Orthopedic Board Prep MCQs: Foot, Knee & Nerve | Part 150

About This Board Review Set

This is Part 150 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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

Topics Covered in Part 150

This module focuses heavily on: Ankle, Arthroplasty, Foot, Knee, Nerve.

Sample Questions from This Set

Sample Question 1: Which of the following deformities is most common after the amputation shown in Figure A?...

Sample Question 2: A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis? Review Topic...

Sample Question 3: The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of...

Sample Question 4: Ayear-oldwomanisreferredforevaluationofapainfulkneereplacement.Sheunderwenttotalkneearthroplasty(TKA)morethan1yearagowithoutperioperativecomplicationsbuthashadconsistentpain sincethesurgery.Thepatient’spreoperativeradiographsandpostoperativ...

Sample Question 5: Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?...

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 deformities is most common after the amputation shown in Figure A?

Explanation

The most common deformity after a midfoot amputation as shown in Figure A is an equinuovarus deformity due to the pull of the Achilles and plantarflexors in face of loss of the common extensors and distal insertion of the tibialis anterior.
Ng et al. review foot and ankle amputations, and review the issues inherent with each amputation level, including prosthesis fitting and use. They also mention that careful repair of all released or transected tendons is needed to maintain a plantigrade foot.
Early reviews the importance of soft tissue balancing with midfoot amputations. They note that the attachment of the resected tendons into the more proximal retained bones is critical for success in restoration of foot position and ambulation capabilities.
Figure A shows a midfoot amputation as the result of trauma. Illustration A shows the lateral view of the amputation, with an obvious equinus deformity.
Incorrect Answers:

Question 2

A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis? Review Topic

Explanation

The MRI scans show a displaced bucket-handle medial meniscus tear that can be visualized on coronal, sagittal, and axial views. The sagittal view shows the typical “double posterior cruciate ligament sign,” in which the low-signal bucket-handle fragment parallels the normal low-signal posterior cruciate ligament. The coronal and axial images both show the displaced medial meniscus in the notch.

Question 3

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Explanation

DISCUSSION: Afferent pain fibers to the lumbar facet joints arise from the medial branch nerves originating from the next two cephalad levels. Therefore, innervation of the L3-L4 facet joint arises from the L2 and L3 medial branch nerves. This effect should be taken into account when considering a medial branch block or facet denervation. The medial branch nerve arises from the dorsal ramus of the exiting nerve root.
REFERENCES: Nade SL, Bell E, Wyke BD: The innervation of the lumbar spinal joint and its significance. J Bone Joint Surg Br 1980;62:255-261
Kornick C, Kramarich SS, Lamer TJ, et al: Complications of lumbar facet radiofrequency denervation. Spine 2004;29:1352-1354.

Question 4

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

Explanation

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

Question 5

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Explanation

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 6

What structure is located at the tip of the arrow in Figure 18?

Explanation

DISCUSSION: The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.
REFERENCE: An H: Diagnostic imaging of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 102-125.

Question 7

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

Explanation

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

Question 8

Which of the following best describes the legal definition of standard of care?

Explanation

DISCUSSION: The standard of care is a legal concept that is elusive and amorphous, although the term is used widely by physicians to mean different things. Different state courts across the United States have also applied different meanings to the term “standard of care.” Most commonly, the standard of care is that which a reasonable physician would have done under similar circumstances. Expert testimony from other physicians is often required to educate a jury in a medical malpractice trial about the applicable standard of care. As a general rule, treatment that exhibits knowledge, skill, diligence, and care on the part of the physician is likely to fall within the standard of care, regardless of variations in the definition of this term.
REFERENCES: Lewis MH, Gohagan JK, Merenstein DJ: The locality rule and the physician’s dilemma: Local medical practices vs the national standard of care. JAMA 2007;297:2633-2637.
AAOS Expert Witness Program, www3.aaos.org/member/expwit/expertwitaess.cfm

Question 9

CLINICAL SITUATION Figure 1 is the radiograph and Figure 2 is the CT image of a 45-year-old woman who fell about 20 feet off her balcony. These images show an isolated, open injury with a 3-cm open medial wound. The best delayed definitive surgical fixation plan would include

Explanation

Discussion: The timely administration of antibiotics has been shown to be the best initial treatment to reduce the incidence of infection following an open fracture. Life threatening injuries must first be addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions should follow antibiotic coverage. Emergency department irrigation is controversial. Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation would be the preferred sequence of management. External fixation to provide provisional limb stabilization would be indicated in this length unstable C type injury to provide soft tissue stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because the patterns make more sense after the restoration of gross length, rotation and alignment in the external fixator. Initial fibular fixation is also not recommended in this case because the location of incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic reduction would be challenging and malreduction could occur and influence subsequent reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue swelling.

Question 10

A 4-year-old child sustains a spiral fracture to the tibia in an unwitnessed fall. History reveals three other fractures to long bones, and the parents are vague about the etiology of each. There is no family history of bone disease. The parents ask if the child has osteogenesis imperfecta (OI); however, there are no clinical or radiographic indications of this diagnosis. In addition to fracture care, management should include

Explanation

DISCUSSION: Child abuse and OI are frequently both in the differential diagnosis of a child with multiple fractures. If OI is suspected, testing is appropriate to confirm this diagnosis. This may include skull radiographs to look for wormian bones and/or fibroblast culturing and collagen analysis of a punch biopsy. Unfortunately, because of the large number of mutations that can yield the disease, DNA testing is not commercially available for OI. In this patient, however, the physician suspects nonaccidental trauma and is legally obligated in most states to notify child protective services. Because the child may be at considerable risk of further injury, hospitalization is indicated to protect the child until child protective services can complete a home investigation and assess the degree of risk. Work-up for both OI and child abuse can be done during the hospitalization.
REFERENCES: Rockwood CA, Wilkins KE, King RE (eds): Fractures in Children. Philadelphia, PA, JB Lippincott, 1984, vol 3, pp 173-175.
Kempe CH, Silverman FN, Stelle BF, Droegemueller W, Silver HK: The battered-child syndrome. JAMA 1962;181:17-24.
Akbarnia BA, Akbarnia NO: The role of the orthopedist in child abuse and neglect. Orthop Clin North Am 1976;7:733-742.

Question 11

A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury?

Explanation

DISCUSSION: Femoral neck fractures in young patients are difficult to treat, and AVN is a significant concern. Despite advances in both imaging and implants, this injury often leads to functional impairment.
Haidukewych et al followed treatment of femoral neck fractures in young patients. They found almost 10% of displaced fractures were associated with the development of nonunion, where as 27% were associated with the development of osteonecrosis. Their results were influenced by fracture displacement and the quality of reduction. Varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation.
Swiontkowski reviews both the treatment and post operative complications in intracapsular hip fractures. In this Current Concept Review, the rate of AVN was discussed as being related to the pre-operative degree of displacement seen on radiographs.
Incorrect Responses:

Question 12

Figure 1 is the clinical photograph of a 22-year-old college pitcher who complains of posterior shoulder pain and feelings of shoulder weakness. He denies shoulder trauma. Evaluation should include

Explanation

Figures 1 and 2 are the CT and MRI scans of a 23-year-old man with a history of recurrent anterior shoulder dislocations. He had his first dislocation while in basic training for the military 4 years ago. Since that time, his shoulder has dislocated with less and less provocation, to the point that it now dislocates in his sleep. Examination demonstrates significant apprehension with abduction/external rotation. What is the most appropriate treatment to prevent recurrent shoulder instability?

Question 13

An elite gymnast injured her ankle in an awkward dismount 36 hours ago. Examination reveals weakness on single leg step-up. A clinical photograph of the medial ankle is shown in Figure 15. Plain radiographs are normal. To help confirm the diagnosis, the next step in evaluation should consist of

Explanation

DISCUSSION: Ecchymosis on the medial side of the ankle is distributed in the posterior tibialis tendon sheath location, posterior to the medial malleolus, and extending inferiorly to the tendon’s attachment on the navicular. MRI is the imaging study of choice to determine the extent of tendon damage. MRI will also help assess the deltoid ligament. Bone scans and CT are helpful in identifying osteochondral fractures and occult fractures; however, these studies are not indicated for this patient. Peroneal tendons are located lateral on the ankle. Arthroscopy of the ankle joint would not be helpful in assessing the posterior tibial tendons.
REFERENCES: Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 307-317.
Rosenberg ZS, Cheung Y, Jahss MH, Noto AM, Norman A, Leeds NE: Rupture of the posterior tibial tendon: CT and MR imaging with surgical correlation. Radiology 1988;169:229-235.

Question 14

Figure 6 shows the clinical photographs of a newborn who underwent a colostomy for an imperforate anus. Examination shows extended knees, flexed hips, and equinovarus feet. Dimpling is noted over the buttocks. Patients with these findings differ from patients with myelodysplasia in that they

Explanation

DISCUSSION: The patient has sacral agenesis. Clinical signs include the classic dimpling over the buttocks and the characteristic lower extremity deformities. Imperforate anus is often associated with this disorder. Although motor function correlates with the level of vertebral defect, sensation is usually intact. This is important therapeutically, because patients are not as prone to pressure sores as are those with myelodysplasia. Kyphosis may develop in many patients with lumbosacral agenesis, but lordosis is unusual. Latex allergy and progressive neural deterioration may occur in patients with either myelodysplasia or sacral agenesis but is more common in the former.
REFERENCE: Renshaw TS: Sacral agenesis. J Bone Joint Surg Am 1978;60:373-383.

Question 15

The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?

Explanation

DISCUSSION: The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon’s canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon’s canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon’s canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon’s canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon’s canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist.
REFERENCES: Gross MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res 1985;196:238-247.
Denman EE: The anatomy of the space of Guyon. The Hand 1978;10:69-76.

Question 16

An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury.
REFERENCES: Myerson MS, McGarvey W: Disorders of the Achilles tendon: Insertion and Achilles tendinitis. Instr Course Lect 1999;48:211-218.
Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic Achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 253-277.

Question 17

What genetic defect is responsible for achondroplasia? Review Topic

Explanation

In achondroplasia the defect is always in the same location on this gene (a defect in FGFR-3), and most children share a very similar clinical phenotype. Achondroplasia is not caused by a defect in the gene for FGF-3, the growth factor itself, but rather the gene coding for the receptor. Trisomy of chromosome 21 is responsible for Down syndrome. Defects in the COL1A1 gene are found in some types of osteogenesis imperfecta. Unlike achondroplasia, the defects occur throughout the gene, with more than 200 mutation sites reported.

Question 18

Acondroplasia and other chondrodysplasias are caused by mutations in the receptors of which of the following families of growth factors?

Explanation

"The gene responsible for achondroplasia has been mapped to chromosome 4p16.3 (ref 7,8); the gentic interval encompassing the disease gene contains a member of the fibroblast growth factor receptor (FGFR3) family which is expressed in articular chondrocytes.

Question 19

A 22-year-old woman has had progressive upper extremity weakness for the past several years. History reveals no pain in her neck or shoulders. Examination reveals scapular winging of both shoulders and weakness in external rotation. She can abduct to only 120 degrees bilaterally, and there is mild supraspinatus weakness. She is otherwise neurologically intact with normal sensation and reflexes; however, she has difficulty whistling. A clinical photograph is shown in Figure 14. What is the most likely diagnosis?

Explanation

DISCUSSION: Progressive weakness is a common sign with a large differential diagnosis. Nerve, muscle, and joint problems should be excluded when a patient has diffuse weakness and atrophy. Fascioscapulohumeral dystrophy is a rare disease characterized by facial muscle weakness and proximal shoulder muscle weakness. The weakness is usually bilateral, and scapular winging is common. If the scapular winging becomes pronounced, elevation of the shoulder can be affected. In severe cases, scapulothoracic fusion or pectoralis muscle transfer to the scapula may be indicated. Duchenne muscular dystrophy is typically severe and progressive. The other diagnoses are not compatible with the history or the physical findings.
REFERENCES: Shapiro F, Specht L: The diagnosis and orthopaedic treatment of inherited muscular diseases of childhood. J Bone Joint Surg Am 1993;75:439-454.
Bunch WH, Siegel IM: Scapulothoracic arthrodesis in fascioscapulohumeral muscular dystrophy: Review of seventeen procedures with three to twenty-one-year follow-up. J Bone Joint Surg Am 1993;75:372-376.

Question 20

A 52-year-old, right hand dominant man comes for evaluation of right shoulder pain that has been intermittently bothering him for three months. The pain is worse with overhead activities. He denies any history of trauma. His range of forward elevation in the plane of the scapula is painful and is limited to 145 degrees, compared to 170 degrees on his unaffected side. A radiograph is shown in Figure A. He saw another orthopedist a month ago, who ordered an MRI, which showed a small, partial thickness supraspinatus tendon tear. He received a subacromial injection of lidocaine at that time which temporarily relieved 90 percent of the pain he felt with passive forward elevation of his shoulder past 90 degrees. Today he is requesting a subacromial injection of platelet rich plasma (PRP). You tell him that with regard to pain, function and range of motion, subacromial injection of PRP: Review Topic

Explanation

At one year, quality of life, pain, disability and shoulder range of motion are the same for patients treated with therapy and placebo versus patients treated with therapy and
PRP injection.
Platelet rich plasma has been used for the treatment of chronic tendinopathy in different areas with mixed results. No benefit to patients with symptoms of subacromial impingement has been demonstrated for subacromial injection of PRP, when added to a standard therapy program.
Kesikburun et al. conducted a randomized controlled trial in which patients with rotator cuff tendinopathy or partial rotator cuff tears were randomized to receive ultrasound-guided subacromial injection of either PRP or lidocaine, followed by a standard six-week therapy program. The authors found no difference in pain, range of motion or validated outcome scores at one year follow up.
Hall et al. reviewed sports medicine applications for PRP. At that time (2009), with regard to PRP, they concluded that there was "little clinical evidence for its use."
Ketola et al. sought to determine the effectiveness of subacromial decompression for the treatment of subacromial impingement syndrome. They randomized 140 patients to a supervised exercise program or arthroscopic subacromial decompression followed by a supervised exercise program. They found no clinically important differences between the two groups at 24 months follow up.
Figure A shows a right shoulder radiograph without osseous pathology. Incorrect answers:

Question 21

A patient has a painful metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis if this patient is having a reaction to metal debris?

Explanation

DISCUSSION
Painful MOM THA and taper corrosion can cause substantial damage to a patient's hip if left untreated. In this case, the workup for a painful MOM THA starts the same as a workup for a painful metal-on-polyethylene bearing couple. Infection must be ruled out in every case with a set of inflammatory markers. If these markers are remotely elevated, this is an indication for joint aspiration. In patients with metal debris, the pathology report often indicates too many cells to count or cellular debris. Metal ion levels do not seem to correlate with prognosis. There are well-functioning patients with high ion levels and poor-functioning patients with low ion levels. Advanced imaging with MARS MRI to evaluate for peritrochanteric fluid collection, a soft-tissue mass, or synovial/capsular hypertrophy will reveal signs of a metal reaction that indicate the need for a revision discussion. A CT scan can show more advanced bony destruction as an indicator of poor prognosis. These films can be used to determine the need for a structural graft or augments for reconstruction of bone loss attributable to metal debris.

Question 22

A 16-year-old swimmer has right shoulder pain with activity. She describes the continued sensation that her shoulder is “loose.” She has been in physical therapy for 7 months to work on strengthening the muscles around her shoulder and scapula. She denies being able to voluntarily dislocate her shoulder. Upon examination, you can feel the humeral head slide over the glenoid rim both anteriorly and posteriorly with the load and shift test. She has a grade III sulcus sign. What is the most appropriate next step?

Explanation

CLINICAL SITUATION FOR QUESTIONS 21 THROUGH 25
A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow.

Question 23

A 220-lb 20-year-old man was involved in a motor vehicle accident. His work-up reveals that he has multiple long bone fractures as well as a splenic injury that is currently being managed nonsurgically. His initial blood pressure in the trauma bay was 70/30 mm Hg. After receiving 4 liters of fluid and 3 units of packed red blood cells, his blood pressure is currently 110/70, his heart rate is 100, his urine output is 90 mL/h (normal 0.5 to 1 mL/kg/h), and his core temperature is 97.9 degrees F (36.5 degrees C). At this point, the patient’s resuscitation can be described as which of the following?

Explanation

DISCUSSION: Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury,

a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 24

Which of the following extensor tendons commonly have multiple slips?

Explanation

DISCUSSION: The extensor digiti mini quinti is most typically a tendon with two slips. The abductor pollicis longus has multiple slips that insert in order of frequency on the base of the first metacarpal, trapezium, and thenar muscles. The extensor pollicis longus, extensor carpi radialis brevis, and extensor indicis proprius consistantly have only one slip.
REFERENCES: von Schroeder HP, Botte MJ: Anatomy of the extensor tendons of the fingers: Variations and multiplicity. J Hand Surg Am 1995;20:27-34.
Bouchlis G, Bhatia A, Asfazadourian H, et al: Distal insertions of abductor pollicis longus muscle and arthritis of the first carpometacarpal joint in 104 dissections. Ann Chir Main Memb Super 1997;16:326-338.

Question 25

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Explanation

Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?

At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?

Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
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OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?

Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
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OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
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OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?

Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
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OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?

Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
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OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?

Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.

OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?

Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
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OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?

Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?

Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
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OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?

Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?

Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?

Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?

Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
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OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?

Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
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OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?

Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?

Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:

OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?

Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.

OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?

Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
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?

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 Corrent answer: 5
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:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:

OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?

Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?

The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?

Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?

Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.

OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?

Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:

OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?

The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?

Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?

Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 26

A 72-year-old woman underwent a primary total hip arthroplasty 14 months ago. She states that the hip has now dislocated four times when rising from a low chair, requiring closed reduction. A radiograph is shown in Figure 3a and a CT scan of her pelvis is shown in Figure 3b. What is the most reliable method for rectifying her instability?

Explanation

DISCUSSION: The radiograph shows well-fixed components without evidence of loosening. The CT scan shows severe retroversion of the acetabular component. Revision of the component into the correct amount of anteversion
will most reliably rectify the instability in the face of severe component malposition.
REFERENCES: Parvizi J, Picinic E, Sharkey PF: Revision total hip arthroplasty for instability: Surgical techniques and principles. J Bone Joint Surg Am 2008;90:1134-1142.
DeWal H, Su E, DiCesare PE: Instability following total hip arthroplasty. Am J Orthop 2003;32:377-382. Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3.
Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475-503.

Question 27

A 55-year-old woman undergoes an anterior cervical diskectomy and fusion at C5-C6 through a left-sided approach. One year later, she requires an anterior cervical diskectomy and fusion on another level. Which of the following is considered a contraindication to performing a right-sided approach for the revision procedure?

Explanation

DISCUSSION: When attempting a revision anterior cervical approach from the side opposite the original approach, it is important to evaluate the function of the vocal cords. If this evaluation reveals dysfunction of the vocal cord on the side of the original approach, then an approach on the contralateral side should not be attempted. Injury to the stellate ganglion, which causes a Horner’s syndrome, should not preclude an approach on the contralateral side. While the side of the symptomatology can influence the surgeon’s choice as to the side of an anterior approach, it does not preclude a certain approach. When approaching the lower cervical spine from the right side, the recurrent laryngeal nerve can cross the surgical field and should be preserved. Excessive intraoperative pressure on the esophagus can increase the incidence of dysphagia, but its incidence is no different with either approach.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 387-394.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 28

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Explanation

DISCUSSION: The number one cause of sudden death in the young athlete is myocardial pathology, with hypertrophic cardiomyopathy being most common. Because of cardiac muscle hypertrophy, the ventricular capacity is diminished and can result in decreased cardiac output. During exertional activities, the increased demand may not be able to be met and leads to sudden death. While the other choices can be the cause of sudden death in an otherwise healthy young athlete, their incidence is even more rare.
REFERENCES: Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647.
Maron BJ, Shirani J, Pollac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.
Mills JD, Moore GE, Thompson PD: The athlete’s heart. Clin Sports Med 1997;16:725-737.

Question 29

A 21-year-old woman sustained a minimally displaced traumatic spondylolisthesis of C2 (Hangman’s fracture) after striking the windshield with her forehead during a motor vehicle accident. Management should consist of

Explanation

DISCUSSION: According to the classification of Levine and Edwards, a type I Hangman’s fracture is minimally displaced without angulation and represents a stable injury. Good clinical success has been achieved with nonsurgical management consisting of use of a rigid collar until the patient reports pain relief, followed by quick mobilization.
REFERENCE: Levine AM, Edwards CC: The management of traumatic spondylolisthesis of the axis. J Bone Joint Surg Am 1985;67:217-226.

Question 30

Figures 2a and 2b are this patient’s proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

Explanation

DISCUSSION
This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair. Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Question 31

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

Explanation

DISCUSSION: The arrow is pointing to the posterior columns of the spinal cord that transmit position sense, vibratory sense, and proprioception. There are no motor tracts in the posterior columns.
REFERENCES: Bohlman H, Ducker T, Levine A: Spine trauma in adults, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 911.
Northrup B: Evaluation and early treatment of acute injuries to the spine and spinal cord, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, p 545.

Question 32

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

Explanation

DISCUSSION: The patient has a failed Silastic implant. Nonsurgical management will not work at this point. A Keller resection will only exacerbate her metatarsalgia. Implant removal with structural bone grafting and MTP fusion is the most appropriate choice because restoration of length is needed to alleviate the forefoot pain and bone grafting is required to fuse the MTP joint because there is an abundance of osteolysis. Total toe implants do not offer good long-term outcomes and are very difficult to fit into the large exploded-out cavity of the proximal phalanx.
REFERENCES: Hecht PJ, Gibbons MJ, Wapner KL, et al: Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty. Foot Ankle Int 1997;18:383-390.
Myerson MS, Schon LC, McGuigan FX, et al: Results of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int

2000;21:297-306.

Question 33

Which of the following increases radiation exposure to patients and personnel during surgery?

Explanation

DISCUSSION: Continuous fluoroscopy and cine radiography expose the patient and personnel to markedly increased levels of direct and scatter radiation exposure. Continuous fluoroscopy should be limited to only what is absolutely needed for safe completion of the procedure. By orienting the cathode ray tube beneath the patient and placing the image intensifier as close as clinically possible to the patient, scatter radiation exposure to the personnel is minimized.
REFERENCE: Wagner L, Archer B: Minimizing Risks from Fluoroscopic X-rays: A Credentialing Program for Anesthesiologists, Cardiologists, Surgeons, Radiologists, and Urologists, ed 3. The Woodlands, TX, Partners in Radiation Management, 2000.

Question 34

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Explanation

DISCUSSION: A superior labrum, when intact, stabilizes the shoulder by increasing its ability to withstand excessive external rotational forces by an additional 32%. The presence of a SLAP lesion decreases this restraint and increases the strain in the superior band of the inferior glenohumeral ligament by over 100%.
REFERENCES: Rodosky MW, Harner CD, Fu FH: The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med 1994;22:121-130.
Itoi E, Kuelchle DK, Newman SR, Morrey BF, An KN: Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75:546-550.

Question 35

A 78-year-old woman undergoes her third lumbar decompression and fusion from L3 to L5 without complication. On the morning of postoperative day 3, examination reveals painless, flaccid weakness of both lower extremities. She also has an absent bulbocavernous reflex and a mild saddle paresthesia. MRI scans of the lumbar spine are shown in Figures 26a and 26b. What is the most appropriate management at this time?

Explanation

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 36

-What gene is implicated in spinal muscular atrophy?

Explanation

Question 37

Figures 100a and 100b are the MRI scans of a 45-year-old man who has had elbow and proximal forearm pain for the past 8 months. He can recall no specific trauma and symptoms have not lessened despite his adopting job modifications that limit lifting. He has discomfort with resisted elbow extension and pronation. The biceps tendon can be easily palpated. Treatment should consist of which of the following? Review Topic

Explanation

The MRI findings are most consistent with a partial tear of the biceps tendon. In the setting of prolonged symptoms that are resistant to nonsurgical interventions like rest,
physical therapy, and modality, surgical treatment is indicated. Exploration, debridement, and reattachment with one of a variety of techniques are the standards of care. No lipomatous mass is seen on the MRI scan. There is no weakness in finger extension to suggest posterior interosseous nerve palsy. Transfer of the biceps would result in loss of supination strength. Endoscopic biceps tendon surgery is reserved for long-head pathology.

Question 38

-Figure 162 is the CT scan of a 74-year-old woman who struck her head during a ground-level fall and has severe neck pain. Examination reveals normal strength and sensation in her upper and lower extremities.What is the most appropriate treatment option?

Explanation

Question 39

A 10-year-old boy with spastic diplegic cerebral palsy walks in a crouched position with the hips and knees flexed. Maximum knee flexion is 15 degrees during early swing phase. Instrumented gait analysis shows quadriceps activity from terminal stance throughout swing phase. Treatment should consist of

Explanation

DISCUSSION: The rectus femoris muscle spans two joints and is active during running, sprinting, and walking at a fast pace during the preswing and early swing phase of gait. In these situations, the muscle helps to generate power to initiate hip flexion while absorbing or controlling the rate of knee flexion during early swing phase. Quadriceps activity, including the rectus femoris, is not normally needed when walking at a routine cadence. However, rectus femoris activity is commonly noted during preswing and the swing phase in patients with cerebral palsy, particularly those with diplegia. In an effort to initiate swing phase, the rectus femoris is “overactive.” As a result, the knee flexion that commonly occurs at terminal stance and initial swing is restricted. Instead of achieving the normal 50 to 60 degrees of flexion during early swing, this patient’s knee flexion is limited to 15 degrees. The goal of treatment is to retain rectus femoris activity for initiation of hip flexion but to diminish its restraint on knee flexion. Studies have shown that transfer of the distal rectus femoris tendon provides more flexion of the knee during the swing phase of gait than simply releasing the tendon. V-Y lengthening of the quadriceps tendon or a Z lengthening of the patellar tendon causes too much weakening of the quadriceps muscle and worsens the crouch deformity. In addition to transfer of the rectus femoris tendon, other procedures are often done concomitantly to obtain the best balance and realignment of hip-knee-ankle activity.
REFERENCES: Aiona MD: Guidelines for managing lower extremity problems in cerebral palsy, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1534-1541.
Chambers H, Laure A, Kaufman K, Cardelia M, Sutherland D: Prediction of outcome after rectus femoris surgery in cerebral palsy: The role of cocontraction of the rectus femoris and vastus lateralis. J Pediatr Orthop 1998;18:703-711.
Ounpuu S, Muik E, Davis RB, Gage JR, Deluca PA: Rectus femoris surgery in children with cerebral palsy. J Pediatr Orthop 1993;13:331-335.

Question 40

Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?

Explanation

DISCUSSION: Simple removal of the loose glenoid component or removal of the loose component followed by implantation of a new glenoid component are both appropriate treatment choices, depending on the remaining glenoid bone stock. However, removal and reimplantation appears to provide the most predictable pain relief and better function than removal alone.
REFERENCES: Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001;10:217-224.
Rodosky MW, Bigliani LU: Surgical treatment of non-constrained glenoid component failure. Oper Tech Orth 1994;4:226-236.

Question 41

The patient undergoes a mobile-bearing UKA. When compared to a fixed-bearing metal-backed unicompartmental arthroplasty, this procedure is associated with a

Explanation

DISCUSSION
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact ACL. The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph will allow the orthopaedic surgeon to determine the correction of the varus deformity and assess the lateral compartment. Inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared to other age groups, but survivorship is lower for UKA than TKA. No studies to date have shown differences in survivorship between fixed- or mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, and this occurs in fewer than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA is low. Arthritis progression may be faster for mobile-bearing UKAs than fixed-bearing UKAs.
The radiographs reveal a fracture of the extensively porous coated stem. This entity, although rare, is associated with higher risk for occurrence when thin stems are implanted in patients with thick cortices and there is a lack of proximal stable support for the prosthesis. Nonsurgical care likely would not help this patient. A triple-phase bone scan would not add any information that would change the treatment plan.

Question 42

Figure 10 shows the radiograph of an 18-year-old woman who sustained a spinal cord injury in a motor vehicle accident. Based on the radiographic findings, her injury is best described as

Explanation

DISCUSSION: The Allen and Ferguson mechanistic classification system is a useful tool for evaluating cervical spine injuries. Cervical fractures are classified as compressive extension, distractive extension, compressive flexion, distractive flexion, vertical compression, and lateral flexion. The patient has a distractive flexion injury.
REFERENCE: Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.

Question 43

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

Explanation

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

Question 44

A 21-year-old right hand-dominant male collegiate swimmer reports painful clicking in the right shoulder. He states that he can occasionally feel his shoulder “slip out” when he is working out. AP, true AP, and axillary radiographs are shown in Figures 39a through 39c. What is the next most appropriate step in management? Review Topic

Explanation

The radiographs show glenoid hypoplasia. The common radiographic findings of glenoid hypoplasia include an inferior and posterior glenoid deficiency, enlargement of the distal end of the clavicle, and sometimes an indentation in the glenoid. It is usually bilateral and rarely associated with other syndromes; therefore, an echocardiogram, abdominal ultrasound, or a skeletal survey is unnecessary unless the patient has stigmata of a syndrome such as Holt-Oram or Apert’s. Although posterior instability has been reported, the results of glenoid osteotomy have been variable and should not be considered initially. Physical therapy is the mainstay of initial management, but the patient should be counseled that this may be a recurrent problem with early osteoarthritis developing in many patients. Radiographs of the contralateral side should be obtained because this is usually bilateral.

Question 45

Figure 82 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. Radiographs show an osteochondritis dissecans (OCD) lesion of the medial femoral condyle. What is the most appropriate treatment? Review Topic

Explanation

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

Question 46

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

Explanation

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

Question 47

A 45-year-old man who is a smoker has a significant hemothorax and bilateral closed femoral fractures. On insertion of a chest tube, 1,100 mL of blood was returned. He has had 75 mL of chest tube output over the last 2 hours while being resuscitated in the ICU. His base deficit is now 2 and his urine output has been 3 mL/kg over the last hour. What is the next most appropriate step in management?

Explanation

DISCUSSION: Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output. External fixation of both femurs is an option but an unnecessary step in the treatment algorithm.
REFERENCES: Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res 2003;415:272-278.
Pape HC, Zelle BA, Hildebrand F, et al: Reamed femoral nailing in sheep: Does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am 2005;87:2515-2522.

Question 48

A 45-year-old man sustains an acute closed posterolateral elbow dislocation. The elbow is reduced, and examination reveals that the elbow dislocates posteriorly at 35 degrees with the forearm placed in supination. What is the best course of action?

Explanation

DISCUSSION: Most closed simple dislocations are best managed with early range of motion. Posterior dislocation typically occurs through a posterolateral rotatory mechanism. When placed in pronation, the elbow has greater stability when the medial ligamentous structures are intact. In traumatic dislocations, MRI rarely provides additional information that will affect treatment. In elbows that remain unstable, primary repair is preferred over ligament reconstruction. Cast immobilization increases the risk of arthrofibrosis.
REFERENCE: O’Driscoll SW, Morrey BF, Korinek S, et al: Elbow subluxation and dislocation: A spectrum of instability. Clin Orthop 1992;280:186-197.

Question 49

An 81-year-old man with severe low back pain reports right extensor hallucis longus and anterior tibialis weakness and difficulty urinating over the past 24 hours. He has a temperature of 101 degrees F (38.3 degrees C). MRI scans are shown in Figures 31a and 31b. Management should consist of

Explanation

DISCUSSION: An epidural abscess with neurologic deficit represents a medical and surgical emergency. The prognosis is related to the timeliness of diagnosis and treatment. Once identified, the primary treatment is surgical decompression of the abscess, followed by organism-specific antibiotics. In the absence of a significant anterior process such as diskitis or vertebral osteomyelitis, lumbar epidural abscesses generally can be drained through a posterior approach. Delayed stabilization usually is not required unless, in the course of decompression, removal of too much of the facets creates an instability; this is an uncommon occurrence.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Reihsaus E, Waldbaur H, Seeling W: Spinal epidural abscess: A meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204.

Question 50

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Explanation

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.
McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 51

A prospective randomized trial is conducted to test the efficacy of Vitamin C versus placebo in treating patients who develop chronic regional pain syndrome (CRPS) after distal radius fractures. At first follow-up, the rates of CRPS are 1% and 9% in the study and placebo group, respectively. Which statistical test is most appropriate to determine significance?

Explanation

In the study provided, we need to determine whether distributions of categorical variables differ from one another. The appropriate study is the chi-square test.
Data can be classified as numerical (continuous) or categorical (proportional). Responses to such questions as "What is your major?" or Do you own a car?" are categorical because they yield data such as "biology" or "no." In contrast, responses to such questions as "How tall are you?" or "What is your G.P.A.?" are numerical. When comparing two independent means from numeric data, a t-test is performed. However, if categorical data is being compared, the chi-square test will determine if the proportions are really different.
Kocher et al. review basic clinical epidemiology and biostatistics relevant to orthopaedic surgery. Amongst other things, they describe that data can be summarized in terms of measures of central tendency, such as mean, median, and mode, and in
terms of measures of dispersion, such as range, standard deviation, and percentiles. Illustration A shows an algorithm for determining which test to use for varying data.
Incorrect Answers:

Question 52

The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Explanation

One of the suggested causes of Perthes disease is a hypercoaguable state in a child. This would lead to thrombotic venous occlusion in the proximal femur resulting in venous hypertension and osteonecrosis of the femoral head. Therefore look for an answer that would result in a hypercoaguable state. There is no link between hypophosphatemia or high dietary cholesterol intake and a hypercoaguable state. Elevated levels of antithrombin III would result in bleeding, not coagulation. The referenced paper demonstrated a familial occurrence in protein S and protein C deficiency and elevated levels of lipoprotien A. Protein C and S are antithrombotic factors and lipoprotein A is a thrombogenic, atherogenic lipoprotein associated with osteonecrosis in adults.

Question 53

Figures 1 through 3 show the radiograph and MR arthrograms obtained from a 25-year-old woman who has had right groin pain since joining the military 4 years ago. She has undergone treatment with NSAIDs, physical therapy, and activity modification. Examination reveals positive flexion abduction and external rotation, a positive external log roll, and increased range of motion. What is the most appropriate treatment?

Explanation

DISCUSSION:
This patient has symptomatic hip dysplasia that has been recalcitrant to nonsurgical management. Radiographs reveal an upsloping sourcil (acetabular index of 18) and a lateral center edge angle of 14, with posterior uncovering. The MR arthrogram shows no definitive evidence of a labral tear. Appropriate surgical management would include periacetabular osteotomy. Viscosupplementation in the hip is controversial in the treatment of osteoarthritis and plays no role in the treatment of dysplasia. Hip arthroscopy with labral repair is controversial in mild hip dysplasia, with studies demonstrating between 60% and 77% good and excellent results, inferior to the results for hip arthroscopy in a femoroacetabular impingement cohort. In moderate to severe dysplasia, hip arthroscopy is not recommended. Because the acetabular cartilage is well maintained, total hip arthroplasty would not be recommended in this young and active patient.

Question 54

What is the best way to determine whether a radial head implant is too thick intraoperatively?

Explanation

Widening of the medial ulnohumeral joint on an AP radiograph is only visible after overlengthening of the radial head by 6 mm or more. At least in this cadaver study, the most sensitive method was to visually assess the lateral aspect of the ulnohumeral joint with the radial head resected and then with the trial radial head in place. This method allows detection of any overlengthening.

Question 55

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

Explanation

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

Question 56

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

Explanation

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

Question 57

A 40-year-old man sustains a fracture-dislocation of C4-5. Examination reveals no motor or sensory function below the C5 level. All extremities are areflexic. The bulbocavernosus reflex is absent. The prognosis for this patient’s neurologic recovery can be best determined by Review Topic

Explanation

The patient has spinal shock. Steroid administration and MRI are appropriate therapeutic and diagnostic procedures. Myelography with CT is of little value unless there is an unusual skeletal variant. Spinal cord-evoked potentials have no value. The best method to determine the patient’s neurologic recovery is repeated physical examinations over the first 48 to 72 hours.

Question 58

A 40-year-old carpenter has a 3-month history of right arm pain and neck pain that now leaves him unable to work. Examination reveals a positive Spurling test, weakness of the biceps, and a mildly positive Hoffman’s sign on the right side. Electromyography and nerve conduction velocity studies show a right C6 deficit. Figures 27a through 27c show MRI scans that reveal two-level spondylotic disease at C5-6 and C6-7, a large herniated nucleus pulposus at C5-6, and a prominent ridge and hard disk at C6-7. Nonsurgical management fails to provide relief, so the patient elects surgical intervention. Which of the following surgical options would give the best long-term results?

Explanation

DISCUSSION: The patient has a single-level deficit by clinical examination but an adjacent level that may be pathologic. Hilibrand and associates, in a review of 374 patients with myeloradiculopathy treated with single-level or multilevel anterior cervical diskectomy and fusion, showed that 25% of patients had an occurrence of new radiculopathy or myelopathy at an adjacent level within 10 years after surgery. Reoperation rates were highest in those patients where the adjacent nonfused segment was C5-6 or C6-7. Those patients who had multilevel fusions had a lower incidence of adjacent segment disease. The authors recommended incorporating an adjacent level in the initial procedure in patients with myelopathy or radiculopathy when significant disease was noted. Posterior keyhole foraminotomy is an excellent procedure for single-level radiculopathy but is not effective in relieving myelopathy. Anterior cervical diskectomy without fusion has an increased incidence of hypermobility and neck pain on long-term follow-up. In a later review, these authors reported improved fusion rates and better clinical outcomes with the use of strut fusions instead of multilevel interbody grafts.
REFERENCES: Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999;81:519-528.
Henderson CM, Hennessy RG, Shuey HM Jr, Shackelford EG: Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: A review of 846 consecutively operated cases. Neurosurgery 1983;13:504-512.
Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut grafting. J Bone Joint Surg Am 2001;83:668-673.

Question 59

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

Explanation

The prosthesis is grossly infected. Removal of the components and placement of an antibiotic spacer is necessary to eradicate the infection and allow for a second stage reimplantation. Resection arthroplasty is an option to treat the infection but the functional outcome would be limited. Bone grafting with concurrent infection is not likely to heal and should be delayed until the second stage. Humeral head exchange and debridement or arthroscopic debridement alone is unlikely to eradicate the infection.

Question 60

Which of the following factors is most commonly associated with mechanical failure of a cemented total hip arthroplasty?

Explanation

DISCUSSION: Varus position of the stem is most commonly associated with failure of the cemented femoral component because of association with an inadequate cement mantle in the proximal medial and distal lateral zones. An inadequate cement mantle and obesity have been associated with increased loosening but not as frequently as a varus deformity. The influences of gender and osteoporotic bone on the outcome of cemented femoral components have not been established.
REFERENCES: Maloney WJ III: Primary cemented total hip arthroplasty, in Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 179-189.
Callaghan JJ, Salvati EA, Pellicci PM, Wilson PD Jr, Ranawat CS: Results of revision for mechanical failure after cemented total hip replacement, 1979 to 1982: A two- to five-year follow-up. J Bone Joint Surg Am 1985;67:1074-1085.

Question 61

A 17-year-old girl with Charcot-Marie-Tooth disease reports the development of progressive instability when walking on uneven surfaces. Her involved heel is positioned in varus when viewed from behind. Examination reveals that she walks on the outer border of the involved foot. She has full passive motion of the ankle and hindfoot joints. She is able to dorsiflex the ankle against resistance. The heel varus fully corrects with the Coleman block test. Standing radiographs reveal a cavus deformity with valgus of the forefoot. She would like to avoid using an ankle-foot orthosis. What is the best surgical option?

Explanation

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 62

A 47-year-old woman has a right bunion that has been symptomatic despite modifications in shoe wear. She requests surgical correction. An AP radiograph is shown in Figure 37. Treatment should consist of

Explanation

DISCUSSION: Because the radiograph reveals an intermetatarsal angle of greater than 15 degrees and an incongruent metatarsophalangeal joint, the treatment of choice is a proximal first metatarsal osteotomy with distal soft-tissue realignment. A distal chevron procedure would not correct this degree of deformity. A Keller procedure is reserved for a less active elderly individual. Arthrodesis is appropriate for a patient with advanced arthritis of the metatarsophalangeal joint. The double osteotomy is reserved for the congruent metatarsophalangeal joint with hallux valgus.
REFERENCES: Coughlin MJ, Carlson RE: Treatment of hallux valgus with an increased distal metatarsal articular angle: Evaluation of double and triple first ray osteotomies. Foot Ankle Int 1999;20:762-770.
Coughlin MJ: Hallux valgus. Instr Course Lect 1997;46:357-391.

Question 63

Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?

Explanation

DISCUSSION: Anterior perforation of the femur has been attributed to a simple mismatch in the radius of curvature of implants and the apex anterior bowed femur.
The radius of curvature is generally smaller (114-120 cm) than many earlier generation femoral nails (up to 300 cm), and the referenced article by Ostrum et al describes a case series of 3 such patients with subtrochanteric fractures. He noted that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures.
Illustration A shows an example of a nail penetrating the anterior femoral cortex.

Question 64

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Explanation

DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment.
REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.

Question 65

Which of the following factors is associated with improved outcomes following surgery for hip fractures?

Explanation

Many studies have looked at patient outcomes following hip fracture surgery. While early surgery in these patients is recommended, medical optimization prior to surgical intervention is warranted in all cases. Anesthetic type and discharge status have not been proven to alter patient outcomes. Total hip arthroplasty has improved function at 1 year compared with hemiarthroplasty; no changes in mortality have been reported.

Question 66

Figure 46 shows the radiograph of a 65-year-old man who reports restricted range of motion and pain with sitting 18 months after undergoing right side revision total hip arthroplasty. What is the most appropriate management? L Intensive physiotherapy

Explanation

DISCUSSION: The presence of Brooker grade 1 or 2 heterotopic ossification (HO) does not influence the outcome of total hip arthroplasty, whereas restricted range of motion and pain may occur in patients with more severe grade 3 or 4 HO. Treatment may be nonsurgical or surgical. Nonsurgical management includes intensive physiotherapy during the maturation phase of the disease in an attempt to limit the final stiffness. There appears to be no data regarding the effectiveness of this treatment. There is no role for NSAIDs or radiotherapy as a treatment for preexisting HO. Surgical treatment involves excision of the heterotopic bone and can be expected to improve the functional outcome. Bisphosphonates have been used in the past, but their use has been discontinued as they only postpone ossification until treatment is stopped.
REFERENCES: Board TN, Karva A, Board RE, et al: The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 2007;89:434-440.
Harkess JW, Crockarell JR: Arthroplasty of the hip, in Canale ST, Beaty JH (eds): Campbell’s Operative
Orthopaedics, ed 11. Philadelphia, PA, Mosby Elsevier, 2008, vol 1, pp 314-483.

Question 67

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely when placing a sharp retractor

Explanation

DISCUSSION
Vascular complications during TKA are rare but do occur. Traditionally, it was taught that the popliteal artery was situated posterior to the PCL; however, more recent anatomic dissections have demonstrated that this artery is usually posterolateral to the PCL.

Question 68

What is the most common complication following reverse total shoulder arthroplasty?

Explanation

A 75-year-old woman with rheumatoid arthritis and a long history of oral corticosteroid use sustains a comminuted intra-articular distal humerus fracture. What is the best surgical option?
A. Open reduction internal fixation (ORIF) with parallel plates
B. ORIF with orthogonal plates and iliac crest bone grafting
C. Total elbow arthroplasty (TEA)
D. Closed reduction and percutaneous pinning
TEA is the best surgical option. McKee and associates published a multicenter randomized controlled trial comparing ORIF with TEA in elderly patients. TEA resulted in better 2-year clinical functional scores and more predictable outcomes compared with ORIF. TEA was also likely to result in a lower reoperation rate; one-quarter of patients with fractures randomized to ORIF could not achieve stable fixation. Further, Frankle and associates reported a comparative study of TEA versus ORIF in 24 elderly women. TEA outcomes were again superior to ORIF at a minimum of 2 years of follow-up. TEA was especially useful in patients with comorbidities that compromise bone stock, including osteoporosis and oral corticosteroid use. Closed reduction and percutaneous pinning studies have not been published on the adult population. Correct answer : C

Question 69

A 20-year-old man has a symptomatic lesion of fibrous dysplasia in the femoral neck. Management should consist of

Explanation

DISCUSSION: Fibrous dysplasia in the femoral neck frequently warrants treatment because of the risk of pathologic fracture. Cortical strut grafts reduce the risk of local recurrence compared with cancellous bone grafting. Because of the consequences associated with fracture in this location, prophylactic fixation is recommended. Radiation therapy and chemotherapy are not used for this benign condition.
REFERENCES: Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 197.
Enneking WF, Gearen PF: Fibrous dysplasia of the femoral neck: Treatment by cortical bone grafting. J Bone Joint Surg Am 1986;68:1415.

Question 70

A 40-year-old woman has progressive pain and limited range of motion in her long finger. Figure 28a shows the radiograph, and Figure 28b shows a biopsy specimen of the same lesion. What is the most likely diagnosis?

Explanation

Giant Cell tumors (GCT) are relatively common in the appendicular skeleton, most common during the 4th or 5th decades of life. GCT’s are destructive lesions with variable amounts of reactive bone at their margin. Successful treatment requires complete surgical excision.

Question 71

Figures 15a through 15d

Explanation

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160. View Abstract at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901. View Abstract at PubMed

Question 72

Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion?

Explanation

DISCUSSION: The Level 2 study by Czisy et al is a review of a randomized trial database that analyzed the prospective clinical outcome of 45 patients who failed closed or open treatment of a displaced intraarticular calcaneal fractures. The cohort underwent a subtalar fusion by distraction bone-block arthrodesis for subtalar arthritis. They found that male worker's compensation patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0 degrees were the most likely to undergo a subtalar fusion.
The meta-analysis by Randle et al reviewed 6 clinical studies comparing the results of operative vs. conservative management of calcaneal fracture studies. They found a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients, however they could not draw any definitive conclusions guiding treatment

Question 73

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Explanation

DISCUSSION: Based on the references provided, the advantages of the lateral position include: facilitates the retraction of the vastus lateralis, allows hip flexion to aid reduction, improves access to the proximal segment (easier to get starting point). Disadvantages of the lateral position include: intraoperative imaging may be more difficult, rotation is more difficult to judge, and lateral positioning may not be practical in the polytraumatized patient.
Advantages of the supine position include: may help protect a potentially unstable spine, facilitates access to sites other than the injured femur, shorter setup time, rotational and angulatory deformities may be more easily appreciated. Disadvantages of the supine position include: starting point localization may be more difficult.

Question 74

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scan shows an acute complete tear of the posterior cruciate ligament. No evidence is seen of a quadriceps tendon rupture, a tibia fracture, or a bone contusion.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 533-557.
Harner CD, Hoher J: Evaluation and treatment of posterior cruciate ligament injuries. Am J Sports Med 1998;26:471-482.

Question 75

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with

Explanation

DISCUSSION: Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to

130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best.

REFERENCES: Rittmeister M, Kerschbaumer M: Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10:17-22.
Visotosky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Werner CM, Steinmann PA, Gilbart M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.

J Bone Joint Surg Am 2005;87:1476-1486.

Question 76

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Explanation

All of the following listed are associated with the female athlete triad except for Low LDL cholesterol levels. In fact, these patients often have elevated levels of LDL due to the hypoestrogenism caused by menstrual dysfunction.
The female athlete triad is an interrelationship of menstrual dysfunction (i.e., amenorrhea or oligomenorrhea), low energy availability (insufficient caloric intake for demand, with or without an eating disorder) and decreased bone mineral density. It is relatively common among young women participating in sports. More recently, it has been suggested that endothelial dysfunction also results, due to an imbalance between vasodilating and vasoconstricting agents triggered from inappropirate levels of nitric oxide on the microscopic level, which predisposes these women to atherosclerotic changes and increases their risk of cardiovascular disease in the future.
Matheson et al. analyzed cases of 320 athletes with bone scan-positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. They found that conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.
Constantini et al. evaluated the prevalence of vitamin D insufficiency and deficiency among young athletes and dancers. They found a higher rate of vitamin D insufficiency among participants who practice indoors, during the winter months, and in the presence of iron depletion.
Nazem et al. reviewed the major components and health consequences of the female athlete triad as well as strategies for diagnosis and treatment of the conditions. They concluded that treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members.
Yagi et al. followed 230 runners participating in high school running teams for a total of 3 years to report occurrence of medial tibial stress syndrome (MTSS) and stress fracture. Predictors of MTSS and stress fracture were investigated. The authors reported a significant relationship between BMI, internal hip rotation angle and MTSS infemales.
Incorrect Answers:

Question 77

-Figures a and b are the MRI scans of the cervical spine without contrast of a 38-year-old man with neck pain radiating into the right upper extremity for the past 4 weeks. He denies numbness or weakness.Examination was significant for reproduction of pain going down the right arm with neck extension and right lateral rotation. What is the next treatment step?

Explanation

Question 78

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

Explanation

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

Question 79

A 63-year-old woman who sustained a distal radial fracture 2 months ago now reports that she is unable to achieve active extension of the thumb at the interphalangeal joint. What type of trauma may lead to this clinical finding?

Explanation

DISCUSSION: Nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon. The extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon.
REFERENCES: Helal B, Chen SC, Iwegbu G: Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand 1982;14:41-47.
Hirasawa Y, Katsumi Y, Akiyoshi T, et al: Clinical and microangiographic studies on the rupture of the EPL tendon after distal radial fractures. J Hand Surg Br 1990;15:51-57.

Question 80

A 24-year-old woman was struck by a mini van in a parking lot and sustained a closed segmental tibia fracture that was treated with an intramedullary nail the following morning. Follow-up examinations reveal a slowly progressive clawing of all five toes, a progressive equinocavovarus contracture, and the patient is unable to perform a single heel rise on the affected limb. At 1 year after surgery, the patient now has a 10-degree equinus contracture that is not relieved with knee flexion. Treatment should now consist of

Explanation

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 81

Figure 30 shows the radiograph of an 82-year-old woman who reports a 1-month history of shoulder pain. She is able to actively elevate her arm to 150 degrees but is experiencing discomfort. Her sleep is disrupted because of the shoulder pain. What is the most appropriate management? Review Topic

Explanation

The patient is experiencing rotator cuff tear arthropathy. Given that this is the first medical treatment she has sought, a nonsurgical treatment plan of anti-inflammatory medication or a corticosteroid injection is warranted. Proceeding to the operating room without a trial of nonsurgical management is not indicated in this patient population. Surgical procedures may be necessary in the future if nonsurgical measures fail.

Question 82

A right-handed 14-year-old pitcher has had a 3-month history of shoulder pain while pitching. Examination reveals full range of motion, a mildly positive impingement sign, pain with rotational movement, and no instability. Plain AP radiographs of both shoulders are shown in Figures 25a and 25b. Management should consist of

Explanation

DISCUSSION: The patient has the classic signs of Little Leaguer’s shoulder, with findings that include pain localized to the proximal humerus during the act of throwing and radiographic evidence of widening of the proximal humeral physis. Examination usually reveals tenderness to palpation over the proximal humerus, but the presence of any swelling, weakness, atrophy, or loss of motion is unlikely. The treatment of choice is rest from throwing for at least 3 months, followed by a gradual return to pitching once the shoulder is asymptomatic.
REFERENCES: Carson WG Jr, Gasser SI: Little Leaguer’s shoulder: A report of 23 cases. Am J Sports Med 1998;26:575-580.
Barnett LS: Little League shoulder syndrome: Proximal humeral epiphyseolysis in adolescent baseball pitchers. A case report. J Bone Joint Surg Am 1985;67:495-496.

Question 83

A 42-year-old woman complains of ankle pain with weightbearing for the last 2 years. She recalls spraining her ankle more than 10 years ago. She plays tennis and regularly walks 5 miles a day for exercise, but has had to give up these activities over the last few months because of pain. Examination reveals limitation in ankle dorsi- and plantar flexion. A course of non-operative management has been unsuccessful. Which of the following options will most likely provide pain relief and allow her to return to her previous activity level?

Explanation

This young, active patient has ankle valgus following previous trauma. A corrective supramalleolar osteotomy of the tibia will provide pain relief and improve range of motion, allowing return to sports.
Supramalleolar osteotomy may be performed for varus (medial opening wedge or lateral closing wedge) or valgus (lateral opening wedge or medial closing wedge) ankles. They are suited for near-normal ROM minimal talar-tilt or varus heel alignment, asymmetric ankle arthritis (confined to medial or lateral compartment; corresponding to Takakura Stage II or IIIA for medial ankle arthritis).
Pagenstert et al. looked at realignment surgery for posttraumatic arthritis in 35 patients. For valgus ankles, they performed 18 medial closing wedge and 1 lateral opening wedge osteotomies. For varus ankles, they performed 7 medial opening wedge and 4 lateral closing wedge osteotomies. There was improvement in pain (7/10 to 3/10), ROM (33° to 38°) and Takakura score (2.3 to 1.3).
Lee et al. described supramalleolar osteotomy for medial arthritis in 16 patients. There was improvement in AOFAS score (62 to 82), Takakura stage (2.9 to 2.3), tibial-anterior surface angle (85 to 100°). Patients with low postoperative talar tilt (TT) had better clinical and radiographic results than those with high TT. Greater postoperative heel valgus predicted for postoperative subfibular pain.
Figure A shows valgus alignment at the ankle. Illustration A shows the same ankle following medial closing wedge supramalleolar osteotomy. Illustration B is a table showing the Takakura classification. Illustration C demonstrates correction of the tibial-anterior surface angle (TAS) following supramalleolar osteotomy.
Incorrect Answers:

Question 84

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

Explanation

DISCUSSION: Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation. Incision and drainage may result in a bacterial infection. Marsupialization is used in the treatment of a chronic paronychia. Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns.
REFERENCES: Fowler JR: Viral Infections. Hand Clin 1989;5:613-627.
Jebsen PL: Infections of the fingertip: Paronychias and felons. Hand Clin 1998;14:547-555.

Question 85

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Explanation

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

Question 86

Figures 20a and 20b show lateral and AP radiographs of a 49-year-old man who sustained a gunshot wound through the left shoulder. He reports neck pain and examination reveals weakness in all four extremities. What is the priority of evaluation?

Explanation

DISCUSSION: The projectile entered the left shoulder and traveled to the right neck; therefore, a high incidence of suspicion must be directed to the airway, great vessels of the neck, and contents of the mediastinum. Immediate assessment of airway, breathing, and circulation takes priority, followed by examination of the neurologic status and other systems, as determined by the examination findings.
REFERENCES: Subcommittee on ATLS of the American College of Surgeons Committee on Trauma 1993-1997, Spine and Spinal Cord Trauma; Advanced Trauma Life Support Student Manual, ed 6, 1997.
International Standards for Neurological and Functional Classification of Spinal Cord Injury. American Spinal Injury Association and International Medical Society of Paraplegia (ASIA/IMSOP).

Question 87

Which of the following conditions is associated with palmoplantar pustulosis?

Explanation

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,

WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 88

A 67-year-old woman has a painful, arthritic proximal interphalangeal (PIP) joint, and nonsurgical measures have failed to improve the pain. What implant and joint replacement approach combination has been demonstrated to have the lowest rate of revision surgery?

Explanation

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate, the worst gain in arc of motion, and the greatest extension lag. However, substantial pain relief and higher satisfaction still were reported after surface replacement arthroplasty, regardless of the complications.

Question 89

Figures 39a and 39b are the radiographs of a 45-year-old man with diabetes who fell 12 feet from a ladder and sustained an isolated closed injury to his left leg. Examination revealed that he was neurovascularly intact and compartments were soft. A damage control knee spanning external fixator was applied and after 2 weeks in the frame, his blisters have resolved and his skin now wrinkles. What is the most appropriate treatment?

Explanation

The patient has sustained a severely comminuted bicondylar fracture of the tibial plateau. The mechanism and radiographs highlight the high-energy mechanism of the injury and should warrant aggressive monitoring for compartment syndrome which is relatively common in this scenario. A staged surgical approach is warranted with application of a spanning damage control external fixator to maintain length and
alignment while the soft-tissue injury recovers and to allow for surveillance and examination of the limb. The radiographs reveal a comminuted bicondylar pattern with significant depression of the lateral articular surface and a split fracture with condylar widening. This element of the fracture will require direct elevation of the joint surface and reduction/buttress of the lateral condyle. This is best achieved with a lateral plate with subchondral rafting screws. The medial articular surface is coronally split and the posteromedial fragment is displaced. This fragment requires direct reduction and buttress via a separate posteromedial approach which is frequently performed prior to the lateral approach and fixation. A lateral buttress plate or a lateral locking plate alone does not reliably capture or adequately support the displaced posteromedial fragment. A medial and lateral plate construct is less soft-tissue friendly, particularly if inserted through a single incision. A medial plate would also fail to give direct buttress to the posteromedial fragment.

Question 90

A 10-month-old infant has a deformity of the right foot. Radiographs, including simulated weight-bearing AP and lateral views and a maximum plantar flexion lateral view, are shown in Figures 57a through 57c. Initial management of the foot should consist of Review Topic

Explanation

The radiographs show a congenital vertical talus. This is confirmed on the maximum plantar flexion lateral view which shows failure of the long axis of the first metatarsal to align with the long axis of the talus. This finding is caused by a fixed dorsal dislocation of the navicular on the head of the talus. The initial treatment should consist of manipulation and serial cast application in an attempt to elongate the contracted dorsolateral tendons, joint capsules, and skin. Surgery is always required to complete the correction. Traditionally, surgical treatment consisted of lengthening of the dorsolateral tendons, release of the talonavicular joint capsule, and lengthening of the Achilles tendon. Recently, Dobbs and associates reported the successful use of manipulation and cast immobilization, followed by pinning of the talonavicular joint and percutaneous tenotomy of the Achilles tendon in patients with idiopathic congenital vertical talus. There are no studies documenting the effectiveness of orthoses for the treatment of this condition. Lateral column lengthening may be indicated in older individuals with a symptomatic flexible flatfoot, especially those with neurologic conditions. Observation may be indicated in a young child with a painless flexible flatfoot.

Question 91

A 55-year-old man has had a mass in his right thigh for the past 2 months. An MRI scan and biopsy specimens are shown in Figures 55a through 55c. What is the most likely diagnosis?

Explanation

DISCUSSION: The histology shows extraskeletal myxoid chondrosarcoma, characterized by abundant blue myxoid matrix with cords and nests of small tumor cells. Treatment consists of wide resection. Despite the name, hyaline cartilage is not a common component of these tumors. Adult rhabdomyosarcoma and malignant fibrous histiocytoma are highly pleomorphic sarcomas often containing multinucleated giant cells. Myxoid liposarcoma contains a prominent capillary network and lipoblasts. Myxoma is less cellular than extraskeletal myxoid chondrosarcoma and does not have a cord-like arrangement of tumor cells.
REFERENCE: Kawaguchi S, Wada T, Nagoya S, Ikeda T, Isu K, Yamashiro K, et al: Extraskeletal myxoid chondrosarcoma. Cancer 2003;97:1285-1292.

Question 92

Figure 177 is an intra-articular photograph taken while viewing from the anterior superior portal during arthroscopy of a right shoulder. Which of the following findings identified at the time of surgery would be the most predictive for recurrence following arthroscopic repair of the demonstrated pathology? Review Topic

Explanation

Anterior glenoid bone deficiency of 35% is most predictive of recurrence. Figure 177 shows an acute tear of the anterior inferior glenoid labrum consistent with a Bankart lesion. It has been clearly shown that there is a direct relationship between failure (ie, recurrent dislocation) of arthroscopic Bankart repair and anterior glenoid bone loss. Anterior glenoid bone loss of greater than 25% in the setting of anterior glenohumeral instability is a relative contraindication to performing arthroscopic stabilization and instead is an indication to perform a bony glenoid augmentation procedure to address the articular arc deficit. Therefore, an anterior bony defect of 35% is the most predictive finding at the time of surgery for recurrent dislocation. An engaging Hill-Sachs deformity has a significant effect on the rate of redislocation, but a nonengaging one should not. An intra-articular loose body, subacromial bursitis, and a partial-thickness articular-sided supraspinatous tear should not lead to an increased risk of recurrent dislocation following Bankart repair.

Question 93

A 24-year-old baseball pitcher reports pain over the posterior aspect of his shoulder that occurs only during throwing. He notes that the discomfort is greatest during the late cocking and early acceleration phases. Examination reveals localized tenderness with palpation over the external rotators and posterior glenoid. Radiographs are shown in Figures 38a through 38c. What is the most likely diagnosis?

Explanation

DISCUSSION: The radiographs show a posterior glenoid osteophyte, often termed a “thrower’s exostosis.” These exostoses are best visualized on the Stryker notch view and may be missed on other more standard radiographic views of the shoulder. CT and MRI scans may be used, but usually add little information to the radiographic findings. Arthroscopic examination of patients with this condition commonly reveals undersurface tearing of the rotator cuff and posterior labrum. Treatment of this condition remains somewhat controversial, with avocation of both nonsurgical and surgical techniques.
REFERENCES: Meister K, Andrews JR, Batts J, Wilk K, Baumgarten T, Baumgartner T: Symptomatic thrower’s exostosis: Arthroscopic evaluation and treatment. Am J Sports Med 1999;27:133-136.
Ferrari JD, Ferrari DA, Coumas J, Pappas AM: Posterior ossification of the shoulder: The Bennett lesion. Etiology, diagnosis, and treatment. Am J Sports Med 1994;22:171-176.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posteriorsuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg 1992;1:238-245.

Question 94

A 16-year-old high school pitcher notes acute pain on the medial side of his elbow during a pitch. Examination that day reveals medial elbow tenderness, pain with valgus stress, mild swelling, and loss of extension. Plain radiographs show closed physes and no fracture. Which of the following diagnostic studies will best reveal his injury?

Explanation

DISCUSSION: The history and findings are consistent with a diagnosis of a sprain of the medial collateral ligament (MCL) of the elbow; therefore, contrast-enhanced MRI is considered the most sensitive and specific study for accurately showing this injury. Arthroscopic visualization of the MCL is limited to the most anterior portion of the anterior bundle only; complete inspection of the MCL using the arthroscope is not possible. CT without the addition of contrast is of no value in this situation. Use of a technetium Tc 99m bone scan is limited to aiding in the diagnosis of occult fracture, a highly unlikely injury in this patient. There are no clinical indications for electromyography.
REFERENCES: Timmerman LA, Andrews JR: Undersurface tear of the ulnar collateral ligament in baseball players: A newly recognized lesion. Am J Sports Med 1994;22:33-36.
Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography: Evaluation of 25 baseball players with surgical confirmation. Am J Sports Med 1994;22:26-32.
Fritz RC, Stoller DW: The elbow, in Stoller DW (ed): Magnetic Resonance Imaging in Orthopedics and Sports Medicine, ed 2. Philadelphia, PA, Lippincott Raven, 1995, pp 743-849.

Question 95

An orthopaedic surgeon is counseling a patient regarding risk for complications following lumbar fusion via a direct lateral approach. Surgery at which level is most likely to injure the lumbosacral plexus?

Explanation

DISCUSSION
During the direct lateral approach, interbody fusion devices are inserted through a lateral window in the psoas muscle. To accomplish this, dilators and retractors are positioned at the posterior half of the disk space, and it must be noted that the lumbosacral plexus lies within the psoas muscle between the transverse process and vertebral body and departs distally at the medial edge of the psoas. Consequently, lateral interbody fusion poses risk for injury to the lumbosacral plexus. A cadaveric study demonstrated that the lumbosacral plexus progressively migrates from dorsal to ventral in the lumbar spine. Therefore, the plexus is most likely to be injured during an L4-L5 fusion because at this level the lumbosacral plexus is closest to the location at which dilators and retractors are placed.
A 2013 retrospective study by Le and associates followed 71 patients who underwent minimally invasive fusion via a lateral interbody approach. In this study, 54.9% (39/71) had immediate postsurgical ipsilateral iliopsoas or quadriceps weakness. Of these patients, the majority had resolution by 3 months (92.3%), and all had complete resolution by 2 years.
RECOMMENDED READINGS
Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
View Abstract at PubMed
Benglis DM, Vanni S, Levi AD. An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009 Feb;10(2):139-44. doi: 10.3171/2008.10.SPI08479. PubMed PMID: 19278328. View Abstract
at PubMed
Knight RQ, Schwaegler P, Hanscom D, Roh J. Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile. J Spinal Disord Tech. 2009 Feb;22(1):34-

Question 96

A patient who underwent an L5-S1 hemilaminotomy and partial diskectomy for radiculopathy 3 weeks ago now reports increasing leg and back pain with radicular signs. An axial T2-weighted MRI scan is shown in Figure 97a, an axial T1-weighted MRI scan is shown in Figure 97b, and a contrast enhanced T1-weighted MRI scan is shown in Figure 97c. What is the most appropriate management for the patient's symptoms? Review Topic

Explanation

The MRI scans show a recurrent disk herniation. There is no increase fluid signal or enhancement to suggest infection or any other pathologic process. There is no infection; therefore, IV antibiotics and debridement are not indicated. Similarly, a pseudomeningocele is not present. In addition, with progressive weakness, physical therapy is not appropriate. A revision diskectomy is useful for recurrent radiculopathy.

Question 97

Figures 34a through 34c show an axial proton density (spin echo long TR, short TE) image, a sagittal inversion recovery (STIR) image, and a sagittal T1-weighted (short TR, short TE) image of the left thigh. What is the most likely diagnosis?

Explanation

DISCUSSION: The images reveal a region of increased signal within the rectus femoris muscle with mild, ill-defined surrounding edema. The presence of high intensity signal on the T1-weighted image favors acute blood, in this case associated with a rectus femoris muscle tear or fatty tissue. However, because of fat suppression, a fatty lesion or lipoma would be dark on STIR, rather than bright as in this image. Most foreign bodies are low intensity signal and if small, are difficult to evaluate with MRI. The lack of adjacent subcutaneous soft-tissue edema or surrounding fluid makes pyomyositis an unlikely diagnosis.
REFERENCE: El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 123.

Question 98

below show the radiographs, and the CT obtained from a year-old woman who underwent cementless left total hip arthroplasty. Nine months after surgery, she continued to have groin pain when actively flexing her hip. She has trouble walking up stairs and getting out of her car. What is the most likely diagnosis?

Explanation

DISCUSSION:
Groin pain after total hip replacement has a number of possible causes, and an exact diagnosis may remain elusive in some patients. Infection should be ruled out with laboratory studies and, if indicated, diagnostic aspiration of the hip joint. Implant loosening should be evaluated by plain radiograph and bone scan, if indicated. Synovitis resulting from wear debris should be considered in patients with polyethylene liners who experience late-onset symptoms or in any patient with a metal-on-metal bearing. This patient's symptoms are classic for iliopsoas tendonitis. Physical examination usually reveals pain and weakness with resisted hip flexion. A cross-table lateral radiograph and CT show that the anterior edge of the acetabulum protrudes beyond the anterior wall, thereby acting as a source of iliopsoas tendon irritation. In such cases, acetabular component revision and repositioning are indicated. Fluoroscope-guided iliopsoas cortisone injection can help to establish the diagnosis and relieve groin pain. If the acetabular component is well positioned, then iliopsoas tenotomy should be considered.

Question 99

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

Explanation

The patient has snapping hip syndrome of the internal type, which is more common in ballet dancers. It is caused by the iliopsoas tendon gliding over the iliopectineal line or the femoral head. The diagnosis usually can be made by the history and physical examination. Snapping is reproduced by hip flexion and extension or flexion with external rotation and abduction. Conventional and dynamic ultrasonography will confirm the snapping structure. Radiographs occasionally show calcifications near the lesser trochanter. MRI can be used to rule out other diagnoses that can simulate snapping hip.

Question 100

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

Explanation

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

Full Question & Answer Text (for Search Engines)

Question 1:

Which of the following deformities is most common after the amputation shown in Figure A?

Options:

Pes cavus
Pes planus
Hindfoot valgus
Equinovarus
Calcaneovalgus

Correct Answer: Pes cavus

Explanation:

Question 2:

A 16-year-old boy sustains a twisting injury to the left knee while wrestling. MRI scans are shown in Figures 22a through 22c. What is the most likely diagnosis? Review Topic

Options:

Anterior cruciate ligament rupture
Posterior cruciate ligament rupture
Bucket-handle medial meniscus tear
Lateral meniscus tear
Osteochondral lesion

Correct Answer: Bucket-handle medial meniscus tear

Explanation:

Question 3:

The afferent pain innervation of the L3-L4 facet joint arises from the medial branch nerve of

Options:

L2.
L3.
L4.
L2 and L3.
L3 and L4.

Correct Answer: L2 and L3.

Explanation:

Question 4:

Options:

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

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

Explanation:

Question 5:

Figures 48a and 48b show the radiographs of a 26-year-old woman who fell down two steps and twisted her foot and ankle. What is the most appropriate treatment for this injury?

Options:

Open reduction and internal fixation with a mini fragment plate and screws
Closed cannulated screw fixation
Short leg casting for 6 weeks
Hard-soled shoe and weight bearing as tolerated
Short leg cast and non-weight-bearing, followed by weight bearing as tolerated for 6 weeks in a fracture brace

Correct Answer: Hard-soled shoe and weight bearing as tolerated

Explanation:

DISCUSSION: The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted.
REFERENCES: Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10.
Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Bucholz R, Heckman JD, Court-Brown CM (eds): Rockwood and Green’s Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 2337-2400.

Question 6:

What structure is located at the tip of the arrow in Figure 18?

Options:

Left L3 nerve root
Right L3 nerve root
Right L4 segmental artery
Right L4 nerve root
Left lateral disk herniation

Correct Answer: Right L3 nerve root

Explanation:

DISCUSSION: The structure shown is the exiting nerve root at the L3-4 disk, which is the right L3 root.
REFERENCE: An H: Diagnostic imaging of the spine, in Principles and Techniques of Spine Surgery. Baltimore, MD, Lippincott Williams & Wilkins, 1998, pp 102-125.

Question 7:

Options:

Strong
Moderate
Limited
Inconclusive

Correct Answer: Moderate

Explanation:

Question 8:

Which of the following best describes the legal definition of standard of care?

Options:

Conforming to a majority norm
Providing the most minimally acceptable care
Providing average care
Providing the care you would expect for yourself or a loved one
Reasonable treatment that exhibits knowledge, skill, diligence, and care

Correct Answer: Reasonable treatment that exhibits knowledge, skill, diligence, and care

Explanation:

Question 9:

Options:

lateral plating of the fibula and a percutaneous medial column plate.
intramedullary fixation of the fibula and an anterolateral tibial plate.
open medial column plating, percutaneous screw fixation of the joint, and lateral fibular plating.
screw fixation of the medial column with an anterolateral tibial plate and lateral fibular plating

Correct Answer: screw fixation of the medial column with an anterolateral tibial plate and lateral fibular plating

Explanation:

Discussion:
The timely administration of antibiotics has been shown to be the best initial treatment to reduce the incidence of infection following an open fracture. Life threatening injuries must first be addressed. But in this isolated open pilon fracture, antibiotics should be initiated early along with tetanus prophylaxis. Reduction and splinting would stabilize the fracture but these interventions should follow antibiotic coverage. Emergency department irrigation is controversial. Closed reduction and splinting, external fixation, CT scan, and delayed open reduction internal fixation would be the preferred sequence of management. External fixation to provide provisional limb stabilization would be indicated in this length unstable C type injury to provide soft tissue stabilization and prevent further chondral injury. Splinting alone would not prevent shortening and would not allow soft tissue recovery. CT scans prior to limb stabilization are not warranted because the patterns make more sense after the restoration of gross length, rotation and alignment in the external fixator. Initial fibular fixation is also not recommended in this case because the location of incisions could affect the definitive surgical tactic. In this multi-fragmentary fibular injury, anatomic reduction would be challenging and malreduction could occur and influence subsequent reconstructions. Delayed open reduction internal fixation is ideal after the resolution of soft tissue swelling.

Question 10:

Options:

notification of child protective services and hospital admission.
a punch biopsy of skin for collagen analysis.
DNA testing for OI.
calcium, phosphate, and alkaline phosphatase studies.
placement of intramedullary rods to prevent further fractures.

Correct Answer: notification of child protective services and hospital admission.

Explanation:

Question 11:

A 27-year-old man sustains a displaced femoral neck fracture and undergoes urgent open reduction internal fixation. What is the most prevalent complication after this injury?

Options:

Flexion contracture
Hip instability
Nonunion
Abductor lurch
Osteonecrosis

Correct Answer: Flexion contracture

Explanation:

Question 12:

Figure 1 is the clinical photograph of a 22-year-old college pitcher who complains of posterior shoulder pain and feelings of shoulder weakness. He denies shoulder trauma. Evaluation should include

Options:

CT scan of the shoulder.
ultrasonography of the rotator cuff.
vascular studies of the upper extremity.
electrodiagnostic studies. The patient has atrophy of the infraspinatus. This would be consistent with either a massive rotator cuff tear or suprascapular neuropathy/compression. Given the patient's age and the atraumatic onset of symptoms, a significant rotator cuff injury is unlikely, making a suprascapular nerve issue the most likely diagnosis. Electrodiagnostic studies would be most accurate in confirming nerve compression and would aid in localizing the area of compression between the spinoglenoid notch and the suprascapular notch. An MRI scan also would be beneficial to evaluate for any compressive lesion on the nerve, such as a paralabral cyst. Because rotator cuff pathology is unlikely, ultrasonography of the rotator cuff would be of little benefit. CT scan of the shoulder may allow grading of the atrophy of the muscle, but will not be as sensitive for a paralabral cyst/labral tear. Vascular studies would not aid in the diagnosis.

Correct Answer: electrodiagnostic studies. The patient has atrophy of the infraspinatus. This would be consistent with either a massive rotator cuff tear or suprascapular neuropathy/compression. Given the patient's age and the atraumatic onset of symptoms, a significant rotator cuff injury is unlikely, making a suprascapular nerve issue the most likely diagnosis. Electrodiagnostic studies would be most accurate in confirming nerve compression and would aid in localizing the area of compression between the spinoglenoid notch and the suprascapular notch. An MRI scan also would be beneficial to evaluate for any compressive lesion on the nerve, such as a paralabral cyst. Because rotator cuff pathology is unlikely, ultrasonography of the rotator cuff would be of little benefit. CT scan of the shoulder may allow grading of the atrophy of the muscle, but will not be as sensitive for a paralabral cyst/labral tear. Vascular studies would not aid in the diagnosis.

Explanation:

Question 13:

Options:

MRI to assess for posterior tibialis tendon damage.
enhanced CT to assess for an osteochondral fracture.
tenography of the peroneal tendons to assess for tendon sheath tearing with subluxation.
a bone scan to assess for occult fracture.
arthroscopy of the ankle to assess for articular cartilage damage.

Correct Answer: MRI to assess for posterior tibialis tendon damage.

Explanation:

Question 14:

Options:

have intact motor function.
have protective sensation.
are at risk for progressive neural deterioration.
are at risk for development of a latex allergy.
are at risk for development of severe lordosis.

Correct Answer: have protective sensation.

Explanation:

Question 15:

The arrows in the axial T 1 -weighted MRI scan shown in Figure 25 show which of the following structures?

Options:

Ulnar artery and accompanying vein
Deep and superficial branches of the ulnar nerve
Radial and ulnar digital nerves to the little finger
Palmar cutaneous and thenar motor branch of the median nerve
Dorsal cutaneous branch of the ulnar nerve and common digital artery to the fourth web

Correct Answer: Deep and superficial branches of the ulnar nerve

Explanation:

DISCUSSION: The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon’s canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon’s canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon’s canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon’s canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon’s canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist.
REFERENCES: Gross MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res 1985;196:238-247.
Denman EE: The anatomy of the space of Guyon. The Hand 1978;10:69-76.

Question 16:

Options:

MRI to rule out a complete rupture
Ultrasound of the tendon apposition
Open reduction and internal fixation of the calcaneal fracture
Symptomatic care and physical therapy
Surgical repair with tendon debridement and flexor hallucis longus transfer

Correct Answer: Surgical repair with tendon debridement and flexor hallucis longus transfer

Explanation:

Question 17:

What genetic defect is responsible for achondroplasia? Review Topic

Options:

Trisomy of chromosome 21
Defect in collagen, type 1, alpha 1 (COL1A1)
Defect in fibroblast growth factor 3 (FGF-3)
Defect in fibroblast growth factor receptor 3 (FGFR-3)

Correct Answer: Defect in fibroblast growth factor receptor 3 (FGFR-3)

Explanation:

Question 18:

- Acondroplasia and other chondrodysplasias are caused by mutations in the receptors of which of the following families of growth factors?

Options:

Insulin-like growth factor (IGF-1)
Fibroblast growth factor (FGF-1)
Platelet-derived growth factor (PDGF)
Transforming growth factor beta (TGF-B)
Bone morphogenetic proteins (BMP)

Correct Answer: Fibroblast growth factor (FGF-1)

Explanation:

Question 19:

Options:

Bilateral long thoracic nerve palsies
Central cervical disk herniation
Duchenne muscular dystrophy, adult onset
Fascioscapulohumeral dystrophy
Disuse atrophy as the result of deconditioning

Correct Answer: Fascioscapulohumeral dystrophy

Explanation:

Question 20:

Options:

Will result in improvement in pain but no difference in function or range of motion compared to therapy alone.
Will result in greater improvement in pain and function compared to therapy alone, with equivalent range of motion at one year
Will prevent development of rotator cuff arthropathy in patients with rotator cuff tears.
Will likely have no effect on pain, function or range of motion at one year, compared to therapy alone.
Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Correct Answer: Will result in worse outcomes in terms of pain, function and range of motion, compared with therapy alone.

Explanation:

Question 21:

A patient has a painful metal-on-metal (MOM) left total hip arthroplasty (THA). Which test(s) best correlate with prognosis if this patient is having a reaction to metal debris?

Options:

Erythrocyte sedimentation rate, C-reactive protein, and white blood cell count
Serum cobalt and chromium ion levels
Metal artifact reduction sequence (MARS) MRI
CT scan of pelvis

Correct Answer: Metal artifact reduction sequence (MARS) MRI

Explanation:

Question 22:

Options:

Arthroscopic superior labrum anterior to superior repair
Arthroscopic Bankart repair
Latarjet procedure
Capsulorrhaphy

Correct Answer: Capsulorrhaphy

Explanation:

DISCUSSION
Nonsurgical treatment with activity modification and physical therapy is generally considered the first-line approach for young athletes with multidirectional instability (MDI) of the shoulder. Physical therapy focuses on exercises to strengthen the scapular stabilizers and rotator cuff muscles and restore scapulohumeral rhythm. Although a definitive length of time
to assess physical therapy failure is not known, many surgeons believe that a patient with MDI should undergo at least 6 months of physical therapy and activity modification before considering surgery. Although an open inferior capsular shift has historically been considered the gold standard for surgical treatment for MDI, studies have shown good success rates for arthroscopic capsulorrhaphy. Arthroscopy can allow a surgeon to assess all intra-articular structures and address a patient’s particular problem based on arthroscopic findings.
CLINICAL SITUATION FOR QUESTIONS 21 THROUGH 25
A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow.

Question 23:

Options:

Complete based on the normalization of his blood pressure, urine output, and heart rate
Cannot be determined based on the data presented
Incomplete based on his fluid requirements calculated using his initial blood pressure as a measure of blood volume loss
Incomplete since he will need surgery on the long bone fractures and should be “tanked up” prior to losing blood in the operating room
Incomplete based on his heart rate

Correct Answer: Cannot be determined based on the data presented

Explanation:

DISCUSSION: Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.
REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912.
Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury,
a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.
Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

Question 24:

Which of the following extensor tendons commonly have multiple slips?

Options:

Extensor pollicis longus and abductor pollicis longus
Extensor digiti mini quinti and abductor pollicis longus
Extensor digiti mini quinti and extensor carpi radialis brevis
Extensor indicis proprius and extensor pollicis longus
Extensor indicis proprius and extensor carpi radialis brevis

Correct Answer: Extensor digiti mini quinti and abductor pollicis longus

Explanation:

Question 25:

5 g/dL and his base deficit is 10mEq/L. What is the most appropriate next step in management?

Options:

Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by reamed intramedullary nailing right tibia, open reduction internal fixation left forearm
Reamed intramedullary nailing bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, open reduction internal fixation left
forearm
External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm
External fixation right femur and right tibia following irrigation and debridement, reamed intramedullary nailing left femur, splinting left forearm

Correct Answer: External fixation bilateral femur fractures, irrigation and debridement followed by external fixation right tibia, splinting left forearm

Explanation:

With a base deficit of 10mEq/L, the patient is under-resuscitated and unstable. Thus, damage control orthopedics via external fixation of the long bone injuries with irrigation and debridement of the open tibia is the appropriate next step in management.
Of all of the reported values, the most important predictor of morbidity and mortality is the base deficit (normal range -2 to +2mEq/L), which represents overall resuscitation status. Another representative parameter of resuscitation status is lactate (normal <2mg/dL). Heart rate, blood pressure and hematocrit are not reliable predictors of normalized resuscitation status, morbidity or mortality.
Callaway et al. retrospectively reviewed a large cohort of blunt trauma patients over a 6 year period. Only base deficit and lactate levels were directly correlated with and were reliable predictors of mortality.
Paladino et al. retrospectively reviewed a prospective database of over 1400 patients. Base deficit and lactate were significant and useful predictors of triage upon initial presentation to denote severe versus non-severe injury.
Martin et al. retrospectively analyzed over 2000 sets of laboratory data in 427 ICU patients. Base deficit (anion status), even in ICU patients with normal lactate levels, were predictive of decreased survival.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male sustains an elbow injury after a fall from a skateboard resulting in valgus and supination forces across the left elbow. A CT scan of the left elbow is shown in Figures A through D. This fracture pattern is most commonly associated with what other traumatic elbow pathology?
Posteromedial rotatory instability
Capitellum fracture
Radial head fracture and posterolateral ulnohumeral dislocation
Trans-olecranon fracture dislocation
Medial (ulnar) collateral ligament rupture
Corrent answer: 3
The clinical presentation is consistent with a coronoid tip fracture. This fracture pattern is associated with a radial head fracture and posterolateral ulnohumeral dislocation - together making up the terrible triad injury.
A terrible triad injury is the result of a valgus and supination injury and involves posterolateral elbow dislocation or lateral collateral ligament injury, radial head fracture, and fracture of the coronoid process. The elbow may dislocate postero-laterally with the anterior bundle of the MCL intact, but if the MCL is injured it is typically the last structure to fail. The coronoid fracture is typically a small fragment isolated to the tip. This is a result of a posteriorly directed force driving the coronoid into the trochlea prior to posterior elbow dislocation. CT scan is a useful modality when small or comminuted fragments are difficult to visualize on plain radiographs.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figures A through D show consecutive 2.00 mm sagittal CT reformats demonstrating a small coronoid fracture fragment which was addressed with suture fixation.
Incorrect Answers:
OrthoCash 2020
A 62-year-old right-hand-dominant school teacher sustains a mechanical fall at home and presents with right shoulder pain. Plain
radiographs of the right shoulder are pictured in Figures A and B. The patient asks you what she can expect in terms of recovery following this injury. Which of the following is the most appropriate statement?
At 1-year post-injury, the right shoulder range of motion will most likely be equal to the contralateral extremity.
At 1-year post-injury, you will most likely have returned to your baseline functional status.
Early range of motion exercises risk fracture displacement and should be avoided until at least 4 weeks post-injury.
Most patients do not return to work following this injury.
One in 5 patients with this fracture go on to nonunion and you may benefit from surgery in the future to address this.
This patient has a minimally displaced (1-part) proximal humerus fracture involving the humeral neck and greater tuberosity. This injury pattern is most commonly managed nonoperatively with the majority of patients returning to their baseline functional status by 1 year.
Proximal humerus fractures (PHF) can be classified by number of parts (Neer classification), with a part defined as a fracture fragment displaced > 1cm (> 5mm for greater tuberosity) or angulated > 45°. One-part PHF comprise ~80% of all PHF and are treated nonoperatively with a sling and early range of motion (ROM).
Tejwani et al performed a prospective study of 67 patients with 1-part PHF. At 1-year follow up the ASES score and functional status was similar to pre-injury status. However, ROM of the affected shoulder was diminished in both external and internal rotation. Forward flexion was preserved.
Hanson et al prospectively analyzed 160 patients with PHF of all types (1-4 parts and head-splitting) managed nonoperatively. At 1-year follow up, 93% showed solid union. Constant and DASH scores improved steadily over time but were still lower compared to the contralateral extremity. Of employed patients, 97.6% returned to work with a median time off of 10 weeks and no difference between manual and nonmanual workers.
Figures A and B are the AP and axillary radiographs of the right shoulder, respectively, demonstrating a 1-part PHF involving the humeral neck and greater tuberosity.
Incorrect Responses:
OrthoCash 2020
A 44-year-old male presents with the isolated injury seen in Figure A after a motor vehicle accident and underwent the operative treatment seen in Figure B within 8 hours from the time of incident. Which of the following complications is this patient at highest risk of developing?
Pulmonary embolus
Periprosthetic fracture
Contralateral hip fracture
Osteonecrosis
Infection
This young male patient has sustained a displaced femoral neck fracture and underwent open reduction internal fixation with 3 cannulated screws. Based on the available options, the patient is most at risk of developing osteonecrosis of the femoral head.
Femoral neck fractures in young patients typically are the result of a high-energy trauma. Fracture displacement has been shown to disrupt vascular supply to the femoral head by interrupting retinacular vessels and ligament teres vascularization, as well as increasing intracapsular pressure, producing a tamponade effect. The incidence of osteonecrosis in patients younger than 60 years with displaced femoral neck fractures has been shown to be between 15-30%. Quality of reduction is one key factor that has been shown to influence outcomes postoperatively.
Loizou et al. prospectively studied 1,023 patients who sustained an intracapsular hip fracture that was treated with internal fixation using standard fixation modalities. They showed that osteonecrosis was less common for undisplaced (4.0%) than for displaced fractures (9.5%). The population at greatest risk were women younger than the age of 60 with displaced fractures.
Barnes et al. review subcapital hip fractures. They found that late segmental collapse was more common in displaced fractures in women younger than age 75 years than in those older than age 75 years treated with internal fixation.
Figure A shows a displaced, Garden 3/Pauwels III hip fracture. Figure B shows anatomical fixation with 3 cannulated screws.
Incorrect Answers:
OrthoCash 2020
A 58-year-old male is involved in a motor vehicle collision and sustains the injury shown in Figure A in addition to right 5th and 6th rib fractures. Upon evaluation in the emergency department, he is noted to have a 2 centimeter laceration over the anterior aspect of his left leg with visible bone. Vitals and labs are normal. Which of the following statements is most accurate regarding surgical management for this patient?
Reamed intramedullary nailing is favored due to increased rates of union
Unreamed intramedullary nailing is favored due to presence of concomitant rib fractures
Reamed intramedullary nailing is favored due to decreased rates of infection
Unreamed intramedullary nailing is favored due to less local trauma
Both unreamed and reamed intramedullary nailing are equivalent
Corrent answer: 5
Both unreamed and reamed intramedullary nailing are equivalent treatments in patients with open tibia fractures. Intramedullary nailing is the treatment of choice for stable patients with tibial shaft fractures.
Tibial shaft fractures can be the result of low energy twisting injuries or higher energy axial loads. Closed fractures with acceptable alignment can be often be treated with closed reduction and casting. Intramedullary nailing, unreamed or reamed, is the treatment of choice for open fractures except in the setting of damage control orthopaedics when an external fixator may be more appropriate.
Bhandari et al. investigated reamed and unreamed intramedullary nailing for tibial shaft fractures in a randomized trial ("SPRINT" Trial - Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators). They concluded that reamed nailing was more beneficial (decreased rate of primary outcome event: need for bone grafting, implant exchange or removal for infection, debridement for infection) for closed fractures, but had no benefit in open fractures.
Finkemeier et al. evaluated consecutive patients treated with unreamed and reamed intramedullary nailing and found similar rates of union in both open and closed tibial shaft fractures at six and twelve months.
Figures A shows AP and lateral xrays of the left tibia showing a tibial shaft fracture.
Incorrect Answers:
OrthoCash 2020
A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
Corrent answer: 5
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:
OrthoCash 2020
A 25-year-old male presents to the emergency department with the injury seen in Figure A after a motorcycle collision. The patient has a blood pressure of 70 systolic, elevated lactate and a tense abdomen with positive FAST examination. Trauma surgery will be performing an emergent laparotomy. Orthopaedic surgery is consulted and places a pelvic external fixator intraoperatvely to assist with resuscitation. What is an advantage of supra-acetabular external fixator pins as compared with iliac crest pins?
Less interference with pelvic surgical incisions
Less risk of pin tract infection
Less risk of malreduction
Less control of posterior pelvic ring
No interference with laparotomy
Corrent answer: 1
One advantage of supra-acetabular external fixator pins is that they do not interfere or contaminate future approaches to the pelvis or acetabulum involving the lateral window.
In multiply injured patients with pelvic trauma external fixation of the pelvic ring is a valuable tool to assist with resuscitation. Pelvic external fixation should be applied rapidly and allow full access to the abdomen for general surgery intervention. Regardless of the technique used, a pelvic external fixator should form a stable construct that minimizes motion of fracture surfaces and allows for clot formation.
Haidukewych et al evaluated the safety of supra-acetabular pin placement in a cadaveric study. The authors found that the lateral femoral cutaneous nerve (LFCN) was most at risk during pin placement.
Figure A demonstrates a widely displaced symphyseal dislocation with associated bilateral sacroiliac (SI) dislocations (APC 3). Illustration A demonstrates an outlet radiograph of a supra-acetabular external fixtator in conjunction with posterior pelvic ring fixation for an LC3 pelvic ring injury.
Illustration B is an illustration of iliac crest external fixation. The video demonstrates techniques for application of both supra-acetabular and iliac
crest external fixation pins.
Incorrect Answers:
OrthoCash 2020
What physical exam finding is most likely to be found in association with the injury shown in Figures A and B?
Numbness in the small finger and ulnar side of the ring finger
No elbow instability
Varus posteromedial rotatory instability
Valgus posterolateral rotatory instability
An anterior open wound
Corrent answer: 3
The x-ray shows a fracture of the anteromedial facet of the coronoid with an intact radial head. Large anteromedial facet fractures are associated with varus posteromedial rotatory instability.
The anteromedial facet of the coronoid provides support to the medial elbow against varus stress. Varus and posteromedial force applied to the elbow results in disruption of the lateral collateral ligament (LCL) from its proximal origin. The coronoid is fractured as it is forced against the medial trochlea.
Coronoid fractures of significant size involving the sublime tubercle (insertion of medial collateral ligament) result in varus instability.
Steinmann reviews the anatomy, diagnosis, classification and treatment of coronoid fractures with a focus on surgical exposures and fixation techniques. He states that when a coronoid fracture is associated with a pattern of varus instability, it requires fixation with either suture, buttress plating or screw fixation. Concomitant LCL repair or reconstruction will also be necessary.
Doornberg et al. reviewed 67 coronoid fractures to determine whether type of coronoid fracture correlated with pattern of instability. They found strong
associations between (1) large coronoid fractures and trans-olecranon fracture-dislocations, (2) small fractures and terrible-triad injuries, and (3) anteromedial facet fractures and varus posteromedial rotational injury mechanisms.
Doornberg et al. evaluated 18 patients with a fracture of the anteromedial facet of the coronoid. They found that malalignment of the anteromedial facet fragment was associated with arthrosis and a fair or poor result.
Figure A is an AP view of an elbow with an anteromedial facet of the coronoid fractured. The lateral joint space is widened due to injury to the LCL. The medial joint space is narrowed and collapsed. A lateral view is shown in Figure
B. Illustrations A and B show AP and lateral views of a coronoid fracture fixed with buttress plating. The LCL origin was fixed with a suture anchor. Illustration C shows the O'Driscoll classification of coronoid fractures. Illustration D lists injury patterns that suggest posteromedial versus posterolateral rotatory instability.
Incorrect Answers:
OrthoCash 2020
A 35-year-old man presents to the ED as the restrained driver of a high speed motor vehicle collision complaining of hip, chest, and abdominal pain. He becomes diaphoretic, tachycardic, and hypotensive in the trauma bay and is noted to have diminished lower extremity pulses. He is found on ATLS workup to have mediastinal widening.
Which of the following injuries is most associated with thoracic aortic injury?
Thoracic aortic rupture is associated with posterior hip dislocation in deceleration trauma mechanism of injuries.
Posterior hip dislocations are infrequently associated with local vascular injuries. With bilateral perfusion deficits, more proximal large vessel trauma should be considered, and in this situation, thoracic surgery should be involved emergently. Screening chest x-ray in the trauma bay should be reviewed for widened mediastinum, suggestive of aortic injury, as shown in illustration A. Given the high energy mechanism associated with these injuries, a full ATLS trauma survey must be done for every patient.
Marymont et al. studies the association between posterior hip dislocation and thoracic aortic injury. They performed a retrospective chart review of 89 posterior hip dislocations and found 8% had an aortic injury. Although not statistically significant, they note the importance of evaluation for aortic injury in patients with posterior hip dislocations given its emergent life-threatening nature.
In addition to associated chest injuries, Schmidt et al. highlight the importance of evaluating the ipsilateral knee after high-energy traumatic hip dislocation. In a prospective study, they identified a 93% rate of ipsilateral knee injury on MRI including effusion (37%), bone bruising (33%), and meniscal tear (30%) as the most common. They recommend a thorough exam but also expanded use of knee MRI after hip dislocation.
Illustration A shows an example of chest x-ray with a widened mediastinum, suggestive of thoracic aortic injury.
OrthoCash 2020
A 31-year-old female smoker was involved in a skiing accident approximately 9 months ago and underwent open reduction internal fixation of the radius and ulna at the time of injury. She now returns to the clinic complaining of increasing pain with range of motion and activity. Radiographs from her most recent follow-up can be seen in Figure A. Laboratory tests show ESR, CRP and WBC count to be within normal limits. Which of the following options is the most appropriate next step in management?
Bone scan
Above elbow cast
Removable splint
Reamed intramedullary nail
Iliac crest bone grafting + compression plating
Corrent answer: 5
This patient is presenting with an atrophic non-union of the ulna after open reduction internal fixation for a both bone forearm fracture 9 months ago. The most appropriate next step in management would be iliac crest bone grafting and compression plating of the ulna.
The primary issue with an atrophic nonunion is biological. The blood supply is poor and therefore incapable of purposeful fracture healing. Smokers, as in this vignette, are at high risk for nonunion. The treatment of an atrophic nonunion involves improving biology at the fracture site through use of autologous bone graft (e.g. iliac crest) and providing mechanical stability by means of compression plating (e.g. 3.5 mm LC-DCP).
dos Reis et al. reports excellent results of 31 cases of diaphyseal forearm fracture non-unions treated with autologous bone grafting and compression
plating. Thirty of thirty-one patients went on to bony union within 3.5 months of revision surgery.
Nadkarni et al. presented a case series of 11 patients with non-unions of various long bones initially managed with intradmedullary (IM) nail fixation. The authors successfully used locking compression plates while retaining the IM nails in the treatment of the nonunion in all cases.
Figure A shows an AP radiograph of a both bone forearm fracture. Figure B shows an AP and lateral radiograph of an atrophic non-union of the ulnar shaft. Illustration A shows a lateral x-ray of a fully healed radius and ulna after hardware removal 1 year after revision surgery.
Incorrect Answers:
OrthoCash 2020
A 27 year-old patient sustains a fracture-dislocation of the acetabulum. Pelvic radiographs (Figures A and B) are taken at initial presentation and a CT scan (Figures C and D) is performed after reduction of the hip in the emergency room. What is the importance of the finding highlighted in the CT scan cuts?
Comminution indicates a better result with non-operative management
Significant marginal impaction could compromise the results of the surgical reduction if the joint surface is not properly restored
The impacted fracture segment will heal without fixation because it is not gapped or translated
The CT scan finding highlighted indicates osteochondral defects to the femoral head, which can be addressed arthroscopically
Intraarticular fracture fragments should be discarded from the surgical field, as incorporation of the fragments into the fixation construct leads to a high rate of avascular necrosis
The CT images shown in Figures C and D display significant marginal impaction of the joint surface.
Marginal impaction is common in posterior wall fractures and fracture-dislocations. Critical review of CT imaging of posterior wall fractures can help with preoperative planning for identifying impaction of the articular surface of the acetabulum. Restoration of the sphericity of the acetabulum to match that of the femoral head is important for successful outcome following ORIF of posterior wall fractures. A common surgical technique to accomplish joint surface restoration includes freeing the impacted articular segments, bone grafting of the void created to support the articular segments, and buttress plating of the posterior wall fracture fragments.
Patel et al. discuss the challenge of interpreting imaging of the acetabulum for assessing fracture characteristics that may significantly impact success or surgical intervention. These characteristics include: articular displacement, marginal impaction, incongruity of the joint surface, intra-articular fragments, and osteochondral injury to the femoral head. Based on expert review of images, determination of significant marginal impaction had a poor intraobserver reliability, as did each of the other modifiers listed.
Figures A and B are radiographs of the posterior wall fracture and hip dislocation. They do not show the large amount of marginal impaction of the acetabular surface. Figure C (coronal reconstruction) and Figure D (sagittal reconstruction) point out a large a amount of marginal impaction of the acetabular. Note the disruption of the joint surface on the intact portion of the acetabulum.
Incorrect answers:
Comminuted posterior wall fractures still should be surgically stabilized if the joint is unstable
This impacted fragment on the margin of the main fracture line will likely heal regardless of restoration of the articular surface; however, this malreduction will lead to a incongruent joint surface
These CT cuts do not show any osteochondral defects of the femoral head; however if found in other CT cuts or intraoperatively, they should be appropriately addressed
Intraarticular fracture fragments should be removed from the joint, but if they make up a substantial portion of the joint surface, they should be incorporated in the fixation construct to obtain the goal of anatomic reduction of the joint surface
OrthoCash 2020
A 32-year-old female is involved in a motor vehicle collision and suffers a right hip dislocation. She is in the twelfth week of pregnancy.
Evaluation in the emergency department reveals no other injuries and ultrasound reveals a strong fetal heart rate and no abnormalities. She undergoes emergent closed reduction but the hip remains unstable and a traction pin is placed. Post-reduction films are shown in Figure
What is the most appropriate next step in management?
Acute open reduction internal fixation
Exam under anesthesia
Skeletal traction for 6-8 weeks
Fetal monitoring until 15 weeks followed by open reduction internal fixation
Percutaneous pinning
This patient has a large posterior wall fracture of the right acetabulum with an unstable hip. The most appropriate next step in treatment is open reduction and internal fixation.
Fixation of acetabular fractures during pregnancy is not contraindicated in the setting of stable fetal heart rate and no abnormalities on pelvic ultrasound.
There is, however, an increased risk of complications for the mother and fetus. Injury severity and mechanism are most closely associated with increased rate of fetal complications. The trimester of pregnancy is not associated with increased risk of complications.
Leggon et al. reviewed 101 cases of pelvic and acetabular fractures in pregnant patients and found mechanism of injury and injury severity were associated with higher mortality for both mother and fetus. Trimester of pregnancy was not associated with increased mortality.
Flik et al. reviewed orthopaedic trauma in a pregnant patients and recommended fetal ultrasound for assessment of fetal well-being in all pregnant patients.
Desai et al. investigated orthopaedic trauma during pregnancy and reported minimal radiation risk to the fetus when obtaining x-rays. They also advocate for LMWH as one of the safest choices for anticoagulation.
Figure A is an x-ray showing a right posterior wall acetabular fracture. Figures B and C are Judet views of the pelvis focusing on the right hip. A large posterior wall fragment is visible in Figure B.
Incorrect Answers:
OrthoCash 2020
Figure A is radiograph of a 50-year-old male science teacher that was involved in a motor vehicle accident. He underwent closed reduction as seen in Figure B and C. What would be the most appropriate treatment?
Open reduction and internal fixation with medial bridge plate and lateral screw in non-lagging mode
Tibiotalocalcaneal arthrodesis
Open reduction and internal fixation with lateral and medial screw in lagging mode
Closed reduction and internal fixation with medial and lateral screw in non-lagging mode
Closed reduction with percutaneous pins
Corrent answer: 1
This patient is presenting with a Hawkins II talar neck fracture with medial wall comminution. The most appropriate treatment of this patient would be open reduction internal fixation with medial plate and lateral screw in non-lagging mode.
The treatment of talar fractures is based on the severity of the fracture, soft-tissues, and patient factors. The fracture and subluxation of the subtalar joint should be reduced and stable anatomical fixation should be obtained. When there is comminution of either the superior, lateral or medial aspects of the talus, one should avoid shortening the medial wall as this will cause a varus malunion. The use of a medial or lateral plate can help to re-establish column length, which can often prevent this potential complication.
Sanders et al. showed significant complications after fixation of talar neck fractures. They showed the incidence of secondary reconstructive procedures following talar neck fractures increased from 24% +/- 5% at 1 year to 48%
+/- 10% at 10 years post-injury.
Vallier et al. retrospectively reviewed the records of 39 fractures of the talar neck treated with open reduction and internal fixation. Twenty-one (54%) of thirty-nine patients had development of posttraumatic arthritis, which was more common after comminuted fractures (p < 0.07) and open fractures (p = 0.09).
Vallier et al. reviewed 81 talar neck fractures to revisit the rate of osteonecrosis and post-traumatic arthritis based on the Hawkins Classification. They found that delaying definitive internal fixation does not increase the risk of developing osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).
Figure A shows a Hawkins II talar neck fracture. Figures B and C are saggital and coronal CT images, respectively, of the foot. There is significant comminution of the medial wall of the talus with extension into the subtalar joint.
Incorrect Answers:
There is some research to suggest primarily subtalar arthrodesis with these injuries. However, to date, there is no high level evidence that has conclusively shown subtalar arthrodesis to be better than ORIF.
OrthoCash 2020
A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputation as shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?
Age less than 30
Marijuana use
Use of negative pressure wound therapy
Male gender
Ability to return to work
Corrent answer: 5
The strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.
The LEAP study is a multicenter, prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.
O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.
Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation or limb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.
Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.
Incorrect Answers:
4: These options are not as strong of a factor of patient satisfaction in longterm follow up after trauma-induced lower extremity amputation.
OrthoCash 2020
A 34 year-old male falls off of motorcycle on an outstretched hand suffering the injuries shown in Figures A and B. He is brought to the operating room and undergoes radial head replacement and fixation and repair of the coronoid and the lateral collateral ligament (LCL). Prior to closing, the elbow is still unstable upon testing range of motion. What is the next best step in management?
Exchange radial head for larger implant
Complete resection of radial head
Cast at 90 degrees of flexion for 6-8 weeks
Reinforce LCL repair with non-absorbable suture
Repair the ulnar collateral ligament
Corrent answer: 5
Following complete fixation and repair of a terrible triad, a final range of motion test should be performed prior to closure. If still unstable, the next step should be to assess and repair the ulnar collateral ligament. Another option
would be to placed a hinged external fixator.
Operative reconstruction of a terrible triad injury should be performed in a systematic fashion, working from deep to superficial. Working through a lateral incision and through the radial head fracture, the coronoid should be fixed first, followed by radial head fixation or replacement and then repair/reconstruction of the LCL. If still unstable, the medial side should be addressed, or the patient placed in a hinged external fixator.
Mathew et al review the anatomic, biomechanic, and operative principles (why the above step-by-step method works) to achieving appropriate stability in order to obtain early range of motion to maximize clinical outcome.
Pugh et al. in this retrospective, multi-center study report outcomes on 36 terrible triad injuries fixed with the standard protocol described above. The authors recommend following this systematic approach to achieve the best results.
Figures A and B are AP and lateral radiographs exhibiting a terrible triad elbow fracture-dislocation.
Incorrect answers:
OrthoCash 2020
When treating the pathology depicted in Figures A through D, which of the following is necessary to preserve the blood supply to the femoral head?
Dissection of the gluteal musculature off the iliac crest
Ligation of the ascending branches of the lateral femoral circumflex artery
Greater trochanteric osteotomy
Identification and detachment of the piriformis tendon
Supine positioning
Figures A-D show a femoral head with associated acetabular fracture (Pipkin IV). Both the posterior wall fracture and the femoral head fracture can be addressed through a surgical dislocation via greater trochanteric osteotomy.
Pipkin IV femoral head fracture (with associated acetabular fractures) are somewhat problematic in that the femoral head fracture is usually anterior, while the acetabular fracture usually involves the posterior wall. A Kocher-Langenbeck approach gives good access to the posterior wall but limited access to the articular surface and femoral head avascular necrosis (AVN) is a concern. A Smith-Peterson approach provides good access to the femoral head
but not to the posterior wall. Combined approaches significantly increase the amount of surgical dissection. Surgical dislocation with trochanteric flip osteotomy provides access to the femoral head and posterior wall while preserving blood supply to the femoral head.
Solberg et al. retrospectively reviewed 12 patients with Pipkin IV injuries treated via a trochanteric flip osteotomy. All patients healed their acetabular fractures. Eleven of 12 patients healed their femoral head fractures and one patient (8.3%) developed osteonecrosis.
Henle et al. likewise treated 12 patients with Pipkin IV injuries through a trochanteric flip osteotomy. Two of 12 patients (16.7%) developed osteonecrosis. The remaining 10 patients (83.3%) had good or excellent results. Heterotopic ossification occurred in five patients, causing significant range of motion loss in four of these.
Figure A is a pre-reduction AP pelvis in which the posterior wall fracture is apparent. Figure B is a post-reduction AP pelvis in which an infra-foveal femoral head fracture is apparent (Pipkin IV). Figure C is an axial CT cut which further characterizes the posterior wall fracture. Figure D is an obturator oblique showing femoral head dislocation and posterior wall fracture. The video shows a surgical hip dislocation technique.
Incorrect Answers:
OrthoCash 2020
A 42-year-old male presents to your clinic for the first time with the radiographs seen in Figure A. He sustained the injury 4 weeks ago while skiing overseas and treatment was provided by the local orthopaedic surgeon. The operative note states that he sustained an Gustilo Type I open fracture. After surgical fixation of this type of injury, what is the most common complication requiring reoperation?
Chronic elbow instability
Post-traumatic arthritis
Infection
Heterotopic ossification
Loss of elbow range of motion
Corrent answer: 5
This patient sustained a terrible triad elbow fracture-dislocation. Reduced range of motion of the elbow joint is the most common complication REQUIRING reoperation with these injuries.
Terrible triad elbow fracture-dislocations are characterized by posterolateral dislocation/lateral collateral ligament (LCL) injury, radial head fracture and coronoid fracture. Displaced fractures result in elbow instability. Acute radial head stabilization, coronoid open reduction and internal fixation, and LCL +/-medial collateral ligament (MCL) repair/reconstruction is considered the most appropriate treatment for displaced fractures. Operative complications include elbow stiffness, recurrent instability, arthritis, failure of hardware, heterotopic ossification, posterior interosseous nerve palsy and infection.
Egol et al. looked at the functional outcomes of 27 patients that underwent fixation of terrible triad injuries. At one year follow-up, the average flexion-extension arc of elbow motion was 109 degrees +/- 27 degrees, and the average pronation-supination arc was 128 degrees +/- 44 degrees. Grip strength averaged 72% of the contralateral extremity. Although operative fixation led to functional elbow stability, results were poor.
They included a reference to McKee et al. to highlight that intra-articular fractures of the elbow have high rates of stiffness. While not specific to terrible
triads, they looked at the effectiveness of the posterior elbow approach in 25 patients that underwent internal fixation of intra-articular distal humerus fractures. They showed poor outcomes at a mean follow-up of 36 months with reduced range-of-motion, decreased strength and high re-operation rates.
Figure A shows AP fluoroscopic image of a terrible triad injury that has undergone operative fixation. The radial head and coronoid have undergone open reduction internal fixation, and the MCL bony avulsion has been repaired.
Incorrect Answers:
OrthoCash 2020
Figure A is a radiograph from a 59-year-old male that was transferred to a Level I trauma center five hours after a motor vehicle accident. Closed reduction and skeletal traction was successfully performed in the trauma bay. Which of the following factors has been shown to increase the risk of unsatisfactory clinical outcome for this patient?
Need for skeletal traction
Mechanism of injury
Gender
Age
Time to reduction
Corrent answer: 4
Age greater than 55-years-old has been found to be an independent risk factor for inferior clinical outcome in patients with combined acetabular fractures and hip dislocations.
The most important initial step in management following resuscitation involves urgent reduction of the dislocated hip. This should be followed by a preoperative CT scan and ultimately surgical fixation of the combined acetabular fracture. Hip dislocations should be reduced within 6-12 hours for optimal outcome, although different critical times have been cited, particularly for dislocations with concomitant acetabular fractures. Skeletal traction may be required to maintain hip reduction.
Moed et. al. present a Level 3 retrospective review of 100 patients who had been treated with open reduction internal fixation of an acetabular fracture. The authors found that factors associated with unsatisfactory clinical outcomes included age greater than 55, intra-articular comminution, osteonecrosis, and delay of greater than 12 hours for reduction of an associated hip dislocation.
Additionally, they showed that there was a strong association of clinical outcome and final radiographic grade.
Figure A demonstrates an acetabular fracture with concomitant hip dislocation. Incorrect Answers:
injury, male gender, and time to reduction <6 hours have not been shown to be related to unsatisfactory outcomes.
OrthoCash 2020
A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
Corrent answer: 3
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.
OrthoCash 2020
A 24-year-old motorcyclist is brought in as a polytrauma after striking a tree at 65 mph. He is found to have injuries involving the chest, abdomen, pelvis, as well as a left open femoral shaft fracture. He undergoes resuscitation in the trauma bay. Which of the following parameters best supports proceeding with irrigation, debridement and external fixation as opposed to immediate reamed intramedullary nailing?
Temperature = 35.5°C (95.9°F)
Fractures of ribs 2-3 with left apical pneumothorax
Grade IV liver laceration with SBP = 85 mmHg
Left superior and inferior pubic ramus fractures
Lactate = 2.3 mg/dL
Significant abdominal trauma with evidence of hemorrhagic shock (SBP < 90 mmHg) following resuscitation is an unstable parameter and therefore is an indication to proceed with damage control orthopaedics (irrigation and debridement of open fractures and temporizing external fixation) in a polytraumatized patient.
The management of orthopaedic injuries in a polytrauma patient depends on the physiological stability of the patient. In an unstable patient, damage control orthopaedics (DCO) is preferred over early total care (ETC) to avoid an iatrogenic second hit with development of adult respiratory distress syndrome (ARDS) and/or multiple organ failure. Clinical parameters indicative of instability include shock (BP < 90 mmHg, refractory to blood products, lactate
> 2.5 mg/dL), coagulopathy (platelet count < 90,000 mm3, fibrinogen < 1 g/L), hypothermia (< 35°C), and significant chest, abdomen or pelvis injuries (pulmonary contusions, severe liver/spleen lacerations, pelvic ring disruption).
Pape et al. (2009) authored a review article detailing the management of a multitrauma patient. Polytrauma patients can be classified as stable, borderline, unstable or in extremis using a variety of criteria pertaining to hemodynamic stability, coagulation, temperature and soft tissue injury.
Patients who are stable or borderline can undergo ETC, while patients who are unstable or in extremis should be managed with DCO.
Pape et al. (2008) concluded that all patients who underwent early femoral nailing demonstrated increased systemic inflammatory response compared to external fixation, regardless of clinical stability. However, unstable patients
with a preexisting elevation of inflammatory status are likely more impacted by this additional increase. Improved postoperative clinical status coincided with a less vigorous inflammatory response.
Illustration A is a table from Pape et al (2009) depicting the criteria used to determine clinical condition of a polytraumatized patient. Illustration B is an algorithm from Pape et al (2009) detailing management of the multitrauma patient.
Incorrect Responses:
OrthoCash 2020
A 92-year-old female sustains the injury shown in Figure A to her nondominant extremity as the result of a non-syncopal ground-level fall. She denies any previous injury or pain of the elbow, and her medical history is significant only for osteoporosis and hypothyroidism. What is the most appropriate treatment for her injury?
Immediate range of motion as tolerated with a sling for comfort
Long arm cast for 3 weeks, then physical therapy for motion
Open reduction and internal fixation
Radiocapitellar arthroplasty
Total elbow arthroplasty
Corrent answer: 5
Use of total elbow arthroplasty (TEA) in the elderly is a well-recognized method of treatment of complex distal humerus fractures. This procedure allows for improved ROM, improved patient-reported outcomes, and decreased revision rates as compared to fixation.
TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. Elderly patients appear to accommodate to objective limitations in function with time, which is important, as most recommendations list restrictions of lifting no more than 5-10 pounds postoperatively.
McKee et al conducted a prospective, randomized, controlled trial to compare functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with open reduction-internal fixation (ORIF) or primary semiconstrained total elbow arthroplasty (TEA). Patients who underwent TEA had a quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Athwal et al review TEA and the options available at the time of publication. They also report on the techniques and purported advantages of arthroplasty as compared to fixation of complex distal humerus fractures.
Frankle et al reviewed patients >65 years old with distal humerus fractures at a minimum of 2 years follow-up. Outcomes were excellent in 33% of cases undergoing ORIF and 92% excellent with TEA. They recommend TEA in instances of arthritis, osteoporosis, or other diagnoses requiring steroids.
Figure A shows a significantly comminuted distal humerus fracture in an osteoporotic patient. Illustration A shows the same patient after undergoing total elbow arthroplasty.
Incorrect Answers:
1:Immediate range of motion is not recommended for this injury, even with the "bag of bones" treatment method. A brief period of immobilization is generally recommended for this technique.
2: Casting is not indicated for this injury.
3: ORIF of this injury will lead to worse outcomes as compared to arthroplasty. 4: Isolated radiocapitellar replacement is not indicated for this injury.
OrthoCash 2020
A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on
the available imaging, which of the following fracture characteristics best justifies this fixation choice?
Fracture displacement
Intra-articular fracture extension
The fracture extends distal to the coronoid
Oblique fracture line
Fracture comminution
This patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.
Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on interfragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.
Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation
was an effective treatment for displaced olecranon fractures, with good functional outcomes.
Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.
Incorrect answers:
OrthoCash 2020
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?
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
Corrent answer: 5
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:
OrthoCash 2020
Which of the following has been shown to be the greatest risk factor for refracture after implant removal from a radial shaft?
Removal of locking screws
Removal of small fragment plates
Removal of metaphyseal implants
Removal of implants less than 1 year after insertion
Removal of protective splinting from limb earlier than 10 weeks postoperatively
Removal of implants earlier than 1 year after insertion is a risk factor for refracture of the bone after implant removal.
The risk of refracture after hardware removal is multifactorial. Multiple
variables have been studied such as protective splinting for 6 weeks after hardware removal, waiting 12 months or more prior to hardware removal, and the location of the fracture. The variable that seems to correlate most with the risk of refracture is a diaphyseal location of the initial fracture. Large fragment plates (4.5 mm), when removed, are also at higher risk for refracture in the forearm.
Deluca et. al reported on a case series of patients who sustained a refracture of a forearm after implant removal. They noted that radiolucency at the site of the original fracture was seen in most refractured patients when the plate was removed. They also recommend delaying implant removal to two years after insertion to minimize risk.
Rumball et. al reported that the incidence of refracture after forearm implant removal is 6% in their series. They found that early removal, lack of postoperative immobilization, and plate size are the most critical risk factors for refracture.
Illustration A shows a forearm with evidence of refracture after implant removal.
Incorrect Answers:
OrthoCash 2020
A 23-year-old male arrives to the trauma bay after a motorcycle crash caused by a drive-by shooting. The patient is awake and alert and following commands. Vital signs include a blood pressure of 145/90 and a heart rate of 117bpm. Initial lactate is reported as 2.4 mmol/L. The patient has 2 rib fractures on the right with a clear chest radiograph. The patient is neurovascularly intact with a 4cm transverse wound over the medial ankle. Figures A, B and C exhibit his orthopaedic injuries. What is the most appropriate management?
Irrigation, debridement and placement external fixator right ankle, external fixation femur and intramedullary fixation tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and tibia
Irrigation, debridement and placement external fixator right ankle, intramedullary fixation femur and external fixation tibia
Irrigation, debridement and placement external fixator right ankle, femur and tibia
Irrigation, debridement and external fixation right ankle and skeletal traction
The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator, temporizing for later definitive fixation.
Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is relatively stable making him a good candidate for long bone stabilization and temporizing external fixation of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be brought back for repeat I&D and possible fixation.
Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures in stable versus borderline patients. Borderline patients were defined as those with multi-system injury (especially to lungs) and exhibited higher lung complications following acute IMN when compared to stable patients with isolated orthopaedic injuries.
O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures. Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with head or lung injury had worse outcomes and pulmonary complications.
Figure A exhibits a right open ankle fracture dislocation. Figure B exhibits a mid-shaft tibia fracture. Figure C exhibits a ballistic mid-shaft femur fracture.
Incorrect Answers:
OrthoCash 2020
Figure A is an anterior-posterior (AP) radiograph of a 27-year-old male who was a bicyclist struck by a motor vehicle. He was intubated in the field and unresponsive in the trauma slot. Ultrasound of his abdomen is positive for blood and he is brought to the operating room emergently for an exploratory laparotomy. He is found to have ischemic bowel and a grade 4 liver laceration. His lactate is 9.0 mg/dL. Which figure represents the next appropriate step in regard to his pelvic ring injury?
The radiograph exhibits an elevated left hemipelvis with complete sacroiliac disruption, which can be temporized with placement in skeletal traction.
The patient is unstable, as indicated by an elevated lactate level. The most appropriate next step is temporizing skeletal traction to reduce the left hemipelvis.
Langford et al. review the initial diagnosis, evaluation and resuscitation in the management of pelvic fractures. Reduction of pelvic volume can be achieved with pelvic binders and temporizing external fixation for anterior posterior compression (APC) and/or lateral compression (LC) fracture patterns, while skeletal traction can help do the same in vertical shear patterns.
Matullo et al. review the uses of skeletal traction in orthopaedic trauma, where lower extremity skeletal traction can be an efficient, fast, easy way to help reduce pelvic volume in vertical shear injuries, especially when the patient is unstable and not cleared for definitive fixation.
Figure A exhibits an elevated left hemipelvis indicative of a vertical shear injury and complete SI disruption. Figure B is an example of a pelvic binder. Figure C is a pelvic reconstruction plate. Figure D is a schematic of an anterior pelvic external fixator. Figure E is a schematic drawing of a patient in lower extremity
skeletal traction. Figure F is a radiograph exhibiting S1 and S2 sacroiliac (SI) screws.
Incorrect answers:
OrthoCash 2020
A 38-year-old man is involved in a motor vehicle collision and suffers the grossly open injury shown in Figure A. He subsequently undergoes irrigation and debridement and placement of an external fixator. In Figure B, if the proximal pin is placed at the red circle as compared to the black circle, the patient is at increased risk for which of the following?
Foot drop
Injury to the anterior tibial artery
Septic arthritis
Flexion contracture of the knee
Patellar tendon rupture
Corrent answer: 3
The patient is at increased risk of septic arthritis when placing the proximal tibial pin too proximal due to penetration of the joint capsule. Pin site flora can track into the joint and lead to a septic knee.
Tibial external fixators can be used to temporize tibial shaft, pilon, and ankle fractures not ready for definitive management due to soft tissue concerns and/or practice of damage control orthopaedics. Intracapsular placement of fixator pins can lead to septic arthritis. The capsular reflection typically extends 14 mm distal to the subchondral line.
DeCoster et al. reported a cadaveric dissection study for safe placement of proximal tibia pins and determined that the capsule inserts 14 mm below the articular surface along the posteromedial and posterolateral surfaces. For fractures requiring extremely proximal pin placement, they recommend
anterior cortex penetration only at least 6 mm distal to articular surface.
Reid et al. investigated safe transtibial pin placement using MRI and cadaveric and volunteer knees. They found that pin placement 14 mm distal to subchondral bone will result in low likelihood of capsular penetration.
Figure A is an AP radiograph showing a segmental middle third tibia/fibula fracture. Figure B is a lateral diagram of the tibia showing potential sites of proximal pin placement.
Incorrect Answers:
OrthoCash 2020
Figures A and B are radiographs of a 43-year-old, right-hand dominant, male that injured his arm in a motor vehicle accident. What would be an absolute indication for surgical fixation of his injury?
Radial nerve palsy
Intra-articular extension
2mm fracture distraction, 5 degrees of rotational malignment
Ipsilateral proximal both bone forearm fracture
Bilateral fracture
This patient has a humeral shaft fracture. An absolute indication for surgery would include a floating elbow, i.e. ipsilateral both bone forearm fracture.
The primary causes of humeral fractures include motor vehicle accidents, falls, or violent injury. Almost all cases are treated non-operatively with functional bracing. The absolute indications for surgical management include: ipsilateral vascular injury, severe soft-tissue injury, open fracture, compartment syndrome, and associated ipsilateral forearm fracture, ie, floating elbow. The relative indications for surgical management include: segmental fracture, intraarticular extension, significant fracture distraction, bilateral humeral fracture, inability to maintain acceptable alignment, and polytrauma.
Klenerman et al. reviewed non-operative treatment of humeral shaft fractures. They showed that acceptable results could be achieved even after 20° of
anterior bowing, 30° of varus angulation, 15° of malrotation, and 3 cm of shortening.
Carroll et al. reviewed the management of humeral shaft fractures. They state the indications for operative fixation to be polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical techniques include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing
Figure A and B shows a comminuted mid-shaft humeral fracture with intraarticular extension.
Incorrect Answers:
OrthoCash 2020
Which of the following findings is a contraindication in retrograde nailing of a periprosthetic distal femur fracture around a total knee arthroplasty?
Posterior-stabilized total knee implant
Cruciate retaining total knee implant
Spiral fracture pattern
Distal femoral replacement
Knee flexion contracture of 15 degrees
Corrent answer: 4
A distal femoral replacement (TKA) implant will generally preclude placement of a retrograde nail due to the long stem on the femoral component.
Supracondylar femur fractures above a well-fixed TKA component are increasingly common. These fractures are often treated with a lateral locking plate, but can also be treated with a retrograde nail in certain circumstances. An important factor in determining if nailing is a viable option are knowing the TKA implant and it's design. In addition, if the TKA component is known, the maximum size of reamer head and nail can be determined preoperatively from the size of the femoral 'box'.
Schutz et al report on a prospective multicenter study of 112 patients who underwent fixation of a distal femur fracture with the LISS system. They report that 90% of fractures went on to union and they attribute all of the failures to either the high-energy nature of particular fractures or a lack of experience in applying the plate in an appropriate pattern. They also note that primary grafting of these fractures is not necessary.
Illustration A shows a periprosthetic femur fracture treated with a retrograde nail.
Incorrect Answers:
1: A posterior-stabilized implant can be treated with an intramedullary nail in many circumstances but can be technically challenging, depending on the components.
2: A cruciate retaining TKA is not a contraindication to use of a retrograde nail. 3: A spiral pattern periprosthetic supracondylar femur fracture can be treated with a femoral nail.
5: A knee flexion contracture will often provide the flexion necessary for access to the box of the femoral component. A knee extension contracture, however, can preclude access to this box for placement of a nail.
OrthoCash 2020
A patient falls and sustains the isolated injury seen in Figures A and B. The surgical plan includes open reduction and internal fixation with a small mini-fragment plate using a direct lateral approach. During the approach, the forearm was placed in a fully pronated position. What would be the correct position of the forearm during plate application?
Full pronation
25 degrees pronation
Neutral
25 degrees supination
Full supination
Using the lateral approach (Kocher or Kaplan), the correct placement of the arm should be in a neutral position so that the plate can be placed on the bare area of the proximal radius.
Displaced radial head fractures with less than 3 fragments can be amendable to open reduction internal fixation. The methods of fixation include buried or headless screws, if placed at the articular surface, or posterolateral plating, if placed in the bare area. The safe zone for plating is located at a 90-110 arc from the radial styloid to Lister's tubercle with the arm in neutral rotation. This position helps to avoid impingement of ulna against the plate with forearm rotation. It should be noted that during the approach, that the forearm should be fully pronated to avoid injury to the posterior interosseous nerve.
Mathew et al. reviewed the concepts of terrible triad injuries of the elbow. Radial head fractures are treated conservatively when there is an isolated minimally displaced (less than 2mm) fracture with no mechanical block to motion. Open reduction internal fixation is used for Mason II or III fractures with < 3 fragments. Radial head replacement is considered for comminuted
fractures (Mason Type III) with 3 or more fragments.
Cheung et al. reviewed the surgical approaches to the elbow. The lateral approach (Kocher or Kaplan) is most commonly used with these injuries. The Kocher approach utilizes the intramuscular plane between anconeus and extensor carpi ulnaris. Kaplan utilizes the plane between extensor digitorum commons and extensor carpi radialis brevis.
Figure A and B show AP and lateral radiographs of the left elbow. There is a displaced radial head fracture. Illustration A shows a schematic diagram of the radial head "safe zone" between the radial styloid to Lister's tubercle.
Incorrect Answers:
OrthoCash 2020
A 38-year-old male is involved in a high speed motor vehicle collision. He has a Glasgow Coma Scale of 13 and receives 2 liters of fluid en route to the emergency department. Upon evaluation in the emergency department, he is found to have a bilateral femoral shaft fractures, a right ankle fracture, and a left both bone forearm fracture. He also has 2 left sided rib fracture and a grade II liver laceration. His heart rate is 130 and blood pressure is 85/50. All of the following
would be indications to practice damage control orthopaedics in this patient except:
Bilateral femur fractures
Rib fractures
Lactate of 5.2
Urine output of 20 cc/hr
Heart rate and blood pressure
Corrent answer: 2
Rib fractures without evidence of further thoracic trauma would not be an indication to practice damage control orthopaedics. This patient is underresuscitated based on his lactate level, urine output, and vital signs and definitive management should be delayed.
Damage control orthopaedics is the practice of delaying definitive management of fractures and utilizing temporary stabilization (such as an external fixator) until a patient has recovered from the initial physiologic insult of trauma.
Patients are at increased risk for perioperative complications such as ARDS and multi-system organ failure during the acute period after polytrauma. In addition to underresuscitation, other indications to practice damage control orthopaedics include: injury severity score>40 (or >20 with thoracic trauma), bilateral femoral fractures, hypothermia below 35 degrees Celsius, and pulmonary contusions.
Pape et al. (2007) studied the incidence of acute lung injuries in polytrauma patients undergoing either intramedullary nailing or external fixation and later definitive fixation of femoral shaft fractures. They found that patients undergoing immediate intramedullary nailing were nearly 6.7 times more likely to have acute lung injury
The Canadian Orthopedic Trauma Society studied the effect of reamed versus unreamed femoral nailing on incidence of ARDS for femoral shaft fractures in trauma patients using a randomized controlled study. They found no difference between the groups.
Pape et al. also examined the pathophysiological cascades that accompany soft tissue injuries of the extremities, abdomen, and pelvis and recommend a more comprehensive for evaluation of patients with these injuries.
Incorrect Answers:
OrthoCash 2020
The anterior intrapelvic (modified Stoppa) approach is most appropriate for which of the following fractures?
The anterior intrapelvic (AIP) or modified Stoppa approach provides access to the quadrilateral plate, which is a common location for fracture displacement in associated both column acetabulum fractures as seen in Figure D.
Compared to the traditional ilioinguinal approach, the modified Stoppa with a lateral window can offer comparable access to the quadrilateral plate, which can allow for its use in associated both column fracture patterns.
de Peretti et al. prospectively followed 25 patients with both column fractures
treated via an iliofemoral approach. Results led the authors to not recommend the extensile approach for both column fractures due to lack of efficiency and high complication rates.
Alonso et al. compared the extensile iliofemoral and triradiate approaches, and both reported acceptable results. However, concerning were the relatively high rates of heterotopic ossification, despite prophylaxis.
Bible al. performed a cadaver study to quantify the amount of access provided by the modified Stoppa approach. This approach provides access to approximately 80% of both the inner pelvis, and the quadrilateral plate, however, comparison to the ilioinguinal approach was not performed.
Shazar et al., in a cohort comparison between the ilioguinal and Stoppa approaches, noted better visualization and potential improve fracture reduction via the Stoppa approach for both column fractures. However, this study was limited in its retrospective and relative observer bias.
Figure A depicts a posterior wall fracture dislocation with concomitant femoral neck fracture. Figure B is an iliac oblique view which depicts a posterior column fracture. Figure C exhibits a posterior column + posterior wall fracture. Figure D depicts acetabular fracture with protrusio. Figure E exhibits a posterior wall fracture.
Incorrect answers:
OrthoCash 2020
Figure A is a radiograph of a 75-year-old woman that fell onto her non-dominant shoulder from a standing height. She was treated nonoperatively for 9 months but continues to complain of pain when she elevates her arm. In patients with this type of fracture pattern, what factor has the greatest impact on fracture healing?
Hand dominance
Angulation of fracture
Smoking
Early physical therapy
Diet
This patient has an impacted varus proximal humerus fracture. Smoking has been shown to increase the nonunion risk up to 5.5 times with these fractures.
Impacted varus proximal humerus fractures can be managed effectively with non-operative care. The major factors that influence non-union are age and smoking. Solid bony union can be seen in 93-98% of patients at 1 year, with more than 97% of people returning to pre-injury level of function. The angulation of fracture, hand dominance and physical therapy does not seem to influence bone union or functional outcomes with this fracture pattern.
Court-Brown et al. looked at the outcomes of impacted varus fractures. They determined that the age of the patient was the major factor in overall outcome. They showed that the best results occurred in younger patients, but results deteriorate with advancing age. Physical therapy was not found to
impact outcome.
Hanson et al. showed that impacted varus fractures can be successfully managed with non-operative care. They found that overall fracture displacement had a minor impact of fracture healing and functional outcome. The predicted risk of delayed union and nonunion was 7% with patients that smoke. This was 5.5 times greater than non-smokers.
Figure A shows an AP radiograph of a varus angulated proximal humerus fracture. This radiograph shows delayed atrophic union.
Incorrect Answers:
OrthoCash 2020
A 26-year-old male epileptic patients presents with right shoulder pain and deformity after a grand mal seizure. After medical stabilization, he denies previous injury to his shoulder. Pre-reduction and post-reduction radiographs of the shoulder are shown in Figures A-C, respectively; physical examination reveals a normal upper extremity neurovascular examination. After shoulder immobilization, what would be the next most appropriate step in management of this patient?
Abduction brace for three weeks, followed by therapy
Right shoulder MR arthrogram
Open reduction and internal fixation
Hemiarthroplasty
Early range of motion
Corrent answer: 3
This patient has presented with a fracture dislocation of the right shoulder. After urgent closed reduction, this patient requires open reduction internal fixation of the proximal humerus, and greater tuberosity fracture fragment in particular.
Isolated greater tuberosity fractures may be associated with shoulder dislocations. Careful review of imaging is critical to identify fracture lines that may extend into the humeral neck and head. If these extensions go undetected, catastrophic propagating fractures may occur during closed reduction maneuvers. Treatment is usually with open reduction internal fixation (ORIF). Young patients with proximal humerus fractures should be treated more aggressively with ORIF as compared to elderly patients. Another example would be a severely impacted valgus proximal humeral fracture in a young patient.
Erasmo et al. examined of 82 cases of humerus fracture dislocations treated with the lateral locking plates. Overall outcomes were excellent to good based on standard scoring systems. Complications included avascular necrosis (12%), varus positioning of the head (4.8%), impingement syndrome (3.6%), secondary screw perforation (3.6%), non-union (2.4%) and infection (1.2%).
Robinson et al. looked at severely impacted valgus proximal humeral fractures treated with open reduction internal fixation in young patients. Anatomic reduction is required with lateral plating to re-establish the normal head/neck angle. Good to excellent results can be achieved with fixation methods.
Figure A shows an anterior fracture-dislocation of the right shoulder. Figure B and C show post-reduction radiographs with a congruent glenohumeral joint. Displacement of the greater tuberosity (GT) fragment is greater than 5mm.
Incorrect Answers:
OrthoCash 2020
Pelvic packing can be performed to temporarily treat a hemodynamically unstable patient with a pelvic ring fracture. Which of the following is the preferred location of the skin incision to perform pelvic packing?
Right anterior superior iliac spine (ASIS) to mid-symphysis, left lateral window incision
Left ASIS to mid-symphysis, right lateral window incision
Subumbilical incision
ASIS to ASIS bilaterally
Pararectus incision
The preferred skin incision location is a subumbilical incision, 6-8cm extending upwards from the pubic symphysis towards the umbilicus; this allows access to all of the appropriate areas for pelvic packing.
Following skin incision, the rectus fascia is then divided in the midline which allows for access to both sides of the bladder for packing deep in the pelvic
brim. On each side, 3 lap pads are placed from sacroiliac joint to the retropubic space, all placed below the level of the pelvic brim.
Hak et al. review the options for emergent treatment in life threatening hemorrhage secondary to pelvic fractures. The authors offer several options for emergent treatment, which includes the use of pelvic binders, the placement of external fixators, pelvic packing and interventional angiography. Goals include reduction of pelvic volume and stopping rapid hemorrhage to save a patient's life. Pelvic packing, properly performed, is done through a subumbilical incision, as described above.
Osborn et al. retrospectively reviewed and compared emergent pelvic packing to angiography in hemorrhagic pelvic fracture clinical scenarios. The authors noted comparable results in mortality with a noted decrease in need for post-procedure transfusions in the pelvic packing group.
Cothren et al. reported their outcomes following an institutional algorithmic change from pelvic ex-fix/angiography to pelvic packing and ex-fix. Since their institutional change, the authors noted a significant decrease in transfusions, need for angiography and mortality.
Incorrect answers:
OrthoCash 2020
A 28-year-old man is brought by ambulance to the emergency department after falling from the roof of his home four hours ago. Upon initial evaluation, he has visible deformities of his bilateral lower extremities and a positive FAST exam. Heart rate is 135, blood pressure 85/58, and urine output is 40 cc over 3 hours. According to ATLS guidelines, what percentage of his blood volume has this patient likely lost?

Question 26:

Options:

Use of an abduction orthosis for 6 weeks
Modular exchange of the femoral head to a 36-mm head and a longer neck
Modular exchange of the polyethylene liner to a constrained acetabular insert
Revision and repositioning of the acetabular component and use of a 36-mm femoral head
A physical therapy program stressing abductor strengthening

Correct Answer: Revision and repositioning of the acetabular component and use of a 36-mm femoral head

Explanation:

Question 27:

Options:

Revision surgery caudad to C6
Persistent left cervical radiculopathy
History of a left-sided Horner’s syndrome
Transient dysphagia following the initial anterior cervical procedure
Nonfunctional left vocal cord

Correct Answer: Nonfunctional left vocal cord

Explanation:

DISCUSSION: When attempting a revision anterior cervical approach from the side opposite the original approach, it is important to evaluate the function of the vocal cords. If this evaluation reveals dysfunction of the vocal cord on the side of the original approach, then an approach on the contralateral side should not be attempted. Injury to the stellate ganglion, which causes a Horner’s syndrome, should not preclude an approach on the contralateral side. While the side of the symptomatology can influence the surgeon’s choice as to the side of an anterior approach, it does not preclude a certain approach. When approaching the lower cervical spine from the right side, the recurrent laryngeal nerve can cross the surgical field and should be preserved. Excessive intraoperative pressure on the esophagus can increase the incidence of dysphagia, but its incidence is no different with either approach.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 387-394.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 28:

A 15-year-old athlete collapses suddenly during practice and dies. What is the most likely cause of death?

Options:

Hypertrophic cardiomyopathy
Atrial fibrillation
Pulmonary embolism
Ruptured aorta
Mitral valve prolapse

Correct Answer: Hypertrophic cardiomyopathy

Explanation:

Question 29:

Options:

skeletal tong traction for 6 weeks.
anterior C2-3 diskectomy, grafting, and plate fixation.
halo application for 8 weeks.
a rigid collar for 4 to 6 weeks, followed by mobilization.
posterior stabilization with C2 pedicle screws.

Correct Answer: a rigid collar for 4 to 6 weeks, followed by mobilization.

Explanation:

Question 30:

Options:

hinged knee bracing, protected weight bearing, and physical therapy.
anteromedialization of the tibial tubercle.
internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
arthroscopic lateral retinacular release.

Correct Answer: internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

Explanation:

Question 31:

Figure 9 shows a cross-sectional view of the spinal cord at the lower cervical level. Injury to the structure indicated by the black arrow will lead to what neurologic deficit?

Options:

Complete paraplegia
Contralateral weakness below the level of the injury
Ipsilateral weakness below the level of the injury
Unilateral loss of position sense, proprioception, and vibratory sense below the level of the injury
Loss of pain and temperature sensation below the level of the injury

Correct Answer: Unilateral loss of position sense, proprioception, and vibratory sense below the level of the injury

Explanation:

Question 32:

Options:

Orthotic with Morton’s extension
In situ great toe fusion with implant removal
Keller resection arthroplasty
Implant removal with structural bone grafting and metatarsophalangeal (MTP) fusion
Implant removal, bone grafting, and titanium total toe implants

Correct Answer: Implant removal with structural bone grafting and metatarsophalangeal (MTP) fusion

Explanation:

DISCUSSION: The patient has a failed Silastic implant. Nonsurgical management will not work at this point. A Keller resection will only exacerbate her metatarsalgia. Implant removal with structural bone grafting and MTP fusion is the most appropriate choice because restoration of length is needed to alleviate the forefoot pain and bone grafting is required to fuse the MTP joint because there is an abundance of osteolysis. Total toe implants do not offer good long-term outcomes and are very difficult to fit into the large exploded-out cavity of the proximal phalanx.
REFERENCES: Hecht PJ, Gibbons MJ, Wapner KL, et al: Arthrodesis of the first metatarsophalangeal joint to salvage failed silicone implant arthroplasty. Foot Ankle Int 1997;18:383-390.
Myerson MS, Schon LC, McGuigan FX, et al: Results of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int
2000;21:297-306.

Question 33:

Which of the following increases radiation exposure to patients and personnel during surgery?

Options:

Orienting the beam in the opposite direction of the working team and keeping the team outside a 6-foot radius of the fluoroscopy machine
Orienting the cathode ray tube beneath the patient with the image intensifier receptor as close to the patient as possible
Limiting the beam on time to only what is clinically important
The use of continuous fluoroscopy whenever possible to ensure proper placement of implants
The use of lead glasses, a thyroid shield, and a lead apron with an equivalent lead thickness of 0.25 mm

Correct Answer: The use of continuous fluoroscopy whenever possible to ensure proper placement of implants

Explanation:

Question 34:

A superior labrum anterior and posterior (SLAP) lesion doubles the strain in which of the following stabilizing structures?

Options:

Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament
Posterior inferior glenohumeral ligament
Subscapularis

Correct Answer: Inferior glenohumeral ligament

Explanation:

Question 35:

Options:

Continued serial neurologic examinations
CT with a myelogram of the lumbar spine
Immediate surgical exploration and hematoma drainage
Electromyography of bilateral lower extremities
IV antibiotics for 24 hours, followed by surgical exploration if symptoms persist

Correct Answer: Immediate surgical exploration and hematoma drainage

Explanation:

DISCUSSION: The MRI scans reveal a large postoperative hematoma causing significant thecal compression. An epidural hematoma with neurologic deficit is a surgical emergency requiring immediate evacuation of the hematoma. Although the incidence of postoperative epidural hematomas is rare, the consequences of a missed diagnosis can be catastrophic. Early recognition and evacuation are essential in preserving or restoring neurologic function. Uribe and associates attributed delayed postoperative hematomas to previous multiple lumbar surgeries as a possible contributing factor.
REFERENCES: Yi S, Yoon do H, Kim KN, et al: Postoperative spinal epidural hematoma: Risk factor and clinical outcome. Yonsei Med J 2006;47:326-332.
Uribe J, Moza K, Jimenez O, et al: Delayed postoperative spinal epidural hematomas. Spine J 2003;3:125-129.

Question 36:

-What gene is implicated in spinal muscular atrophy?

Options:

Survival motor neuron I (SMN-I)
Peripheral myelin protein 22 (PMP22)
Dystrophin
Androgen receptor DISCUSSION-Deletions in the SMN-I gene are found in 95% to 98% of patients with spinal muscular atrophy. Genetic testing is typically part of the diagnostic workup for spinal muscular atrophy. A positive test result is diagnostic, and, in most cases, eliminates the need for muscle biopsy. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy, and mutations in the androgen receptor cause spinobulbar muscular atrophy (Kennedy’s disease).

Correct Answer: Survival motor neuron I (SMN-I)

Question 37:

Options:

Release of the lacertus and transfer of the biceps to the brachialis tendon
Open detachment, debridement, and reattachment of the biceps tendon
Anterior exploration and decompression of the posterior interosseous nerve
Excision of the anterior intramuscular lipoma
Endoscopic debridement of the biceps tendon

Correct Answer: Open detachment, debridement, and reattachment of the biceps tendon

Explanation:

Question 38:

Options:

Cervical traction
Halo-vest orthosis
Anterior single-level fusion
Posterior single-level fusion
Posterior multilevel fusion

Correct Answer: Posterior multilevel fusion

Question 39:

Options:

proximal release of the proximal tendon of the rectus femoris.
release of the distal tendon of the rectus femoris.
transfer of the distal rectus femoris tendon.
V-Y lengthening of the quadriceps tendon.
Z lengthening of the patellar tendon.

Correct Answer: transfer of the distal rectus femoris tendon.

Explanation:

Question 40:

Options:

Removal of the humeral and glenoid components
Removal of the glenoid component
Removal of the loose glenoid component and reimplantation of a new glenoid component
Removal of the glenoid component followed by biologic resurfacing of the glenoid
Arthrodesis after removal of both components

Correct Answer: Removal of the loose glenoid component and reimplantation of a new glenoid component

Explanation:

Question 41:

The patient undergoes a mobile-bearing UKA. When compared to a fixed-bearing metal-backed unicompartmental arthroplasty, this procedure is associated with a

Options:

higher risk for failure attributable to wear.
higher risk for failure attributable to bearing spinout.
lower risk for loosening.
lower risk for arthritic progression of the lateral compartment.

Correct Answer: higher risk for failure attributable to bearing spinout.

Explanation:

Question 42:

Figure 10 shows the radiograph of an 18-year-old woman who sustained a spinal cord injury in a motor vehicle accident. Based on the radiographic findings, her injury is best described as

Options:

distractive extension.
compressive extension.
lateral flexion.
distractive flexion.
compressive flexion.

Correct Answer: distractive flexion.

Explanation:

Question 43:

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

Options:

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

Correct Answer: Triangular fibrocartilage complex

Explanation:

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

Question 44:

Options:

Echocardiography
Abdominal ultrasound
Skeletal survey
Glenoid osteotomy
Physical therapy

Correct Answer: Physical therapy

Explanation:

Question 45:

Options:

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

Correct Answer: Arthroscopic or open reduction and internal fixation

Explanation:

Question 46:

Options:

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

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

Explanation:

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

Question 47:

Options:

Continued skin traction
Skeletal traction of both femurs
External fixation of both femurs
Intramedullary nailing of one femur and external fixation and delayed nailing for the other femur
Intramedullary nailing of both femurs

Correct Answer: Intramedullary nailing of both femurs

Explanation:

DISCUSSION: Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output. External fixation of both femurs is an option but an unnecessary step in the treatment algorithm.
REFERENCES: Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures. Clin Orthop Relat Res 2003;415:272-278.
Pape HC, Zelle BA, Hildebrand F, et al: Reamed femoral nailing in sheep: Does irrigation and aspiration of intramedullary contents alter the systemic response? J Bone Joint Surg Am 2005;87:2515-2522.

Question 48:

Options:

Cast immobilization for 6 weeks
Hinged brace with early range of motion in supination
Hinged brace with early range of motion in pronation
Primary ligament repair
Lateral collateral ligament reconstruction with tendon graft

Correct Answer: Hinged brace with early range of motion in pronation

Explanation:

Question 49:

Options:

hospital admission for IV antibiotics and observation.
an epidural steroid.
anterior diskectomy and fusion with autologous bone graft.
laminectomy for decompression and debridement.
laminectomy for decompression with an instrumented posterolateral fusion.

Correct Answer: laminectomy for decompression and debridement.

Explanation:

Question 50:

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.
McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 51:

Options:

Single factor analysis of variance
Chi-square test
Student t-test
Mann-Whitney rank sum test
Wilcoxon rank sum test

Correct Answer: Mann-Whitney rank sum test

Explanation:

Question 52:

- The familial occurrence of Legg-Calve-Perthes disease may, in some cases, be attributed to

Options:

hypophosphatemia
high dietary cholesterol intake
deficiency of lipoprotein A
deficiency of protein S and protein C
elevated levels of antithrombin III

Correct Answer: deficiency of protein S and protein C

Explanation:

Question 53:

Options:

Viscosupplementation of the right hip
Hip arthroscopy with labral repair
Periacetabular osteotomy
Total hip arthroplasty

Correct Answer: Periacetabular osteotomy

Explanation:

Question 54:

What is the best way to determine whether a radial head implant is too thick intraoperatively?

Options:

Visually assess the radiocapitellar joint.
Visually assess widening of the lateral ulnohumeral joint.
Assess widening of the radiocapitellar joint on an AP radiograph.
Assess the elbow for concentric reduction on a lateral radiograph.
Assess widening of the medial ulnohumeral joint on an AP radiograph.

Correct Answer: Visually assess widening of the lateral ulnohumeral joint.

Explanation:

Question 55:

Options:

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

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

Explanation:

Question 56:

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

Options:

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

Correct Answer: Transient radicular leg pain

Explanation:

Question 57:

Options:

myelography with CT.
spinal cord-evoked potentials.
repeat physical examinations.
MRI.
electromyography and nerve conduction velocity studies.

Correct Answer: repeat physical examinations.

Explanation:

Question 58:

Options:

Posterior keyhole foraminotomy, diskectomy, and decompression on the right side at C5-6
Anterior cervical diskectomy with no fusion
Anterior cervical diskectomy with interbody fusion (Smith-Robinson) at C5-6
Anterior cervical diskectomy with interbody fusion (Smith-Robinson) at C6-7
Two-level diskectomy at C5-6 and C6-7, with fusion at C5-7

Correct Answer: Two-level diskectomy at C5-6 and C6-7, with fusion at C5-7

Explanation:

Question 59:

Options:

Removal of the components and placement of an antibiotic spacer
Removal of the components, placement of an antibiotic spacer, and bone grafting of the glenoid defect
Resection arthroplasty
Exchange of the humeral head and debridement
Arthroscopic debridement

Correct Answer: Removal of the components and placement of an antibiotic spacer

Explanation:

Question 60:

Which of the following factors is most commonly associated with mechanical failure of a cemented total hip arthroplasty?

Options:

Increased stem offset
Varus position of the stem
Osteoporotic bone
Patient weight of greater than 154 lb
Gender

Correct Answer: Varus position of the stem

Explanation:

Question 61:

Options:

Dorsiflexion osteotomy of the first metatarsal
Dorsiflexion osteotomy of the first metatarsal combined with anterior transfer of the tibialis posterior
Triplanar osteotomy at the apex of the deformity
Triplanar osteotomy at the apex of the deformity combined with valgus calcaneal osteotomy
Triplanar osteotomy at the apex of the deformity combined with anterior transfer of the tibialis posterior

Correct Answer: Dorsiflexion osteotomy of the first metatarsal

Explanation:

DISCUSSION: This deformity is early in the disease process. The foot is still flexible, as evidenced by correction with the Coleman block test. A simple dorsiflexion osteotomy of the first metatarsal should provide a plantigrade foot. More complex osteotomies are required later in the disease process when the foot is not flexible and the deformity does not correct with the Coleman block test. The patient may also require a tibialis anterior transfer later in the disease process but not at the present time.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Upate: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 135-144.
Dehne R: Congenital and acquired neurologic disorders, in Coughlan MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 525-557.

Question 62:

Options:

distal chevron bunionectomy.
osteotomy of the proximal first metatarsal with distal soft-tissue realignment.
a Keller bunionectomy.
arthrodesis of the first metatarsophalangeal joint.
double osteotomy of the first metatarsal with distal soft-tissue realignment.

Correct Answer: osteotomy of the proximal first metatarsal with distal soft-tissue realignment.

Explanation:

Question 63:

Anterior perforation of the distal femur from antegrade femoral nailing has been attributed to what factor?

Options:

Non-anatomic reduction
Mismatch of the radius of curvature of implant and bone
Usage of too large an implant
Lateral patient positioning
Lateral proximal starting point

Correct Answer: Non-anatomic reduction

Explanation:

Question 64:

When performing a Weil osteotomy of a lesser metatarsal, the desired angle of the saw cut should be approximately

Options:

perpendicular to the shaft of the metatarsal.
parallel with the inclination of the metatarsal.
parallel with the plantar surface of the foot.
45 degrees to the shaft of the metatarsal.
10 degrees to the shaft of the metatarsal.

Correct Answer: parallel with the plantar surface of the foot.

Explanation:

DISCUSSION: Appropriate orientation of the saw cut when performing a Weil osteotomy is approximately parallel with the plantar surface of the foot. This is done in an effort to minimize plantar displacement of the capital fragment. The removal of additional bone from the osteotomy site either by removing a separate wafer of bone or using a thicker saw blade has also been described to minimize plantar displacement of the distal fragment.
REFERENCES: Trnka H, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int 2001;22:47-50.
Grimes J, Coughlin M: Geometric analysis of the Weil osteotomy. Foot Ankle Int 2006;27:985-992.

Question 65:

Which of the following factors is associated with improved outcomes following surgery for hip fractures?

Options:

Immediate surgical intervention
Early discharge to a skilled nursing facility
Choosing spinal versus general anesthesia for surgery
Choosing total hip arthroplasty instead of hemiarthroplasty for a displaced femoral neck fracture
Correction of metabolic abnormalities prior to surgical intervention

Correct Answer: Correction of metabolic abnormalities prior to surgical intervention

Explanation:

Question 66:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 67:

Injury to the popliteal artery during total knee arthroplasty (TKA) is most likely when placing a sharp retractor

Options:

directly posterior to the posterior cruciate ligament (PCL).
posteromedial to the PCL.
posterolateral to the PCL.
in the posteromedial corner of the knee.

Correct Answer: posterolateral to the PCL.

Explanation:

Question 68:

What is the most common complication following reverse total shoulder arthroplasty?

Options:

Scapula spine/acromial fracture
Dislocation/instability
Implant loosening
Periprosthetic fracture Complications encountered following reverse total shoulder arthroplasty include dislocation, infection, hardware failure, hematoma, neurologic injury, periprosthetic fracture, scapular notching, and acromial/scapular spine fractures. The incidence and risks of these complications are related to the indication for the procedure. Dislocation is the most common complication, with an incidence of 1.5% to 31%. Risk factors associated with postoperative dislocation include male sex, previous shoulder surgery, proximal humeral bone loss, axillary nerve injury, and subscapularis deficiency. Commonly used methods to prevent instability include lateralization of the glenosphere and/or baseplate, eccentric baseplate placement, humeral lateralization or distalization, use of large glenosphere, and increased socket constraint.

Correct Answer: Dislocation/instability

Explanation:

Question 69:

A 20-year-old man has a symptomatic lesion of fibrous dysplasia in the femoral neck. Management should consist of

Options:

curettage, cortical strutting, and internal fixation.
curettage only.
observation.
neoadjuvant chemotherapy.
radiation therapy.

Correct Answer: curettage, cortical strutting, and internal fixation.

Explanation:

Question 70:

- A 40-year-old woman has progressive pain and limited range of motion in her long finger. Figure 28a shows the radiograph, and Figure 28b shows a biopsy specimen of the same lesion. What is the most likely diagnosis?

Options:

Enchondroma
Osteoblastoma
Giant cell tumor
Aneurysmal bone cyst
Fibrous dysplasia

Correct Answer: Giant cell tumor

Explanation:

Question 71:

Figures 15a through 15d

Options:

T-type fracture
Anterior column fracture
Anterior wall fracture
Posterior wall fracture
Posterior column and posterior wall fracture
Transverse with posterior wall fracture

Correct Answer: T-type fracture

Explanation:

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160.
View Abstract
at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901.
View Abstract at PubMed

Question 72:

Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion?

Options:

Male worker's compensation patient who participates in heavy labor work with an inital Böhler angle less than 0 degrees
Female worker's compensation patient who participates in heavy labor work with an inital Böhler angle >15 degrees
Male non-worker's compensation patient who participates in heavy labor work with an inital Böhler angle less than 0 degrees
Male worker's compensation patient who participates in heavy labor work with an inital Böhler angle >15 degrees
Female non-worker's compensation patient who participates in heavy labor work with an inital Böhler less than 0 degrees

Correct Answer: Male worker's compensation patient who participates in heavy labor work with an inital Böhler angle less than 0 degrees

Explanation:

Question 73:

All of the following are advantages of supine over lateral positioning during intramedullary nailing of subtrochanteric femur fractures EXCEPT:

Options:

Can be protective to an injured spine
Facilitates access to other injured sites in the polytrauma patient
Provides easier fluoroscopic imaging
Allows for easy reduction of the distal fragment to the flexed proximal fragment
Easier to assess rotation

Correct Answer: Can be protective to an injured spine

Explanation:

Question 74:

Figure 50 shows the MRI scan of a 20-year-old female college soccer player with knee pain. What is the most likely diagnosis?

Options:

Normal knee
Posterior cruciate ligament tear
Quadriceps tendon rupture
Proximal tibia fracture
Femoral subchondral contusion

Correct Answer: Posterior cruciate ligament tear

Explanation:

Question 75:

The best candidate for a reverse total shoulder arthroplasty is a patient with rotator cuff tear arthropathy with

Options:

anterior superior escape.
rheumatoid arthritis.
an acromial stress fracture.
a centered head and an external rotation lag sign of 50 degrees.
active forward elevation of 130 degrees.

Correct Answer: anterior superior escape.

Explanation:

DISCUSSION: Reverse total shoulder arthroplasty is relatively contraindicated in patients with acromial stress fractures and rheumatoid arthritis. A patient with active forward elevation to
130 degrees is better treated with a hemiarthroplasty because the motion already exceeds the average forward elevation attained in most studies using the reverse prosthesis. A centered case of rotator cuff tear arthropathy is also better treated with a hemiarthroplasty, especially in patients with a large external rotation lag sign because the reverse prosthesis has been shown to decrease active external rotation. However, hemiarthroplasties have not performed well in patients with anterior superior escape and in this group of patients, the reverse prosthesis is best.
REFERENCES: Rittmeister M, Kerschbaumer M: Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10:17-22.
Visotosky JL, Basamania C, Seebauer L, et al: Cuff tear arthropathy: Pathogenesis, classification, and algorithm for treatment. J Bone Joint Surg Am 2004;86:35-40.
Werner CM, Steinmann PA, Gilbart M: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.
J Bone Joint Surg Am 2005;87:1476-1486.

Question 76:

All of the following conditions are associated with the female athlete triad EXCEPT? Review Topic

Options:

Amenorrhea
Osteoporosis
Low LDL levels
Decreased immune function
Insufficient caloric intake

Correct Answer: Amenorrhea

Explanation:

Question 77:

Options:

Physical therapy
Epidural steroid injection
High-dose intravenous steroid
Posterior cervical foraminotomy
Anterior cervical discectomy and fusion

Correct Answer: Physical therapy

Question 78:

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

Options:

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

Correct Answer: Long thoracic nerve

Explanation:

Question 79:

Options:

Nondisplaced fracture
Open fracture
Severely comminuted fracture
Dorsal perilunate dislocation
Repeated attempts at reduction

Correct Answer: Nondisplaced fracture

Explanation:

Question 80:

Options:

physical therapy and bracing.
reassurance that these problems will resolve with time.
posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.
Achilles tendon lengthening, and flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with transfer of the posterior tibial tendon to the dorsum of the foot.
flexor digitorum longus and flexor hallucis longus tenotomies at the individual digits with midfoot capsular release and hallux interphalangeal fusion.

Correct Answer: posterior capsule release, Achilles tendon lengthening, and excision of the scarred muscle and tendon in the leg and foot.

Explanation:

DISCUSSION: This is an example of a missed deep posterior compartment syndrome that typically presents 6 months after the injury with progressive clawing due to necrosis, scarring, and contracture of the posterior tibial tendon, flexor digitorum longus, and flexor hallucis longus. Treatment consists of debridement of necrotic muscle and scar tissue with corresponding tendon excision. After debridement and posterior capsule release, if the equinus is relieved with knee flexion, a gastrocnemius slide may be performed. Otherwise, the lengthening should be at the level of the Achilles tendon. Bracing will not address the claw toes.
REFERENCES: Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 212-213.
Manoli A II, Smith DG, Hansen ST Jr: Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop Relat Res 1993;292:309-314.
Early JS, Ricketts DS, Hansen ST: Treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. J Orthop Trauma 1994;8:445-448.

Question 81:

Options:

Total shoulder arthroplasty
Hemiarthroplasty
Reverse shoulder arthroplasty
Arthroscopic shoulder debridement
Trial of anti-inflammatory medication or cortisone injection and/or deltoid strengthening

Correct Answer: Trial of anti-inflammatory medication or cortisone injection and/or deltoid strengthening

Explanation:

Question 82:

Options:

referral to a pitching coach to improve throwing mechanics.
a weight-training program that concentrates on rotator cuff strengthening.
rest until symptoms have resolved, followed by a gradual return to pitching.
a metabolic work-up.
cessation of pitching until the physis is closed.

Correct Answer: rest until symptoms have resolved, followed by a gradual return to pitching.

Explanation:

Question 83:

Options:

Arthroscopic debridement
Supramalleolar osteotomy
Talar resurfacing
Total ankle replacement
Ankle arthrodesis

Correct Answer: Arthroscopic debridement

Explanation:

Question 84:

A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of

Options:

observation.
marsupialization of the nail fold.
application of copper sulfate.
application of calcium gluconate.
incision and drainage of the pulp.

Correct Answer: observation.

Explanation:

Question 85:

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Options:

A girl younger than age 15 years
A boy younger than age 15 years
An unstable SCFE
A stable SCFE
A stable SCFE associated with morbid obesity

Correct Answer: An unstable SCFE

Explanation:

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

Question 86:

Options:

Detailed neurologic examination
Direct laryngoscopy
Immediate examination of extremities for other possible injuries
Airway, breathing, and circulation
Hemoglobin, hematocrit, and toxicology screening

Correct Answer: Airway, breathing, and circulation

Explanation:

Question 87:

Which of the following conditions is associated with palmoplantar pustulosis?

Options:

Condensing osteitis
Sternoclavicular hyperostosis
Friedreich’s disease
Scleroderma
Reiter syndrome

Correct Answer: Sternoclavicular hyperostosis

Explanation:

DISCUSSION: Sternoclavicular hyperotosis is a seronegative and HLA-B27 negative rheumatic disease. In this condition, hyperostosis may appear in the spine, long bones, sacroiliac joints, and the sternoclavicular region. This entity is also associated with palmoplantar pustulosis.
REFERENCES: Wirth MA, Rockwood CA: Disorders of the sternoclavicular joint, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder. Philadelphia, PA,
WB Saunders, 2004, vol 2, pp 608-609.
Sonozaki H, Azuma A, Okai K, et al: Clinical features of 22 cases with inter-sterno-costo-clavicular ossification: A new rheumatic syndrome. Arch Orthop Trauma Surg 1979;95:13-22.

Question 88:

Options:

Silicone replacement arthroplasty through a volar approach
Surface replacement arthroplasty through a volar approach
Silicone replacement arthroplasty through a dorsal approach
Surface replacement arthroplasty through a dorsal approach

Correct Answer: Silicone replacement arthroplasty through a volar approach

Explanation:

EXPLANATION:
A recent systematic review compared silicone replacement, pyrocarbon replacement, and surface replacement arthroplasty for PIP arthritis. Silicone arthroplasty through a volar approach showed the greatest gains in arc of motion and had the lowest rate of revision surgeries. The rates of revision surgeries from low to high for each type of arthroplasty were 6% for silicone volar, 10% for silicone lateral, 11%
Surface replacement arthroplasty through a volar
for silicone dorsal, 18% for surface replacement dorsal, and 37% for surface replacement volar. Revision surgeries include implant replacement (to silicone or maintaining the surface replacement), arthrodesis, explantation, amputation, and other procedures.
approach showed the highest revision rate
,
the worst gain in arc of motion
, and
the greatest extension lag.
However, substantial pain relief and higher satisfaction still were reported after surface replacement
arthroplasty, regardless of the complications.

Question 89:

Options:

Conversion to a periarticular 'hybrid' frame
Open reduction and internal fixation with a lateral nonlocking plate
Open reduction and internal fixation with a lateral locking plate
Open reduction and internal fixation with medial and lateral plates
Open reduction and internal fixation with posteromedial and lateral plates

Correct Answer: Open reduction and internal fixation with posteromedial and lateral plates

Explanation:

Question 90:

Options:

manipulation and cast application.
basic orthopaedic shoes with a scaphoid pad and reinforced medial counter.
open reduction of the talonavicular joint and Achilles tendon lengthening.
lateral column lengthening osteotomy.
observation.

Correct Answer: manipulation and cast application.

Explanation:

Question 91:

A 55-year-old man has had a mass in his right thigh for the past 2 months. An MRI scan and biopsy specimens are shown in Figures 55a through 55c. What is the most likely diagnosis?

Options:

Extraskeletal myxoid chondrosarcoma
Rhabdomyosarcoma
Malignant fibrous histiocytoma
Myxoma
Liposarcoma

Correct Answer: Extraskeletal myxoid chondrosarcoma

Explanation:

Question 92:

Options:

Nonengaging Hill-Sachs deformity
Intra-articular loose body
Anterior glenoid bone deficiency of 35%
Subacromial bursitis
10% partial-thickness, articular side tear of the supraspinatous

Correct Answer: Anterior glenoid bone deficiency of 35%

Explanation:

Question 93:

Options:

Fracture of the posterior glenoid
Triceps insertion avulsion
Calcific tendinitis
Posterior glenoid exostosis
Loose body

Correct Answer: Posterior glenoid exostosis

Explanation:

Question 94:

Options:

Technetium Tc 99m bone scan
Contrast-enhanced MRI
CT
Electromyography
Arthroscopy

Correct Answer: Contrast-enhanced MRI

Explanation:

Question 95:

Options:

L1-2
L2-3
L3-4
L4-5

Correct Answer: L4-5

Explanation:

DISCUSSION
During the direct lateral approach, interbody fusion devices are inserted through a lateral window in the psoas muscle. To accomplish this, dilators and retractors are positioned at the posterior half of the disk space, and it must be noted that the lumbosacral plexus lies within the psoas muscle between the transverse process and vertebral body and departs distally at the medial edge of the psoas. Consequently, lateral interbody fusion poses risk for injury to the lumbosacral plexus. A cadaveric study demonstrated that the lumbosacral plexus progressively migrates from dorsal to ventral in the lumbar spine. Therefore, the plexus is most likely to be injured during an L4-L5 fusion because at this level the lumbosacral plexus is closest to the location at which dilators and retractors are placed.
A 2013 retrospective study by Le and associates followed 71 patients who underwent minimally invasive fusion via a lateral interbody approach. In this study, 54.9% (39/71) had immediate postsurgical ipsilateral iliopsoas or quadriceps weakness. Of these patients, the majority had resolution by 3 months (92.3%), and all had complete resolution by 2 years.
RECOMMENDED READINGS
Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
View Abstract at PubMed
Benglis DM, Vanni S, Levi AD. An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine. 2009 Feb;10(2):139-44. doi: 10.3171/2008.10.SPI08479. PubMed PMID: 19278328.
View
Abstract
at PubMed
Knight RQ, Schwaegler P, Hanscom D, Roh J. Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile. J Spinal Disord Tech. 2009 Feb;22(1):34-

Question 96:

Options:

Irrigation and debridement of deep wound infection
CT-guided needle biopsy and IV antibiotics
Revision laminotomy and diskectomy
L4-L5 anterior debridement and fusion
Open repair of the L4-L5 pseudomeningocele

Correct Answer: Revision laminotomy and diskectomy

Explanation:

Question 97:

Options:

Soft-tissue foreign body
Lipoma
Hematoma
Pyomyositis
Liposarcoma

Correct Answer: Hematoma

Explanation:

Question 98:

Options:

Trochanteric bursitis
Femoral component loosening
Iliopsoas tendonitis
Acetabular component loosening

Correct Answer: Iliopsoas tendonitis

Explanation:

Question 99:

Options:

Radiographs
Bone scan
CT
Ultrasonography
MRI

Correct Answer: Ultrasonography

Explanation:

Question 100:

Options:

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

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

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

Orthopedic Board Prep MCQs: Foot & Ankle, Knee Arthroplasty, Nerve | Part 150

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 150

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index