garfin SR, Zigler JE (eds): Spine Trauma. Philadelphia, PA,
WB Saunders, 1998, pp 372-374.

Question 13:

Lymphatic metastasis is a common feature of which of the following lesions?

Options:

Liposarcoma
Nodular fasciitis
Rabdomyosarcoma
Malignant fibrous histiocytoma
Extra-abdominal desmoid tumor

Correct Answer: Rabdomyosarcoma

Explanation:

Question 14:

- A 19-year-old man sustains a complete spinal cord injury at the C7 level as a result of diving into a lake. He has a blood pressure of 90/50 mm Hg, a pulse of 60/min, and respirations of 20/min. These values most likely signify

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 15:

Options:

First metatarsophalangeal arthrodesis
Soft-tissue interposition arthroplasty
First metatarsophalangeal total joint arthroplasty
First metatarsophalangeal resurfacing hemiarthroplasty
Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer: First metatarsophalangeal arthrodesis

Explanation:

DISCUSSION: All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray.
REFERENCES: Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.
Myerson MS, Schon LC, McGuigan FX, et al: Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int
2000;21:297-306.

Question 16:

A knock-out mouse for the Vitamin D receptor has which of the following phenotypes?

Options:

Osteopetrosis
Renal failure
Rickets
Jansen-type metaphyseal dysplasia
Compensatory hyperparathyroidism and no skeletal phenotype

Correct Answer: Rickets

Explanation:

Question 17:

Among the ankle arthroscopy portals described below, which portal is at highest risk for serious complications?

Options:

Posterolateral: lateral to the Achilles tendon
Anterolateral: lateral to the peroneus tertius tendon
Anteromedial: medial to the tibialis anterior tendon
Posteromedial: medial to the Achilles tendon

Correct Answer: Posteromedial: medial to the Achilles tendon

Explanation:

DISCUSSION
All of the portals listed pose risk for some structures. Because they have been shown to be the safest, the most common anterior portals are the anteromedial and the anterolateral. The safest posterior portal is the posterolateral portal. Because of the location of the posterior medial tendons and the neurovascular bundle, the posteromedial portal is at highest risk for serious complications.
RECOMMENDED READINGS
Golanó P, Vega J, Pérez-Carro L, Götzens V. Ankle anatomy for the arthroscopist. Part I: The portals. Foot Ankle Clin. 2006 Jun;11(2):253-73, v. Review. PubMed PMID: 16798511.
View Abstract at PubMed
Ferkel RD, Hommen JP. Arthroscopy of the ankle and foot. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:1641-1726.
Figure 90 is an intraoperative image showing the medial approach to the elbow. The arm is proximal and to the right, and the forearm is distal and to the left. The blue arrow points to the medial epicondyle. A black arrow points to a piece of glass in a nervous structure. This injury most likely would affect which distal muscular structure?
Extensor digiti minimi
Flexor digitorum superficialis (FDS) to the index finger
77
Abductor pollicis brevis
First dorsal interossei
DISCUSSION
The intraoperative image shows a piece of glass splitting the ulnar nerve in the cubital tunnel. The extensor digiti minimi is innervated by the radial nerve. The FDS to the index finger and the abductor pollicis brevis are innervated by the median nerve. The first dorsal interossei is the last muscle innervated by the ulnar nerve.
RECOMMENDED READINGS
Miller MD. Review of Orthopaedics. 3rd ed. New York, NY: Saunders; 2000.
Anderson JE. Grant’s Atlas of Anatomy. 8th ed. Baltimore, MD: Williams & Wilkins; 1983.

Question 18:

Options:

Numbness over dorsal aspect of the foot, weakness to gluteus medius
Numbness over plantar foot, weakness to his gastrocsoleus complex
Numbness over medial malleolus, and weakness to quadriceps
Numbness over medial calf, weakness in his EHL
Numbness over lateral malleolus, weakness to hip adduction

Correct Answer: Numbness over medial calf, weakness in his EHL

Explanation:

The MRI demonstrates a left paracentral L4/5 disc protrusion which leads to compression of the traversing (descending) left L5 nerve root. Numbness over the dorsal aspect of the foot and weakness to gluteus medius is consistent with a L5
radiculopathy.
While nerve root innervation shows some variability by patient, L5 is "characteristically" responsible for the sensation to the dorsal aspect of the foot, ankle dorsiflexion (tibialis anterior - along with L4), great toe extension (EHL), and hip abduction (gluteus medius).
Suri et al. reported on specific physical exam findings that significantly increased the likelihood of nerve root impingement at specific lumbar levels. They found: L2 was associated with decreased anterior thigh sensation. L3 was associated with a positive femoral stretch test. L4 was associated with a blunted patellar reflex, decreased medial ankle sensation or a positive crossed femoral stretch test. L5 was associated with was associated with decreased hip abductor strength.
Luri et al. reported 8-year follow up on the patients in the spine patient outcomes research trial who underwent surgical vs. conservative care for treatment of lumbar herniated disc. They found that patients who underwent surgical treatment had superior results that were maintained at 8 years compared to patients who underwent conservative management.
Figure A is an axial MRI at the L4/5 disc space that shows a left paracentral disc herniation compressing the descending L5 nerve root. Illustration A identifies the structures in the MRI image. Illustration B demonstrates the dermatome, reflex and motor function associated with the L4, L5 and S1 nerve root.
Incorrect Answers:
(SBQ13PE.102) An 26-year-old male presents to your office complaining of bilateral hip and low back pain. On physical examination, he has 10 degree bilateral hip flexion contractures. An AP pelvis radiograph is demonstrated in figure A. Which of the following findings is consistent with this patient's presentation?
Review Topic
A positive flexion, adduction, internal rotation (FADDIR) test
A history of untreated slipped capital femoral epiphysis (SCFE)
A thrombophilia
Normal serum ESR and CRP
Positive Human Leukocyte Antigen B27 (HLA-B27)
The patient has large joint arthralgia and sacroiliac joint sclerosis on AP pelvis radiograph, which is consistent with ankylosing spondylitis. Patients with ankylosing spondylitis have positive Human Leukocyte Antigen B27 (HLA-B27).
Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy that affects the axial skeleton as well as large joints including the hips and knees. The most common initial site of pain is the sacroiliac (SI) joint, and is demonstrated as sacroiliitis on pelvic radiograph. Hip involvement is common, and typically manifests as hip pain and flexion contracture. Serologic studies will be typically be negative for rheumatoid factor, but positive for HLA-B27 in 90% of patients.
Kubiak et. al. review orthopaedic management of AS. Common orthopaedic manifestations include SI joint pain, hip flexion contractures, and stiffness of the cervical and lumbar spine. They report that laboratory analysis of patients with active disease will typically demonstrate mild elevation of ESR, CRP, and WBC. Patients with chronic AS may demonstrate a normocytic anemia. If HLA-B27 is negative, a high clinical suspicion should still be maintained.
Gensler et al. review the different clinical conditions that compose of juvenile-onset spondyloarthritis. They report on the different spondyloarthritides includes ankylosing spondylitis, reactive arthritis, arthropathy associated with inflammatory bowel disease, and that associated with psoriasis. They emphasize that the appearance of sacroiliac joint and spinal disease in the form of ankylosing spondylitis usually takes 5–10 years after initial symptom presentation, and therefore, a definite diagnosis can take several years leading to a delay in diagnosis.
Figure A is an AP pelvis radiograph of a skeletally mature individual demonstrating sclerosis of the SI joint indicative of sacroiliitis. Illustration A shows a axial CT image of the patient in the stem. Sclerosis and bone erosion can be seen in the sacroiliac joint.
Incorrect Answers:
osteonecrosis Answer 3: A infarctions,
of
the
femoral
epiphysis.
thrombophilia may have
osseous manifestations such as bone
which
are
not
evident
on
this
image.

Question 19:

Which of the following lumbar disk components has the highest tensile modulus to resist torsional, axial, and tensile loads? Review Topic

Options:

Nucleus pulposus
Cartilaginous end plate
Anterior longitudinal ligament
Annulus fibrosis
Cellular matrix

Correct Answer: Annulus fibrosis

Explanation:

Question 20:

Options:

humeral head arthroplasty.
observation.
arthroscopic capsular release.
grafting of the humeral head defect.
electrical stimulation.

Correct Answer: observation.

Explanation:

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 21:

Options:

resectional arthroplasty.
metatarsophalangeal joint arthrodesis.
dorsal closing wedge osteotomy.
physical therapy.
a rigid steel shank shoe with a rocker bottom sole.

Correct Answer: a rigid steel shank shoe with a rocker bottom sole.

Explanation:

Question 22:

A 75-year-old female with a longstanding history of brachial plexus palsy 2 . A 63-year-old male with a 6 month history of shoulder pain and inability to abduct past 30 degrees

Options:

A 67-year-old female with chronic shoulder pain and evidence of significant proximal migration of the humerus on x-ray
A 70-year-old female with severe shoulder pain and radiographic evidence of glenoid erosion to the coracoid process
A 72-year-old male who is 9 months status post right TKA for OA with debilitating shoulder pain and an MRI demonstrating an intact rotator cuff

Correct Answer: A 67-year-old female with chronic shoulder pain and evidence of significant proximal migration of the humerus on x-ray

Explanation:

A total shoulder arthroplasty (TSA) is indicated in the 72 year old male with debilitating shoulder pain and an intact rotator cuff on MRI. The other patient scenarios are examples of contraindications for TSA.
A TSA involves replacement of the humeral head with a metal head and resurfacing of the glenoid to a cemented all-polyethylene surface. In order to achieve optimal results, patients must be selected carefully. Patients with an irreparable rotator cuff tear, non-functioning deltoid, inadequate glenoid bone stock and brachial plexopathy are poor candidates for TSA.
Edwards et al. conducted a multicenter randomized controlled trial to compare TSA versus hemiarthroplasty in patients with primary osteoarthritis of the shoulder. They found that TSA provided better scores for pain, mobility, and activity than hemiarthroplasty at 2 year follow-up. Boileau et al. followed 45 consecutive patients who underwent reverse TSA ( rTSA) for cuff tear arthropathy (CTA), post-traumatic arthritis, and failure of revision arthroplasty. After a mean follow-up of 40 months, they found that the reverse prosthesis improved function and was able to restore active elevation in patients with incongruent cuff-deficient shoulders. They also found that
the results were less predictable and complication and revision rates were higher in patients undergoing revision surgery as compared to those patients undergoing rTSA for CTA.
Illustrations A and B show the preoperative and postoperative x-rays of a patient with characteristic OA of the glenohumeral joint that was treated with TSA.
Incorrect Answers:
Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?
Immobilization in external rotation for 6 weeks Arthroscopic bony Bankart repair
Arthroscopic Remplissage procedure
Glenoid augmentation using coracoid transfer Glenoid augmentation using tricortical iliac crest graft
This patient has recurrent shoulder instability with a small bony defect of the anterior glenoid and no previous surgery. The most appropriate definitive management in this patient would be arthroscopic bony Bankart repair.
Older (>20 years old), recreational athletes with minor glenoid bone loss (<20 % of the glenoid surface area) may be treated with soft tissue stabilization procedures using suture anchors. Goals of this procedure include tightening and repairing the torn ligament and labrum to the glenoid.
Younger, contact sports athletes with large glenoid defect (>20%) may require bony augmentation type of procedures.
Lynch et al. review the clinical presentation, assessment and treatment algorithm for surgical management of bone loss associated with anterior shoulder instability. While defects larger than 25% of glenoid width should be managed with bony augmentation, they recommend soft-tissue stabilization in smaller defects.
Balg et al. analyzed 131 patients following Bankart procedure and identified following risk factors for failure: age <=20, competitive participation in contact sports, shoulder hyperlaxity, Hill-Sachs on AP radiograph, glenoid bone loss of contour on AP radiograph.
Using human cadaveric shoulders with various anterior glenoid defects sizes, The MOON Shoulder Group compared radiography, MRI and CT to determine the most reliable imaging modality for predicting bone loss. Three-dimensional CT, followed by regular CT were the most reliable and reproducible imaging modalities for predicting glenoid bone loss.
Figure A shows an en face sagittal 3D reconstruction of a glenoid with 10% surface area loss. Incorrect Answers:
A latissimus dorsi tendon transfer is a well established procedure for treatment of massive irreparable posterosuperior rotator cuff tears. All of the following factors have been shown to result in worse clinical outcomes after a transfer EXCEPT?
Nonsynergistic action of the transferred muscle Fatty atrophy of the supraspinatus and infraspinatus Deficiency of the subscapularis
Absence of the coracoacromial ligament Deltoid weakness
A latissimus dorsi tendon transfer can be utilized in patients with a massive, irreperable rotator cuff tear involving the supraspinatus and infraspinatus. It has been reported to relieve pain and improve function in a carefully selected patient population. Those patients with deficiency of the deltoid or subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration of the posterosuperior cuff have worse clinical outcomes. Absence of the CA ligament may allow anterosuperior escape in RC deficient shoulders but has not been shown to lead to worse outcomes after a tendon transfer.
The paper by Warner, et. al demonstrated that poor tendon quality, stage 3/4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score noting that salvage reconstruction of a previous cuff repair had more limited gains as compared to primary. The reference by Ianotti, et. al showed that synchronous in-phase contraction of the transferred latissimus dorsi is associated with a better clinical result while improved preoperative shoulder function and general strength also positively influence the clinical result.
An active 68-year-old woman undergoes an uncomplicated rotator cuff repair with a double-row construct using biocomposite knotless anchors. At her two month follow up, she is noted to have increased shoulder pain, weakness and limited motion. Imaging reveals failure of the rotator cuff repair. What is the most likely mechanism of failure?
Anchor fatigue and breakage Anchor pull out from bone
Suture rupture secondary to anchor eyelet abrasion Suture pull out from the repaired tissue
Infection
Rotator cuff repair (RCR) failure most commonly occurs from a failure of the repaired tissue to heal with suture anchor pull out from the repaired tissue.
The overall complication rate of arthroscopic RCR is roughly 10%. Failed RCR most commonly results from failure to heal (19-94%) secondary to poor rotator cuff tissue, insufficient vascularity or poor bone quality. Other causes of RCR failure include surgical complications (deltoid disruption, infection, foreign body reaction, stiffness, neurologic injury), diagnostic errors (missed lesions of the rotator interval, long head of biceps or subscapularis tear), and technical errors (excessive tension due to lack of proper tissue mobilization, anchor pull out secondary to improper anchor placement).
George et al evaluated the causes of failed RCR and results of revision RCR. While results of revision RCR are inferior to primary RCR, arthroscopic repair yields > 60% good or excellent results. Risk factors for poor results following revision RCR include poor tissue quality, detachment of the deltoid origin and multiple previous surgeries.
Diduch et al reviewed the design and composition of various anchors used in arthroscopic shoulder surgery. Current advancements in the field include highstrength polyethylene sutures, new biocompatible anchor materials (PEEK, biocomposite) and modified designs including knotless systems. With improved strength of the current anchors and repair constructs, the most common mode of arthroscopic RCR failure is now related to tissue failure occurring at the tissue-anchor interface.
Cole et al discussed the different primary rotator cuff repair constructs, including single row, double row, transosseous and transosseous equivalent. The authors concluded that construct selection depends on tear acuity, size and tissue quality. For acute tears < 12mm in anteroposterior length, singlerow configuration likely has sufficient strength to maintain the repair and promote healing. For more chronic tears, poor tissue quality, or tears > 1215 mm in the anteroposterior dimension, the authors recommend double-row or transosseous-equivalent repair to better restore the anatomic footprint and provide optimal mechanical stability to achieve healing. Illustration A is an algorithm from George et al detailing the decision-making process when considering revision RCR for a symptomatic failed RCR.
Incorrect Responses
Biocomposite anchors exhibit high load-to-failure and result in fatigue failure less commonly than metal anchors.
A 32-year-old cross-training athlete awakens with severe left neck and shoulder pain after a day of intense upper body training. Aside from a recent viral illness, he is otherwise healthy. His pain improves, but two weeks later he notes significant left shoulder weakness. Examination reveals weakness of shoulder abduction, forward elevation and external rotation with the arm at his side. Radiographs are normal. Electromyography demonstrates 2+ positive sharp waves and fibrillations. Sensory nerve conduction studies show reduced amplitudes. MRI of the brain, cervical spine and shoulder are shown in Figures A-D, respectively. Which of the following is true of his prognosis?
Decompression will result in improved muscle strength and function.
The patient can expect a gradual return of muscle strength without long term functional deficits. Immunomodulators may decrease the number and severity of his relapses. 4 . Arthroscopic repair will result in the best functional outcomes given the patient's high activity level.

Question 23:

Options:

Arthroscopic debridement
Arthrodesis
Resection arthroplasty
Hemiarthroplasty
Cortisone injection

Correct Answer: Hemiarthroplasty

Explanation:

Question 24:

What is the most appropriate treatment?

Options:

Arthroscopic washout
CT scan
Observation
Aspiration

Correct Answer: Observation

Explanation:

Question 25:

Options:

Arthroscopic posterior capsulolabral repair
Thermal capsulorrhaphy
Open anterior capsulorrhaphy
Intra-articular injection of corticosteroid
Immobilization for 6 weeks in external rotation

Correct Answer: Arthroscopic posterior capsulolabral repair

Explanation:

Question 26:

Options:

Continued IV antibiotics for 4 weeks
Continued oral antibiotics for 6 weeks
Bone scan, biopsy, and metastatic work-up
Surgical débridement along with antibiotics

Correct Answer: Surgical débridement along with antibiotics

Explanation:

EXPLANATION:
This patient has a septic distal interphalangeal joint, which was treated with antibiotics alone. As a result, the patient developed osteomyelitis with bone destruction and abscess. The best way to treat this problem is to perform surgical débridement of bone and soft tissue, along with abscess drainage and an appropriate antibiotic regimen. Antibiotic treatment without surgery would not be successful in eliminating this particular infection. Bone scan with biopsy is not the correct option, because this problem is an infection
and not a tumor, and MRI already has provided enough diagnostic information.

Question 27:

Options:

Unicompartmental arthroplasty
Total knee arthroplasty
Lateral closing wedge proximal tibial osteotomy
Medial opening wedge proximal tibial osteotomy
Medial closing wedge supracondylar femoral osteotomy

Correct Answer: Medial closing wedge supracondylar femoral osteotomy

Explanation:

DISCUSSION: Patients with a valgus alignment about the knee can have lateral compartment arthritis. Similar to a high tibial osteotomy, a supracondylar femoral osteotomy is indicated in younger patients who have a more active lifestyle and isolated unicompartmental disease. In this young patient who works in a factory and has a valgus knee, a medial closing wedge supracondylar femoral osteotomy is the treatment of choice. The role of arthroplasty is limited in younger patients.
REFERENCES: Mathews J, Cobb AG, Richardson S, et al: Distal femoral osteotomy for lateral compartment osteoarthritis of the knee. Orthopedics 1998;21:437-440.
Cameron HU, Botsford DJ, Park YS: Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee. Can J Surg 1997;40:114-118.

Question 28:

Options:

midfoot arthrodesis.
a rocker sole shoe with orthotic inserts.
shock wave or orthotripsy.
an ankle-foot orthosis.
triple arthrodesis.

Correct Answer: midfoot arthrodesis.

Explanation:

DISCUSSION: The patient has advanced arthrosis of the midfoot, and orthotic management has failed to provide relief. Therefore, the treatment of choice is midfoot arthrodesis. Shock wave treatment has not been shown to be beneficial for arthritis. An ankle-foot orthosis would not be appropriate based on findings of a normal ankle joint. Triple arthrodesis would not be helpful because the hindfoot joint is not affected in a Lisfranc injury.
REFERENCES: Sangeorzan BJ, Veith GR, Hansen ST Jr: Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis. Foot Ankle 1990;10:193-200.
Komenda
GA
, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Question 29:

Options:

Debridement and IV antibiotics
Wide resection of the lesion
Chemotherapy alone
Observation
Amputation

Correct Answer: Wide resection of the lesion

Explanation:

DISCUSSION: In an adult with an anterior cortical tibial lesion, this is the classic histologic appearance and anatomic location for an adamantinoma. The histology reveals areas of epithelial cells (in a glandular pattern) within a fibrous stroma. The epithelial cells are shown in nests. They would stain positively for keratin. Adamantinoma is a rare malignant bone tumor with a propensity for late metastasis. It has a high incidence of local recurrence unless resected with a wide margin. Chemotherapy and radiation therapy are not helpful in the treatment of this disease. Amputation generally is not necessary because a diaphyseal resection is usually possible.
REFERENCES: McCarthy EF, Frassica FJ: Pathology of Bone and Joint Disorders with Clinical and Radiographic Correlation. Philadelphia, PA, WB Saunders, 1998, p 263.
Moon NF, Mori H: Adamantinoma of the appendicular skeleton: Updated. Clin Orthop Relat Res 1986;204:215-237.

Question 30:

Options:

suppressive antibiotics.
open irrigation and debridement with polyethylene exchange.
one-stage resection arthroplasty and reimplantation.
two-stage resection arthroplasty and reimplantation.
arthroscopic irrigation and debridement.

Correct Answer: two-stage resection arthroplasty and reimplantation.

Explanation:

Question 31:

Options:

Posterior tibial tendinitis
Osteoid osteoma
Posterior ankle impingement
Tibial stress fracture
Flexor hallucis longus tendinitis

Correct Answer: Tibial stress fracture

Explanation:

Question 32:

A 30-year-old patient has acetabular dysplasia and moderate secondary osteoarthrosis. Which of the following studies will best help predict the success of periacetabular osteotomy?

Options:

High-resolution CT with coronal and sagittal reconstructions
Glycosaminoglycan MRI
Functional radiographic or fluoroscopic evaluation
Gadolinium-contrast arthrography with MRI
Routine AP and lateral radiographs

Correct Answer: Functional radiographic or fluoroscopic evaluation

Explanation:

Question 33:

Autosomal dominant

Options:

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

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

Explanation:

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

Question 34:

An active, right-handed 71-year-old woman fell on her left shoulder and sustained the injury shown in the radiographs in 52a and 52b and the CT scan in 52c. Management should consist of

Options:

hemiarthroplasty
open reduction and internal fixation
closed reduction and percutaneous pinning
a sling and early pedulum exercises
a sling and swathe for 6 weeks, followed by shoulder rehabilitation

Correct Answer: hemiarthroplasty

Explanation:

Question 35:

Options:

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

Correct Answer: occipital-cervical fusion with instrumentation.

Explanation:

Question 36:

Options:

Total knee arthroplasty with standard components
Correction of tibial deformity with osteotomy and nonsurgical management of the osteoarthritis
Arthrodesis with a long antegrade nail
Total knee arthroplasty with a constrained device

Correct Answer: Total knee arthroplasty with a constrained device

Explanation:

Question 37:

What is the current 5-year survival rate for patients with classic nonmetastatic, high-grade osteosarcoma of the extremity?

Options:

Correct Answer: 70%

Explanation:

Question 38:

Options:

Disk herniation
Synovial cyst
Arachnoid cyst
Epidural lipomatosis

Correct Answer: Synovial cyst

Explanation:

DISCUSSION
This patient has neurogenic claudication as demonstrated by her “shopping cart” sign. Typically, spinal stenosis is attributable to bony spurs and/or a thick ligamentum flavum. However, for this patient, a large synovial cyst is the main contributing factor to stenosis. A cyst typically is filled with gelatinous material. If symptomatic, surgical excision is typically recommended because success with aspiration is unreliable. The need for fusion is debatable.
A disk herniation is not bright on T2. An arachnoid cyst is a sac filled with cerebrospinal fluid. Spinal arachnoid cysts are relatively uncommon, and typically are intradural, but they also can be extradural. Epidural lipomatosis is a condition caused by excessive accumulation of fat within the epidural space. It is not well circumscribed as seen with this lesion.
RECOMMENDED READINGS
Epstein NE, Baisden J. The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration. Surg Neurol Int. 2012;3(Suppl 3):S157-66. doi: 10.4103/2152-7806.98576. Epub 2012 Jul 17. PubMed PMID: 22905322.
View Abstract at PubMed
Xu R, McGirt MJ, Parker SL, Bydon M, Olivi A, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases. Spine (Phila Pa 1976). 2010 May 1;35(10):1044-53. PubMed PMID: 20173680.
View Abstract at PubMed

Question 39:

Options:

Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction
Decreased pain following surgery; sensory deficits and bladder function are not likely to improve
No change in her symptoms following surgery
Complete resolution of pain and will have normal sensation and bladder function following surgery
Improvement in her pain and complete return of bladder function following surgery; sensation may not return

Correct Answer: Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction

Explanation:

Question 40:

A 46-year-old man with a sacral chordoma is treated with sacrectomy.

Options:

Deep surgical-site infection
Adjacent segment degeneration
Pressure ulcers
Iatrogenic neurologic injury
Incidental durotomy
Hardware failure

Correct Answer: Deep surgical-site infection

Explanation:

DISCUSSION
Complications frequently occur following treatment for spinal disorders. Postsurgical morbidity may range from minor complications such as urinary tract infection to death. Wound infections are among the most commonly encountered complications following any surgical intervention; however, their incidence after spine surgery has been reported to be in the range of only 1% to 6%. Meanwhile, risk for adjacent segment degeneration, particularly following a fusion procedure performed with an interbody device, has been documented as high as 30%. Pressure ulcers can occur when spinal injuries are treated with rigid orthoses, especially in individuals who are immobile. Risk for pressure sores and decubiti is further elevated in patients who are obtunded and cannot communicate regarding pain levels and their need to mobilize. Hardware failure may occur following any instrumented spine procedure, but risk for this complication is elevated in the event of pseudarthrosis or in settings in which no fusion is performed.
In the recent work of Lee and associates, hardware failure was the only complication encountered among patients who were treated with percutaneous stabilization without fusion for thoracolumbar burst fractures. Similarly, iatrogenic neurologic injury may transpire in the setting of any spinal intervention (its incidence is rare). For example, in a large cohort of
more than 10000 patients undergoing surgical treatment for spondylolisthesis, acute neurologic injury was reported in only 0.8% of cases. Postsurgical wound infection, although relatively rare in cases of elective spine surgery, is common following large tumor resection such as sacrectomy performed for treatment of chordomas.
RECOMMENDED READINGS
Eismont FJ, Norton RP, Hirsch BP. Surgical management of lumbar degenerative spondylolisthesis. J Am Acad Orthop Surg. 2014 Apr;22(4):203-13. doi: 10.5435/JAAOS-22-04-203. Review. PubMed PMID: 24668350.
View Abstract at PubMed
Bransford RJ, Morgan RA. Thoracolumbar trauma. In: Schmidt AH, Teague DC, eds. Orthopaedic Knowledge Update: Trauma 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2010:373-385.
Lee JK, Jang JW, Kim TW, Kim TS, Kim SH, Moon SJ. Percutaneous short-segment pedicle screw placement without fusion in the treatment of thoracolumbar burst fractures: is it effective? comparative study with open short-segment pedicle screw fixation with posterolateral fusion. Acta Neurochir (Wien). 2013 Dec;155(12):2305-12; discussion 2312. doi: 10.1007/s00701-013-1859-x. Epub 2013 Sep 10. PubMed PMID: 24018981.
View
Abstract at PubMed
Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 41:

Which of the following changes of calcium metabolism accompany the loss of bone during menopause?

Options:

Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss
A net negative change in calcium balance because of a decrease in intestinal absorption and a lesser decrease in urinary calcium loss
An increase of intestinal resorption with an increase of free 1,25-dihydroxyvitamin D
Loss of estrogen stimulating loss of calcium via increased PTH levels and subsequent decreased renal tubular absorption of calcium
No true change in calcium metabolism, but rather a net increased turnover of bone because of a decrease in circulating estrogen

Correct Answer: Negative changes in external calcium balance with a decrease in intestinal calcium absorption and an increase in urinary calcium loss

Explanation:

DISCUSSION: There is a negative change of calcium balance with a decrease
in intestinal absorption and an increase in urinary calcium loss. The reduction of
intestinal absorption is accompanied by reduced circulating concentrations of total, but
not free 1,25-dihydroxyvitamin D. However, estrogen may also directly regulate intestinal calcium resorption independent of vitamin D. Tubular resorption of calcium is higher in the presence of estrogen. Studies of the levels of PTH in the presence of estrogen are controversial.
REFERENCES: Oh KW, Rhee EJ, Lee WY, et al: The relationship between circulating osteoprotegerin levels and bone mineral metabolism in healthy women. Clin Endocrinol (Oxf) 2004;61:244-249.
Reid IR: Menopause, in Favus MJ (ed): Primer on Metabolic Bone Diseases and Disorders of Mineral Metabolism, ed 4. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 55-57.

Question 42:

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Options:

Large-diameter components
Age 40 or older for men
Age 40 or younger for women
Diagnosis of primary osteoarthritis

Correct Answer: Age 40 or younger for women

Explanation:

The recent experience of a large clinical cohort revealed the most likely
risk factors
as being
female
gender
,
age younger than 40
,
small components
, and a
diagnosis of hip dysplasia causing osteoarthritis
. Failure was least likely among men and after procedures involving larger components. These data have prompted some authors to caution against using metal-on-metal hip resurfacing in women and to primarily target candidates who are men younger than age 50. Small components may be more prone to failure because of malpositioning and edge loading, which have been noted to be more common in dysplasia cases.

Question 43:

What is the primary sign/symptom with unidirectional posterior instability of the shoulder? Review Topic

Options:

Instability
Dead arm symptoms
Locking or catching
Decreased range of motion
Pain

Correct Answer: Pain

Explanation:

Question 44:

Figure 19 shows the radiograph of a 45-year-old woman who has a painful nonunion. Treatment should consist of

Options:

revision internal fixation with a longer side plate and bone grafting.
open reduction and internal fixation with a 95° fixed angle device and bone grafting.
hardware removal and retrograde intramedullary nailing.
placement of an implantable bone stimulator.
proximal femoral resection and total hip arthroplasty.

Correct Answer: open reduction and internal fixation with a 95° fixed angle device and bone grafting.

Explanation:

Question 45:

What is the recommended optimal timing of presurgical antibiotic administration to prevent infection in patients undergoing total joint replacement surgery?

Options:

Within 1 hour before incision
Within 2 hours before incision
Immediately after incision
Within 1 hour after incision

Correct Answer: Within 1 hour before incision

Explanation:

Question 46:

The force generated by a muscle is most highly dependent on its

Options:

cross-sectional area.
fiber type.
length.
morphology.
level of conditioning.

Correct Answer: cross-sectional area.

Explanation:

Question 47:

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future?

Options:

Asymmetric tonic neck reflex
Moro reflex
Extensor thrust
Positive parachute reaction
Absent foot placement

Correct Answer: Positive parachute reaction

Explanation:

DISCUSSION: For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.
REFERENCES: Bleck EE: Orthopaedic Management in Cerebral Palsy. Lavenham, Suffolk, The Lavenham Press, 1987, pp 121-139.
Tachdjian MO: The neuromuscular system: Cerebral palsy, in Wickland EH Jr (ed): Pediatric Orthopaedics, ed 2. Philadelphia, PA, WB Saunders, 1990, vol 2, p 1621.

Question 48:

The radiographic finding in Figure 58 is indicative of what type of acetabular fracture?

Options:

Anterior column
Posterior column
Associated both column
Transverse
Associated transverse plus posterior wall

Correct Answer: Transverse

Explanation:

The radiographic image is an obturator oblique view of the left acetabulum and demonstrates a "spur" sign. It represents a spike of bone from the intact hemipelvis and no articular surface remains with the hemipelvis, which defines the associated both column fracture. The weight-bearing surface of the acetabulum is displaced with the femoral head. In all other patterns, at least part of the articular surface remains with the intact hemipelvis.
(SBQ12TR.58) A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?
Review
Topic
Bilateral open reduction and internal fixation
Open reduction internal fixation on the right, reamed intramedullary nailing on the left
Temporizing external fixation on the right, open reduction and internal fixation on the left
Bilateral reamed intramedullary nailing
Bilateral temporizing external fixation
This patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.
Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.
Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which carries a higher complication rate compared to temporary fixation.
Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.
Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.
Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.
Incorrect Answers:

Question 49:

Options:

Oblique radiographs
Arteriogram
Exploration of the brachial artery at the elbow
Closed reduction and pinning of the elbow
Open reduction and internal fixation of the elbow

Correct Answer: Closed reduction and pinning of the elbow

Explanation:

Question 50:

Options:

Renal osteodystrophy
Diastrophic dysplasia
Metaphyseal dysplasia
Osteogenesis imperfecta
Fibrous dysplasia

Correct Answer: Renal osteodystrophy

Explanation:

Question 51:

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Options:

Fungal infection
Ingrowth of the medial nail
Benign exostosis
Malignant neoplasm
Reactive pyogenic granuloma

Correct Answer: Benign exostosis

Explanation:

Question 52:

A patient has a C6-7 herniated nucleus pulposus. What is the most likely distribution of symptoms? Review Topic

Options:

Pain in the posterior neck and scapula, numbness over the clavicle, and weakness of the head and neck extensors
Pain in the shoulder, numbness over the lateral shoulder, weakness of the deltoid
Pain at the elbow, numbness over the thumb and index finger, weakness of the biceps and wrist extensors
Pain at the forearm and hand, numbness of the middle finger, weakness of the triceps and finger extensors
Pain at the wrist, numbness in the little and ring fingers, weak finger flexors

Correct Answer: Pain at the wrist, numbness in the little and ring fingers, weak finger flexors

Explanation:

A C6-7 herniated nucleus pulposus is most likely to produce a C7 radiculopathy resulting in pain at the forearm and hand, numbness of the middle finger, and weakness of the triceps and finger extensors. Alternative answers represent sequelae of symptomatic disk herniations at C3-C4 (1), C4-C5 (2), C5-C6 (3), and C7-T1 (5), respectively.
(SBQ12SP.27) A 24-year-old male sustains the injury shown in Figure A. What was the most likely mechanism of injury?
Review Topic
Hyperextension
Flexion-distraction
Flexion-compression
Rotational
Pure axial load
Figure A shows a quadrangular fracture pattern of C5. These injuries are observed with flexion-compression loads.
Quadrangular fractures of the cervical spine are considered flexion teardrop fractures. However, they present with a larger anterior lip fragment compared to the classic teardrop fracture pattern. The radiographic findings include a quadrangular-shaped fragment from the anterior one-third of the vertebral body with significant posterior vertebral subluxation, angular kyphosis, and an increased interspinous space with facet subluxation due to disruption of the posterior elements. These are unstable fractures, and almost always require anterior and posterior stabilization.
Moore et al. studied the reliability of Cervical Spine Injury Severity Score to measure stability after cervical spine trauma. The classification system is based on morphologic descriptions and, secondly, on stability based on a quantifiable value. They showed that the Cervical Spine Injury Severity Score had excellent reliability with intra-observer intraclass correlation coefficients (ICC) >0.97 and inter-observer ICC >0.88.
Vaccaro et al. published the subaxial cervical spine injury classification system (SLIC). This systems involves 3 main categories (injury morphology, disco-ligamentous complex, and neurologic status). The overall injury severity score is obtained by summing the scores from each category. They propose that SLIC < 4 can be treated non-operatively.
Allen et al. published a classification system of cervical spine injuries which breaks injuries of the subaxial spine into six phylogenic groups based on mechanism of injury. These include: 1) flexion-compression 2) vertical-compression 3) flexion-
distraction 4) extension-compression 5) extension-distraction 6) lateral flexion. Facet
dislocation
is
caused
by
flexion-distraction
force.
Figure A shows a lateral radiograph of the cervical spine demonstrating a typical flexion-compression fracture with anteriorly displaced quadrangular fragment. Illustration A shows a flexion-compression injury. Illustration B shows the mechanism of injury for a quadrangular fracture of the cervical spine. This unstable fracture pattern is characterized by anterior column failure in flexion/compression and posterior column failure in tension. Illustration C shows an illustration of the fracture morphology according to the Allen and Ferguson classification.
Incorrect Answer 1:
Hyperextension injuries
Flexion-distraction injuries usually result in facet dislocations.

Question 53:

What is the most commonly reported complication following elbow arthroscopy?

Options:

Synovial cutaneous fistula
Nerve transection
Compartment syndrome
Infection
Transient neurapraxia

Correct Answer: Transient neurapraxia

Explanation:

DISCUSSION: The complication rate following elbow arthroscopy is reported at 5%. The most commonly reported complication is transient neurapraxia, with nerve transection remaining an unfortunate and rare event. While infection remains the most common serious complication, it is uncommon (0.8%). Synovial cutaneous fistula and compartment syndrome, while reported, are the least frequent complications of elbow arthroscopy.
REFERENCES: Kelly EW, Morrey BF, O’Driscoll SW: Complications of elbow arthroscopy.
J Bone Joint Surg Am 2001;83:25-34.
Morrey BF: Elbow complication, in Morrey BF (ed): The Elbow and Its Disorders, ed 3. Philadelphia, PA, WB Saunders, 2001, pp 519-522.

Question 54:

What is the primary benefit of using rhBMP-2 instead of autogenous bone graft inside an anterior spinal fusion cage?

Options:

Substantially improved radiographic fusion success rate
Substantially decreased time to fusion healing
Substantially decreased hospital stay
Elimination of autograft harvest
Elimination of need for postoperative bracing

Correct Answer: Elimination of autograft harvest

Explanation:

Question 55:

Which of the following factors is responsible for causing the distal femur to pivot about a medial axis as the knee moves from full extension into early flexion?

Options:

Differential forces generated from the vastus lateralis and vastus medialis
Differential tension within the bundles of the posterior cruciate ligament
Differential radius of curvature between the medial and lateral femoral condyles
Asymmetry of the tibial tubercle on the anterior surface of the tibia
Asymmetric forces generated from the uneven patellar facets

Correct Answer: Differential radius of curvature between the medial and lateral femoral condyles

Explanation:

DISCUSSION: The radius of curvature of the distal femur is greater over the distal aspect of the lateral femoral condyle than the distal aspect of the medial femoral condyle. As the femur rolls posteriorly during early knee flexion, both condyles undergo similar angular changes equal to the amount of flexion. With a similar amount of angular rotation, the sphere with the larger radius experiences greater net rollback, producing a pivoting motion. Although the anterior cruciate ligament plays a role in producing tibial rotations, the posterior cruciate ligament does not play a significant role in producing such rotations. Similarly, the tibial tubercle does not play a significant role in producing normal rotations of the femur relative to the tibia. The popliteus may also play a role in producing rotational pivots, as might differential laxity of the medial and lateral collateral ligaments in early knee flexion.
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, pp 239-240.
Insall JN, Windsor RE, Scott WN, et al (eds): Surgery of the Knee, ed 2. New York, Churchill Livingstone, 1993, pp 1-13.

Question 56:

Primary arthrodesis is associated with which outcome when compared to outcomes associated with open reduction and internal fixation (ORIF) without arthrodesis?

Options:

Decreased secondary surgeries
Increased pain
Increased risk for infection
Poorer function at 2-year follow-up

Correct Answer: Decreased secondary surgeries

Explanation:

DISCUSSION
There are longitudinal, oblique, and transverse ligaments at the TMT complex that are further defined by their location as dorsal, interosseous, or plantar. There are 3 ligaments between the medial cuneiform and the second MT base, the most important of which is the oblique interosseous ligament, which is also known as the Lisfranc ligament. Plantar and dorsal oblique ligaments contribute to stability to a lesser degree. The dorsal ligaments are weakest and may be the first to fail in a Lisfranc injury.
The second MT base should be aligned with the middle cuneiform at the medial borders, and the fourth MT base should be aligned with the cuboid at the medial borders on the oblique view. The dorsal and plantar aspects of the MTs
should align with the cuneiforms/cuboid on the lateral view. Any malalignment should raise the suspicion of a Lisfranc injury. Diastasis between the second MT and the first MT/medial cuneiform complex of more than 2 mm indicates injury, as does TMT joint subluxation of 2 mm more than seen on the uninjured contralateral side. Diastasis between the first and second MT up to 2.7 mm can be normal. Another radiographic sign of injury includes avulsion fracture of the second MT base or medial cuneiform. Additional imaging studies that may be helpful in identifying subtle injuries include weight-bearing radiographs and CT or MRI images.
Two prospective randomized studies compared primary fusion with ORIF Lisfranc injuries. The second study included fracture-dislocations, whereas the first looked at primarily ligamentous injuries. Results conflicted with an earlier study demonstrating improved results (less pain, better function) with primary fusion, while a more recent study showed no difference. Neither study showed worse results with primary fusion, and the rate of secondary surgery was more common in the ORIF group (salvage arthrodesis or hardware removal).
RECOMMENDED READINGS
Solan MC, Moorman CT 3rd, Miyamoto RG, Jasper LE, Belkoff SM. Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation. Foot Ankle Int. 2001 Aug;22(8):637-41. PubMed PMID: 11527024.
View Abstract at PubMed
Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010 Dec;18(12):718-28. Review. PubMed PMID: 21119138.
View Abstract
at PubMed
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. J Bone Joint Surg Am. 1990 Dec;72(10):1519-22. PubMed PMID: 2254360.
View Abstract at PubMed
Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20. PubMed PMID: 16510816.
View
Abstract at PubMed
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009 Oct;30(10):913-22. doi: 10.3113/FAI.2009.0913. PubMed PMID: 19796583.
View
Abstract at PubMed

Question 57:

Which of the following is included in safety checks on the World Health Organization Safe Surgery Guidelines Checklist?

Options:

Check if antibiotics has been given within 60 minutes prior to skin incision
Check if blood products are on standby
Check if venous thromboembolism prophylaxis has been ordered
Check if the implant representative is either present, or has been notified
Check if all members of the surgical and anesthetic team have been properly credentialed

Correct Answer: Check if all members of the surgical and anesthetic team have been properly credentialed

Explanation:

Question 58:

Retrograde ejaculation is most commonly associated with what surgical approach?

Options:

Anterior retroperitoneal approach to L5-S1
Anterior transperitoneal approach to L5-S1
Anterior retroperitoneal approach to L4-5
Minimally invasive lateral trans-psoas approach to L4-5
Open lateral approach to L4-5

Correct Answer: Anterior transperitoneal approach to L5-S1

Explanation:

DISCUSSION: Retrograde ejaculation is the sequela of an injury to the superior hypogastric plexus. This structure needs protection, especially during anterior exposure of the lumbosacral junction. Although the superior hypogastric plexus can be injured with anterior or anterolateral spine surgery at any lumbar level, it is most at risk with anterior transperitoneal approaches to the lumbosacral junction. To avoid this complication, the use of monopolar electrocautery should be avoided during deep dissection in this region. The ideal anterior exposure starts with blunt dissection just to the medial aspect of the left common iliac vein sweeping the prevertebral tissues toward the patient’s right side.
REFERENCES: Flynn JC, Price CT: Sexual complications of anterior fusion of the lumbar spine. Spine 1984;9:489-492.
Watkins RG (ed): Surgical Approaches to the Spine. New York, NY, Springer-Verlag, 1983,
p 107.
An HS, Riley LH III: An Atlas of Surgery of the Spine. New York, NY, Lippincott Raven, 1998, p 263.

Question 59:

Figure 93 is the radiograph of 3½-year-old girl who was evaluated for a progressive increase in tibia vara and complains that her feet are turning in. What is the most appropriate course of action?

Options:

Bilateral tibia and fibular osteotomies
Valgus positioning knee-ankle-foot orthosis (KAFO)
Use of a Denis-Browne bar
Schedule a return visit in 4 months

Correct Answer: Bilateral tibia and fibular osteotomies

Explanation:

Question 60:

Options:

Closed reduction and long arm cast immobilization
Closed reduction and short arm cast immobilization
Closed reduction and percutaneous pinning
Open reduction and internal fixation with Kirschner wires
Open reduction and internal fixation with a headless, cannulated compression screw

Correct Answer: Open reduction and internal fixation with a headless, cannulated compression screw

Explanation:

DISCUSSION: The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210.
Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79.
Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.
McCallister WV, Knight J, Kaliappan R, et al: Central placement of the screw in simulated fractures of the scaphoid waist: A biomechanical study. J Bone Joint Surg Am 2003;85:72-77.

Question 61:

Figure 8 shows the radiograph of a 76-year-old man who has knee pain and swelling. History reveals that he underwent total knee arthroplasty 18 years ago. What is the most likely diagnosis?

Options:

Loose femoral component
Loose tibial component
Particle-mediated osteolysis
Polyethylene failure
Infection

Correct Answer: Polyethylene failure

Explanation:

DISCUSSION: The radiograph reveals complete loss of joint space with particulate metal debris consistent with total polyethylene failure and metal-on-metal articulation. The components appear to be well fixed and minimal osteolysis is evident.
REFERENCES: Kilgus DJ, Moreland JR, Finerman GA, et al: Catastrophic wear of tibial polyethylene inserts. Clin Orthop Relat Res 1991;273:223-231.
Vince KG: Why knees fail. J Arthroplasty 2003;18:39-44.

Question 62:

4 mg/kg for 48 hours

Options:

Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours
Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 48 hours

Correct Answer: Administration of naloxone with an initial bolus of 30 mg/kg followed by 5.4 mg/kg for 24 hours

Explanation:

Question 63:

Options:

external beam radiation.
curettage and cementation of the lesion with a compression hip screw and side plate fixation.
curettage and cementation of the lesion with intramedullary fixation.
cemented bipolar hemiarthroplasty.
radioactive iodine infusion.

Correct Answer: cemented bipolar hemiarthroplasty.

Explanation:

Question 64:

Options:

Humeral head erosion
Glenoid erosion
Rotator cuff integrity
Status of the coracoacromial ligament
Acromioclavicular arthritis

Correct Answer: Rotator cuff integrity

Explanation:

Question 65:

Options:

A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?
Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion-extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability. Retained hardware from prior surgery was not deemed a contraindication.

Correct Answer: Inflammatory elbow arthritis

Explanation:

Figure 1 is the radiograph of a 12-year-old baseball player who has posterolateral elbow pain with throwing. The area of interest is designated by the black arrow. His range of motion and strength are full. No previous treatment has been provided. What is the most appropriate initial treatment?
Elbow arthroscopy with debridement
Immobilization and rest for 6 weeks
Corticosteroid injection
Open osteochondral autograft transfer
Osteochondritis dissecans of the capitellum is a painful condition that affects immature athletes who undergo repetitive compression of the radiocapitellar joint. Management is based primarily on the integrity of the articular cartilage surface and the stability of the lesion. Nonsurgical treatment is typically selected for patients
with early-grade, stable lesions, and it involves activity modification with cessation of sports participation. The duration of activity modification is dictated by symptoms, with 3 to 6 weeks of rest followed by return to sport in 3 to 6 months commonly used as a guideline. Strengthening and stretching exercises are commonly incorporated after the pain has subsided. Surgical intervention or corticosteroid injection would not be first-line treatment.
Figures 1 and 2 are the radiographs of a 69-year-old man with a history of treated prostate cancer and hemodialysis-dependent end- stage renal disease who presents to the emergency department with progressively worsening right shoulder pain and stiffness. Laboratory tests reveal a white blood cell count of 17,000, erythrocyte sedimentation rate, 75, and CRP, 10.1. He has a draining sinus located along the anterior shoulder. What is the best next step?

Question 66:

A lower chance of failure when using an extensor mechanism allograft to address a chronic disruption of an extensor tendon is associated with

Options:

retention of the patient's patellar remnant.
tensioning the allograft in full extension.
use of a freeze-dried allograft.
resurfacing the patellar surface of the allograft.

Correct Answer: tensioning the allograft in full extension.

Explanation:

Question 67:

Options:

Distal chevron osteotomy bunionectomy with lesser metatarsal head resections
Proximal first metatarsal osteotomy with flexor-to-extensor tendon transfer for the lesser toes
First metatarsophalangeal arthrodesis with lesser metatarsal head resections
First tarsometatarsal realignment arthrodesis (Lapidus procedure) with flexor-to-extensor tendon transfer for the lesser toes
Resection of the base of the hallux proximal phalanx (Keller procedure) with flexor-to-extensor tendon transfer for the lesser toes

Correct Answer: First metatarsophalangeal arthrodesis with lesser metatarsal head resections

Explanation:

Question 68:

Options:

CT of the pelvis to delineate the fracture pattern
Application of a pelvic sling
Radiographs of the long bones
Angiography to stem the flow of retroperitoneal bleeding
Immediate open reduction of the fracture

Correct Answer: Application of a pelvic sling

Explanation:

Question 69:

Which of the following structures is predominantly composed of Type 1 collagen? Review Topic

Options:

Epithelial Basement Membrane
L4 disc nucleus pulposus
Anterior cruciate ligament
Medial femoral condyle articular cartilage
Dupuytren's contracture tissue

Correct Answer: Epithelial Basement Membrane

Explanation:

Question 70:

Options:

Strict elevation
Removal of hardware
Immediate carpal tunnel release
Carpal tunnel release if no resolution at 6-12 weeks
Trial of night splinting

Correct Answer: Strict elevation

Explanation:

Question 71:

Options:

Hindfoot valgus
Midfoot supination
Sinus tarsi impingement
Anterior ankle impingement
Hammertoe deformity

Correct Answer: Hindfoot valgus

Explanation:

Question 72:

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Options:

serum and urine protein electrophoresis.
a chest CT scan.
MRI with intravenous contrast.
age-appropriate presurgical laboratory studies.

Correct Answer: age-appropriate presurgical laboratory studies.

Explanation:

Question 73:

-Four months after injury, the tibia is showing evidence of slow healing on radiographs. What is the optimal treatment for this potential nonunion?

Options:

Convert to circular external fixation
Exchange nailing and autograft
Exchange nailing and bone morphogenetic protein
Tibial plate
Observation until 6 months after injury

Correct Answer: Observation until 6 months after injury

Explanation:

DISCUSSION FOR QUESTIONS 108 THROUGH 110:
This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.

Question 74:

Options:

non-weight bearing bilateral lower extremities and right upper extremity
weight bearing as tolerated bilateral lower extremities and right upper extremity
non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

Correct Answer: non-weight bearing bilateral lower extremities and right upper extremity

Explanation:

Question 75:

Options:

Repeat radiographs while the patient is weight bearing
Ultrasonography of the lower extremity and calf
Stress radiographs
CT scan

Correct Answer: Stress radiographs

Explanation:

Question 76:

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 77:

Radiographs of a pediatric patient reveal a suspected osteosarcoma of the distal femur. Additional staging studies should consist of

Options:

a radiograph and CT of the chest and a bone scan.
a radiograph and MRI of the primary tumor.
CT of the abdomen and pelvis.
CT of the abdomen, chest, and pelvis, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.
CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.

Correct Answer: CT of the chest, radiographs of the chest and primary tumor, MRI of the primary tumor, and a bone scan.

Explanation:

Question 78:

Options:

Immediate MRI of the brain
Physical therapy and observation
Subacromial injection
Decompression of the suprascapular nerve at the suprascapular notch
Decompression of the infraspinatus branch of the suprascapular nerve at the spinoglenoid notch

Correct Answer: Physical therapy and observation

Explanation:

Question 79:

Which of the following 50-year-old patients with an irreparable rotator cuff tendon is the best candidate for an isolated latissimus dorsi muscle transfer? Review Topic

Options:

Man with active elevation to 90 degrees
Woman with active elevation to 45 degrees
Woman with a Hornblower's sign (complete absence of external rotation with abduction)
Man with superior escape of the humeral head
Man with full motion and a positive lift-off test

Correct Answer: Man with active elevation to 90 degrees

Explanation:

Question 80:

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

Options:

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

Correct Answer: Backbone of the proteoglycan aggregate

Explanation:

Question 81:

Options:

Physical therapy for range-of-motion exercises
Aspiration for possible infection
MRI to evaluate for possible rotator cuff tear
Sling immobilization and reevaluation in 4 weeks
Duplex ultrasound for possible upper extremity deep venous thrombosis

Correct Answer: Physical therapy for range-of-motion exercises

Explanation:

Question 82:

Options:

Hematoma
Edema
Soft-tissue sarcoma
Antecubital lipoma
Brachial artery aneurysm

Correct Answer: Edema

Explanation:

DISCUSSION: The MRI scans reveal a chronic distal biceps tendinitis. The T
1
-weighted scan shows the anatomic detail of the biceps tendon, and the T
2
-weighted scan shows increased signal caused by edema surrounding the tendon. The T
1
-weighted scan is not consistent with an antecubital lipoma. The chronicity of the lesion makes hematoma unlikely. An aneurysm usually appears with blood flow through the region and is dark on T
1
- and T
2
-weighted scans.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, pp 492-504.
Morrey B: Distal biceps tendon rupture, in Master Techniques in Orthopedic Surgery:
The Elbow, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2002, pp 173-192.

Question 83:

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Options:

Intrinsics of the hand
Wrist extensor
Thumb extensor
Thumb IP flexor
Digital extensor

Correct Answer: Intrinsics of the hand

Explanation:

Question 84:

Options:

Ankle ligament repair
Resection of the accessory navicular
Resection of the talocalcaneal coalition
Subtalar arthrodesis
Triple arthrodesis

Correct Answer: Resection of the talocalcaneal coalition

Explanation:

Question 85:

Options:

casting.
closed reduction, casting, and no weight bearing for 6 weeks.
open reduction and internal fixation.
closed reduction and percutaneous Kirschner wire fixation.
closed reduction and percutaneous screw fixation.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: Myerson and associates studied the outcomes of 19 patients with tarsometatarsal joint injuries during athletic activity. Injuries were classified as first- or second-degree sprains of the tarsometatarsal joint or a third-degree sprain with diastasis between the metatarsals or cuneiforms. Poor functional results were seen in those with a delay in diagnosis and with inadequate treatment. For patients with third-degree sprains, poor results were obtained with nonsurgical management. These patients required open reduction and internal fixation for optimal return to function. The anatomic reduction is critical to the outcome; therefore, open reduction is preferred.
REFERENCES: Baxter DE: The Foot and Ankle in Sport, ed 1. St Louis, MO, Mosby, 1995,
pp 107-123.
Curtis MJ, Myerson M, Szura B: Tarsometatarsal joint injuries in the athlete. Am J Sports Med 1993;21:497-502.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.
Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex. J Am Acad Orthop Surg 2003;11:260-267.

Question 86:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

Question 87:

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of

Options:

cast immobilization for 6 weeks.
brief immobilization followed by rest for 6 weeks.
internal fixation with a compression screw.
internal fixation with a tension band wire.
bone stimulation.

Correct Answer: internal fixation with a compression screw.

Explanation:

Question 88:

Options:

Stretching exercises with a physical therapist
Arthroscopic debridement
Core decompression of the humeral head
Humeral hemiarthroplasty
Resection of the proximal humerus

Correct Answer: Humeral hemiarthroplasty

Explanation:

Question 89:

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 90:

Options:

rotator cuff repair.
open reduction.
shoulder arthrodesis 4- total shoulder arthroplasty. 5- humeral head arthroplasty.
back answer Question 114.03

Correct Answer: rotator cuff repair.

Explanation:

Question 91:

Which of the following best describes athletic pubalgia?

Options:

A syndrome of lower abdominal and adductor pain
Painful symptoms emanating from the symphysis pubis
Painful symptoms associated with dysfunction of the iliopsoas tendon
Stress fracture of the pubic ramus
Entrapment of the pudendal nerve

Correct Answer: A syndrome of lower abdominal and adductor pain

Explanation:

Question 92:

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Options:

In the second stage there is decreased catabolic activity with less matrix breakdown.
In the second stage there is less chondrocyte proliferation and decreased matrix production.
Matrix degradation includes increased proteoglycan production, more proteoglycan
production, and longer glycosaminoglycan chains.
Cartilage degeneration may be initiated by inflammation, overload, or decreased matrix production.
Chondrocyte repair responses improve with aging.

Correct Answer: production, and longer glycosaminoglycan chains.

Explanation:

Question 93:

A 28-year-old woman has left shoulder pain and a tender soft-tissue mass. Based on the MRI scan and biopsy specimens shown in Figures 74a through 74c, what is the most likely diagnosis?

Options:

Malignant fibrous histiocytoma
Lymphoma
Synovial sarcoma
Schwannoma
Neurofibroma

Correct Answer: Schwannoma

Explanation:

DISCUSSION: Schwannomas (neurilemomas) occur at all ages but are most frequently seen in persons between the ages of 20 and 50 years. MRI features of schwannomas are fairly nonspecific, but when they are associated with a large named nerve, the identification of a mass in continuity with that nerve is highly suggestive of a schwannoma. Most have a fairly homogeneous appearance with a high water content and often fusiform shape. Classically, the histology shows alternating Antoni A (dense spindle cell region) areas and Antoni B (loose myxoid tissue) areas. They also demonstrate uniform intense immunostaining with S-100 protein.
REFERENCES: Damron TA, Sim FH: Soft-tissue tumors about the knee. J Am Acad Orthop Surg 1997;5:141-152.
Weiss SW, Goldblum JR, Enzinger FM: Enzinger and Weiss’s Soft Tissue Tumors, ed 4. Philadelphia, PA, Elsevier, 2001, pp 1146-1167.

Question 94:

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

Options:

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

Correct Answer: Enhanced neurogenic adaptations

Explanation:

Question 95:

Options:

Intracompartmental pressure monitoring
Immobilization of the knee in a flexed position
Fasciotomy of the thigh
MRI scan of the femur This athlete has experienced a quadriceps contusion with hemorrhage and swelling into the anterior compartment of the thigh. Initial treatment for these injuries is immobilization of the knee in flexion to reduce the amount of bleeding into the anterior compartment. Rest and anti-inflammatory medication may be used in the rehabilitation process but should not take the place of immobilization in flexion. The compartments are soft and therefore, there is no indication for fasciotomy. MRI scan of the femur may demonstrate hematoma in the anterior thigh compartment but is not required to make the diagnosis.

Correct Answer: Immobilization of the knee in a flexed position

Explanation:

Question 96:

What is the most frequent complication of percutaneous repair of an acute Achilles tendon rupture?

Options:

Sural nerve entrapment
Re-rupture
Infection
Suture granuloma
Wound healing complications

Correct Answer: Sural nerve entrapment

Explanation:

DISCUSSION: Sural nerve entrapment is the major risk of percutaneous repair. A small mini-open technique with a suture guide can obviate that issue. Re-rupture rates after surgical repair are approximately 3%. Infection and wound problems are rarely encountered with percutaneous repair; they are issues with open repair.
REFERENCES: Aracil J, Pina A, Lozano JA, et al: Percutaneous suture of Achilles tendon ruptures. Foot Ankle 1992;13:350-351.
Sutherland A, Maffulli N: A modified technique of percutaneous repair of the ruptured Achilles tendon. Oper Orthop Traumatol 1998;10:50-58.
Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures: A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am
2002;84:161-170.

Question 97:

Options:

Non-weight bearing bilateral lower extremities and right upper extremity
Weight bearing as tolerated bilateral lower extremities and right upper extremity
Non-weight bearing left lower extremity and weight bearing as tolerated right upper and right lower extremities
Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities
Weight bearing as tolerated bilateral lower extremities and non-weight bearing right upper extremity

Correct Answer: Non-weight bearing right lower extremity and weight bearing as tolerated right upper and left lower extremities

Explanation:

Question 98:

Options:

Vascularized fibular graft
Locked intramedullary rodding
Tricortical iliac crest grafting and compression plating
Cancellous autograft and plating
BMP-7

Correct Answer: Cancellous autograft and plating

Explanation:

Question 99:

Figures 29a and 29b show the radiograph and CT scan of a 48-year-old man who has diffuse spinal pain. What is the most likely diagnosis?

Options:

Rheumatoid arthritis
Diffuse idiopathic skeletal hyperostosis (DISH)
Normal findings
Ankylosing spondylitis
Osteopetrosis

Correct Answer: Ankylosing spondylitis

Explanation:

Question 100:

Options:

Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
ORIF of the acetabular fracture and hemiarthroplasty
Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer: Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation:

DISCUSSION:
The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginal
impaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

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

OITE & ABOS Orthopedic Board Prep MCQs: Hip, Sports Medicine & Oncology | Part 148

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 148

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index