OITE & AAOS Orthopedic Board Review MCQs: Part 152

About This Board Review Set

This is Part 152 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 152

This module focuses heavily on: Arthroplasty, Fracture, Hip, Knee, Revision, Shoulder.

Sample Questions from This Set

Sample Question 1: A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patien...

Sample Question 2: 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 phys...

Sample Question 3: A “p value” of 4% (p=0.04) indicates that the...

Sample Question 4: A 20-year-old man has activity-related deep-seated shoulder pain in his dominant right shoulder. He has taken 3 months off training as a college javelin thrower, and management consisting of physical therapy has failed to provide relief. Sh...

Sample Question 5: What postoperative complication occurs at a significantly higher rate in patients undergoing bilateral simultaneous total knee arthroplasty than in patients undergoing unilateral total knee arthroplasty?...

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

A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?

Explanation

DISCUSSION: Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
Jehovah’s Witnessess Official Web Site: Medical Care and Blood, 2008, http://www.watchtower.org/e/medical_care_and_blood.htm

Question 2

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 3

A “p value” of 4% (p=0.04) indicates that the

Explanation

The paper cited is an excellent review in detail about confidence intervals including the mathematical equations.
The p value is the probability that the chance selection of patients might suggest a difference in treatment that was not real. Only with a small p value are we willing to believe that the observed difference in treatment is very likely real and not simply due to chance.
The confidence interval provides a measure of the magnitude of the possible difference between two groups of patients, regardless of whether or not the p value was small. This makes the confidence interval more informative than the p value when different treatments are compared. This is much beyond the scope of this review.

Question 4

A 20-year-old man has activity-related deep-seated shoulder pain in his dominant right shoulder. He has taken 3 months off training as a college javelin thrower, and management consisting of physical therapy has failed to provide relief. Shoulder arthroscopic views are shown in Figures 16a through 16c. What is the underlying association with this condition? Review Topic

Explanation

The patient is involved in overhead athletics and reports deep-seated pain. The arthroscopic views show a SLAP tear with posterior extension that is typical of internal impingement. The history lacks a component of gross instability expected in traumatic anterior dislocations or multidirectional instability associated with a connective tissue disorder, and it also lacks risk factors for osteonecrosis. The images do not show evidence of an unstable humeral cartilage flap or a supraspinatus tear.

Question 5

What postoperative complication occurs at a significantly higher rate in patients undergoing bilateral simultaneous total knee arthroplasty than in patients undergoing unilateral total knee arthroplasty?

Explanation

DISCUSSION: Parvizi and associates studied the 30-day mortality rate after more than 22,000 total knee arthroplasties and found that the rate after bilateral total knee arthroplasty was significantly higher than after unilateral total knee arthroplasty. Aseptic loosening, bleeding, and range of motion have not been shown to be statistically different between patients who had unilateral and simultaneous bilateral total knee arthroplasty.
REFERENCE: Parvizi J, Sullivan TA, Trousdale RT, Lewallen DG: Thirty-day mortality after total knee arthroplasty. J Bone Joint Surg Am 2001;83:1157-1161.

Question 6

A prospective, randomized controlled trial of 150 patients undergoing total hip arthroplasty is performed to test whether repair of the capsule during a posterior approach reduces post-operative dislocations in the first three months. The study found no difference in dislocation rate if the capsule was repaired versus not repaired (p = .34). Subsequently, a multicenter follow-up study of 2000 patients showed that repairing the capsule led to a decreased dislocation rate in the first three months (p = .03). Assuming the second study reflects reality, which of the following errors occurred in the first study?

Explanation

In this situation, the null hypothesis was accepted when it should have been rejected. This is a type-II error.
A study can have two types of errors. Type-I errors, or alpha errors, occur when the null hypothesis is rejected when it should have been accepted. The alpha level refers to the probability of a type-I error. By convention, the alpha level of significance is set at 0.05, which means that we accept the finding of a significant association if there is less than a one in twenty chance that the observed association was due to chance alone. Type-II errors, or beta errors, occur when the null hypothesis is accepted when it should be rejected. This often occurs when studies are underpowered. In the example above, the null hypothesis is that repair of the capsule does not reduce dislocations within the first three months. Since the first study did not show a
statistically significant difference, the null hypothesis was accepted. Since a more powered study showed that repair of the capsule does reduce dislocations, the null hypothesis should have been rejected in the initial study (if it was adequately powered).
Fosgate et al. review the importance of sample size calculations when performing research. They state that sample size ensures statistical significance if the subsequent data collection is perfectly consistent with the assumptions made for the sample size calculation (assuming power was set as 50% or greater).
Illustration A shows the difference between type-I and type-II errors. Video V is a lecture discussing statistical definition review of PPV, NPV, sensitivity and specificity.
Incorrect Answers:

Question 7

What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage?

Explanation

Hyaluronic acid (HA) is abundant in cartilage and synovial fluid and is thought to be integral to joint lubrication, although its role is not clearly understood. HA binds to lubricin, a glycoprotein, creating a cross-linked network. Boundary lubrication occurs when the fluid film has been depleted and the contacting bearing surfaces are separated only by a boundary lubricant of molecular thickness, which prevents excessive bearing friction and wear. In articular cartilage, this monolayer of glycoprotein is adsorbed on each of the opposing articular surfaces. Friction experiments in a porcine model have shown that with compression, HA diffuses out of the cartilage and becomes physically trapped and constricted by the collagen network at the interface. This in effect creates a "boundary lubricant." Vitronectin is a glycoprotein similar in the N and C terminal to lubricin. It does not bind to HA. Aggrecan is the second-most-common protein by dry weight of cartilage extracellular matrix. Aggrecan interacts with HA and link proteins to create a proteoglycan aggregate that attracts water to cartilage and gives the tissue its viscoelastic properties. Chondroitin sulfate contributes to matrix proteoglycan structure rather than boundary lubrication.

Question 8

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

Explanation

The patient needs restrictions on his external rotation to allow healing of the subscapularis tendon repair. Limitation to 60 degrees is common if the tendon repair is robust and shows no evidence of tension on range-of-motion testing during the
surgery. Restriction from external rotation stretching for even 3 weeks would compromise his ultimate functional recovery.

Question 9

Which of the following types of sarcoma of the bone is most sensitive to external beam radiation?

Explanation

Parosteal osteosarcoma occurs on the surface of the metaphyseal regions of the distal femur or the proximal humerus most commonly. The treatment is wide surgical resection versus limb salvage. Dedifferentiated chondrosarcoma has a moth eaten appearance and may occur as a transformation of chondrosarcoma. Treatment is resection and prognosis is poor. Low-grade intramedullary chondrosarcoma is also treated with surgical resection. High-grade intramedullary osteosarcoma is usually treated with pre-op chemo and resection. The only tumor listed where radiation is an option is Ewings tumor.

Question 10

Figure 4 shows the AP radiograph of a 28-year-old woman who has had moderate pain in the left hip for the past year. Nonsurgical management has failed to provide relief. She denies any history of hip pain, pathology, or trauma. Management should consist of

Explanation

DISCUSSION: The radiograph shows developmental dysplasia of the hip with the hip reduced and congruent. The treatment of choice is a periacetabular osteotomy because it can improve hip biomechanics and prolong the function of the hip joint. This procedure should be performed prior to the development of severe degenerative changes. Observation will not alter the patient’s natural history or the biomechanics of the hip. A total hip arthroplasty should be delayed until severe degenerative changes are present. A Chiari osteotomy is a salvage osteotomy used for a noncongruent subluxated hip. A Pemberton osteotomy requires an open triradiate cartilage; therefore, it is not an option in an adult.
REFERENCES: Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs SL: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.
Pemberton PA: Pericapsular osteotomy of the ilium for the treatment of congenital subluxation and dislocation of the hip. J Bone Joint Surg Am 1965;47:65-86.

Question 11

A 26-year-old male underwent statically locked intramedullary nail fixation for a comminuted left femur fracture. An early post-operative computed tomography (CT) scanogram was taken to check rotational alignment, as shown in Figure A. What would be the next best step in the management of this patient?

Explanation

The CT scanogram shows the operative left femur is 8 degrees externally rotated compared to the native right femur. No correction is required unless malalignment is
>15 degrees and symptomatic. Therefore, the most appropriate next step would be to continue with postoperative observation and close follow-up.
The primary purpose of CT scanogram is to measure the angle of rotation of the femoral neck relative to the femoral condyle. To do this, the right and left femurs must be scanned together using a 5mm helical slice scanner at the hip and knee. The first slice should reveal the alignment of the femoral neck, so as to allow for measurement of the femoral neck-to-horizontal (FNH) angle. The second slice should reveal the alignment of the posterior femoral condyles. This allows measurement of the posterior condyle-to-horizontal (PCH) angle. Finally, to calculate the rotational alignment (RA), the FNH angle and PCH angles are subtracted (e.g., RA = FNH -PCH). Normal RA is usually +5 to +20 degrees, which is also referred to as 5 to 20 degrees of femoral anteversion.
Lindsey et al. reviewed femoral malrotation following intramedullary nail fixation. They showed the incidence of rotational malalignment was ~28%. Normal femoral neck anteversion (angle of the femoral neck relative to the transverse axis through the femoral condyles) is ~11-13°. However, they noted that some patients have up to 15° difference in rotation in native limbs. Therefore <15 degrees of rotational difference after fixation is considered acceptable.
Gugala et al. examined the long-term functional implications for patients with iatrogenic femoral malrotation following femoral intramedullary nail fixation. They
showed that patients can compensate for even significant femoral malrotation (up to 30 degrees) and tolerate it well. However, external femoral malrotation (more common) appears to be better compensated/tolerated than internal malrotation.
Figure A shows that the left femoral neck is externally rotated (ER) by 15° to the horizontal (ER15). The right femoral neck is externally rotated (ER) by 4° to the horizontal (ER4). The left distal fragment is ER10. The right distal fragment is internally rotated (IR) by 9°. Thus, left femur has a total (ER15)-(ER10)= (+15)-(+10)=(+5), and right femur has (ER4)-(IR9)= (+4)-(-9)=(+13) to the horizontal. Therefore, the difference is 8 degrees.
Incorrect Answers:
>15 degrees and symptomatic.

Question 12

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Explanation

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 13

A 35-year-old construction worker continues to have weakness with lifting overhead 2 years after he was treated with physical therapy for a "chest muscle" tear. An obvious deformity noted in his axilla worsens with resisted extension and adduction. A clinical photograph and MRI scan are shown in Figures 119a and 119b. What is the most appropriate treatment? Review Topic

Explanation

This scenario describes a chronic, symptomatic pectoralis major tendon rupture in a young laborer. Direct repair is difficult at this time; therefore, allograft reconstruction is a good alternative to recover strength. Tendon transfers, electrical stimulation, shoulder arthrodesis, and arthroscopy are not indicated in this patient. They will not offer proper reconstruction of the lost muscle tendon unit and/or cosmetic repair.

Question 14

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Explanation

DISCUSSION: BMPs signal through the activation of a transmembrane serine/threonine kinase receptor that leads to the activation of intracellular signaling molecules called SMADs. There are currently eight known SMADs, and the activation of different SMADs within a cell leads to different cellular responses. The other mediators are not believed to be directly involved with BMP signaling.
REFERENCES: Lieberman J, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: Biology and clinical applications. J Bone Joint Surg Am 2002;84:1032-1044.
Li J, Sandell LJ: Transcriptional regulation of cartilage-specific genes, in Rosier RN, Evans C (eds): Molecular Biology in Orthoapedics, Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 21-24.
Zuscik MJ, Drissi MH, Reynolds PR, et al: Molecular and cell biology in orthopaedics, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006,

in press.

Question 15

Anabolic steroid use has which of the following effects on serum lipoprotein levels?

Explanation

DISCUSSION: The use of anabolic steroids causes a decrease in high-density lipoprotein levels but has no effect on low-density lipoprotein levels. An abnormally low high-density lipoprotein level should alert the physician to the possibility of steroid use in an athlete.
REFERENCES: Hartgens F, Rietjens G, Keizer HA, et al: Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a). Br J Sports Med 2004;38:253-259.
Blue JG, Lombardo JA: Steroids and steroid-like compounds. Clin Sports Med
1999;18:667-689.

Question 16

A 14-year-old boy reports a 4-month history of increasing backache with difficulty walking long distances. His parents state that he walks with his knees slightly flexed and is unable to bend forward and get his hands to his knees. He denies numbness, tingling, and weakness in his legs and denies loss of bladder and bowel control. A lateral radiograph of the lumbosacral spine is shown in Figure 18. What is the best surgical management for this condition? Review Topic

Explanation

The patient has a grade 4 spondylolisthesis. Optimal surgical management is posterior spinal fusion from L4 to the sacrum. The use of instrumentation is controversial. Vertebrectomy is typically reserved for spondylo-optosis (grade 5) cases. Spinal fusion from L5 to S1 usually is not successful for a slip that is greater than 50%. Isolated anterior spinal fusion has not been successful, and direct repair of the pars defect is only useful for spondylolysis without spondylolisthesis.

Question 17

What factor is associated with the highest risk for in-hospital complications for patients undergoing a lumbar fusion for degenerative spondylolisthesis? Review Topic

Explanation

Age and having three or more comorbidities is associated with a higher rate of complications in patients undergoing a lumbar fusion for lumbar degenerative spondylolisthesis. Race, gender, and hospital size have not been found to be associated with higher complication rates.

Question 18

Which of the following findings is considered the strongest indication for surgical treatment of a mallet fracture of the distal phalanx?

Explanation

DISCUSSION: The majority of mallet fractures can be treated nonsurgically with a distal interphalangeal joint extension splint. Excellent results can be obtained in most patients with splinting alone. The fragment size, amount of displacement, and degree of articular incongruity usually do not affect final outcome, as long as the joint is reduced. Surgical fixation takes on several forms but is fraught with complications including skin/wound problems, loss of fixation, nonunion, and stiffness of the distal interphalangeal joint. Volar subluxation of the distal phalanx remains the primary indication for surgical treatment.
REFERENCES: Green DP, Butler TE Jr: Fractures and dislocations in the hand, in Rockwood CA, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 621-623.
Light TR (ed): Hand Surgery Update 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 19-28.

Question 19

An 86-year-old woman sustained a fracture of the humerus and underwent surgical fixation 8 weeks ago. There was no radial nerve function below the elbow after surgery. Radiographs are shown in Figures 51a and 51b. What is the most appropriate management at this time?

Explanation

DISCUSSION: Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified.
REFERENCES: Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.
Green DP: Radial nerve palsy, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 112.

Question 20

Figure 1 shows a radiograph obtained from an active 30-year-old man who sustained an injury to his ring finger 1 week earlier. The most appropriate treatment is

Explanation

EXPLANATION:

Figure 1 reveals evidence of an intra-articular distal phalanx fracture with a distal interphalangeal (DIP) joint dorsal subluxation. This injury is unstable and requires surgical management for an active individual. Volar distal phalanx fractures are often associated with flexor digitorum profundus avulsion injuries, which are addressed concomitantly. This injury was treated with ORIF of the intra-articular fracture, pinning of the DIP joint, and repair of an avulsed flexor digitorum profundus tendon with a button on the dorsal nail plate, as shown in Figure 2. Splint immobilization would not maintain a reduction of this unstable injury. The terminal tendon is not injured in this patient but is often injured in a dorsal distal phalanx fracture with a volar dislocation. Arthrodesis of the DIP is a salvage procedure and would not be considered acutely.

Question 21

The Coleman block test is used to test for Review Topic

Explanation

The Coleman block test is used to determine the flexibility of the hindfoot. When a block is placed under the lateral border of the foot, the medial column is unsupported. As a result, the first metatarsal drops off the side of the block. If the subtalar joint is flexible, there is no fixed varus deformity of the hindfoot. The hindfoot will no longer be in varus from behind. The varus deformity of the hindfoot will be corrected. If there is no subtalar motion, the varus deformity remains fixed.

Question 22

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

Explanation

DISCUSSION: The most common malignant disease to arise in conjunction with chronic osteomyelitis is squamous cell carcinoma particularly in patients with a long-standing draining sinus tract.
REFERENCES: Dell PC: Hand, in Simon MA, Springfield D (eds): Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott-Raven, 1998, pp 405-420.
McGrory JE, Pritchard DJ, Unni KK, Ilstrup D, Rowland CM: Malignant lesion arising in chronic osteomyelitis. Clin Orthop 1998;362:181-189.

Question 23

-Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision. Examination reveals normal strength and sensation in both upper and lower extremities, normal rectal tone, and no other injuries. The C1-C2 lateral mass overhang measures 8.5 mm. What is the most appropriate treatment option?

Explanation

Question 24

Figure 1 is the axial cut MRI scan of a 35-year-old woman who has had posteriorly based right hip pain for 3 months. Examination demonstrates full and symmetric range of motion between the right and left hips, negative impingement test, but reproduction of her pain with passive extension of the right hip. Which muscle is indicated by the arrow?

Explanation

This patient has ischiofemoral impingement, in which there is abnormal contact between the lesser trochanter and the lateral border of the ischium. Patients typically present with posteriorly based hip pain and do not respond to intra-articular diagnostic injections. Examination can demonstrate pain with long strides, pain with palpation over the area, as well as reproduction of symptoms with the patient in the contralateral decubitus position and taking the affected hip into passive extension (ischiofemoral impingement test). MRI demonstrates a narrowed ischiofemoral space, as well as increased signal within the quadratus femoris muscle. The diagnosis can be confirmed with a diagnostic injection into this area. Treatment is typically nonsurgical, with surgical intervention consisting of resection of the lesser trochanter reserved for refractory cases.

Question 25

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Explanation

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 26

A 10-day-old girl has decreased active motion of the left upper extremity. The mother reports a difficult vaginal delivery with presumed shoulder dystocia. Examination shows full passive range of motion of the shoulder, elbow, and wrist but only active flexion of the fingers and wrist. Factors predictive of a good outcome include which of the following?

Explanation

Return of active biceps before 3 months and preservation of full passive shoulder range of motion are predictors of a good outcome. Breech delivery is usually associated with preganglionic injury. Preganglionic injury can result in a Horner's sign, which includes ptosis, myosis, and anhydrosis. Preganglionic injuries are unlikely to recover. The Moro reflex is elicited by dropping a baby's head a short distance and observing active elbow extension and fanning of the fingers, followed by elbow flexion and crying. Absence of the Moro reflex suggests a poor prognosis.

Question 27

Which of the following advantages does the use of a vascularized fibula graft have over a nonvascularized fibula graft?

Explanation

A vascularized fibula graft, because its osteogenic potential remains unhampered by loss of vascularity it will begin to remodel and hypertrophy more quickly. Both types of grafts would act equivocably as scaffolding for osteoconduction. Early risk of fracture is increased if the nonvascularized fibula graft is over 12 centimeters in length as compared to a vascularized graft.
And a vascularized graft requires greater technical skills and a larger dissection to isolate the vascular pedicle with associated increased donor site morbidity.

Question 28

Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed to respond to nonsurgical management. What is the most appropriate surgical treatment at this time?

Explanation

DISCUSSION: The radiograph reveals developmental dysplasia of both hips. The patient has classic anterolateral undercoverage of the femoral head on the right side as demonstrated by a high acetabular index (measured at 27 degrees). Anterior undercoverage can be determined by drawing the marking for the anterior wall that fails to overlap the femoral head in this patient. Currently in North America, the most accepted surgical management for symptomatic dysplasia of the hip with good joint space is a Bernese (Ganz) periacetabular osteotomy. Surgical dislocation of the hip and femoroacetabular osteoplasty may be considered for patients with symptomatic femoroacetabular impingement of the hip.
REFERENCES: Ganz R, Klaue K, Vinh TS, et al: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Trousdale RT, Ekkernkamp A, Ganz R, et al: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.

Question 29

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Explanation

DISCUSSION: Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.
REFERENCES: Lemos MJ: The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137-144.
Rockwood CA Jr, Green DP, Bucholz RW, et al: Fractures in Adults, ed 5. Philadelphia, PA, Lippincott-Raven, 2001, pp 1209-1240.

Question 30

A 19-year-old male collegiate rower has a 3-month history of right shoulder pain. There was no inciting trauma prior to the onset of his pain. He also complains of weakness, particularly in abduction and overhead activity. Examination reveals no range-of-motion deficits. Strength testing of the right shoulder demonstrates 4/5 motor strength in forward elevation and abduction. His Beighton hypermobility score is 3/9. Figure 1 shows his scapular position during a wall pushup maneuver. An EMG would likely reveal damage to what nerve?

Explanation

Figure 1 reveals medial scapular winging secondary to weakness of the serratus anterior, which is innervated by the long thoracic nerve. Damage to the long thoracic nerve can occur via repetitive stretching, compression, or iatrogenic injury during a surgical procedure. Lateral thoracic winging is caused by weakness of the trapezius, which is innervated by cranial nerve XI (spinal accessory nerve). The direction of scapular winging is judged by the upper medial border of the scapula. Observation of a period of at least 6 months with serratus anterior strengthening while the nerve recovers is the mainstay of treatment for medial scapular winging.

Question 31

What is the most important factor in determining recovery after surgical repair of a complete laceration of a nerve at the wrist?

Explanation

DISCUSSION: All other factors being equal, a patient’s age is the most important factor in determining outcome after peripheral nerve injury. Repair of a nerve laceration within the first 2 weeks is generally considered appropriate. Fascicular repair may be of benefit in larger proximal nerves to reapproximate appropriate nerve bundles; distally perineural or epineural repair is sufficient. Use of a fibrin tissue sealant for nerve repair does not result in improved outcomes over suture repair. Nerve conduits have shown promise in digital nerves but do not have proven benefit in larger caliber nerves.
REFERENCES: Sunderland S: Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY, Churchill Livingstone, 1991.
Wilgis ES, Brushart TM: Nerve repair and grafting, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1325.
Narakas A: The use of fibrin glue in repair of peripheral nerves. Orthop Clin North Am 1988;19:187-199.
Weber RA, Breidenbach WC, Brown RE, et al: A randomized prospective study of

polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 2000;106:1036-1045.

Question 32

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Question 33

The most common neurologic injury following an anterior cervical diskectomy and fusion (ACDF) is injury to which of the following structures? Review Topic

Explanation

The most common neurologic injury in ACDF is injury to the recurrent laryngeal nerve. It is most vulnerable on the right because it crosses from lateral to midline more cephalad in the incision after it passes under the subclavian artery; conversely, on the left the course is more caudal because it passes under the aortic arch, a more caudal structure. The superior laryngeal nerve runs along with the superior thyroid artery in the upper cervical spine, putting it at risk during surgical procedures on the upper cervical spine which are less commonly performed. A C5 root palsy more commonly occurs as a result of multilevel posterior decompressive procedures, possibly because of its short transverse take-off from the cord. The sympathetic chain lies on top of the longus colli and can be injured if retractors are not placed under the longus colli muscle.

Question 34

A 59-year-old active woman undergoes elective total hip replacement in which a posterior approach is used. She has minimal pain and is discharged to home 2 days after surgery. Four weeks later, she dislocates her hip while shaving her legs. She undergoes a closed reduction in the emergency department. Postreduction radiographs show a reduced hip with well-fixed components in satisfactory alignment. What is the most appropriate management of this condition from this point forward?

Explanation

DISCUSSION:
First-time early dislocations are often treated successfully without revision surgery, especially when no component malalignment is present. In this clinical scenario, it appears the patient would benefit from better education about dislocation precautions. Hip orthoses are of questionable benefit unless the patient is cognitively impaired. Revision surgery can be successful but is usually reserved for patients with recurrent dislocations.

Question 35

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

Explanation

DISCUSSION: The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.
REFERENCES: Schenck CD: Anatomy of the innervation of the upper extremity, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face, ed 2. St Louis, MO, Mosby-Year Book, 1991.
Hershman EB: Brachial plexus injuries. Clin Sports Med 1990;9:311-329.

Question 36

In the spine, osteoblastomas usually originate in the

Explanation

DISCUSSION: Osteoblastomas are benign lesions that represent less than 5% of benign bone tumors. Most lesions are located in the spine, followed by the femur, tibia, and skull. Patients with spinal lesions usually have pain that may be associated with scoliosis. The most common location in the spine is within the posterior elements.
REFERENCE: Frassica FJ, Waltrip RL, Sponseller PD, Ma LD, McCarthy EF Jr: Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am 1996;27:559-574.

Question 37

A 27-year-old woman reports the acute atraumatic onset of burning pain in her right shoulder followed a week later by significant weakness and the inability to abduct her shoulder. One week prior to this incident she had recovered from a flu-like syndrome. Examination reveals full passive motion of the shoulder and the inability to actively raise the arm. Sensation in the right upper extremity is normal. Cervical spine examination is normal. Radiographs of the shoulder and cervical spine are normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.
REFERENCES: Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.
Omer GE, Spinner M, Van Beek AL (eds): Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 101-104.

Question 38

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Explanation

Posterolateral disk herniations will generally compress the transversing nerve root. Therefore, a posterolateral disk herniation at the L4-5 level will typically compromise the L5 nerve root. Far lateral (extraforaminal) disk herniations generally compromise the exiting nerve root. Therefore, an extraforaminal herniation at the L4-5 level will typically compromise the exiting L4 nerve root.

Question 39

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Explanation

DISCUSSION: Most patients who undergo transmetatarsal amputation do not require custom shoe wear or an orthosis above the ankle. A molded toe filler is used to prevent excessive shear that can lead to ulceration. Use of a soft toe filler without stiffening of the sole results in excessive flexibility from the shortened lever arm, which reduces the efficiency of gait. A firm footplate or carbon fiber base adds rigidity to aid in push-off. A rocker bottom also may be added to the shoe.
REFERENCES: Philbin TM, Leyes M, Sferra JJ, Donley BG: Orthotic and prosthetic devices in partial foot amputations. Foot Ankle Clin 2001;6:215-228.
Marks RM: Mid-foot/mid-tarsus amputations. Foot Ankle Clin 1999;4:1-16.

Question 40

A 20-year-old man sustains the injury shown in Figures 1a and 1b in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by

Explanation

DISCUSSION: Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability.
REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.

Question 41

A study is designed that examines fractures in children with osteogenesis imperfecta after being treated with bisphosphonates compared with a placebo. A difference is found for which the P value is greater than what is considered to be statistically significant. What is the next appropriate statistical analysis?

Explanation

DISCUSSION: When a study yields a negative result between treatment groups, the next step is to perform a power analysis. The power, by definition, is the probability of rejecting the null hypothesis: in this example the null hypothesis would be that children treated with bisphosphonates would have fewer fractures than the untreated control population. The power analysis helps answer the question as to whether the null hypothesis should be rejected and the finding is real, or whether the sample size was too small or the effect of treatment too subtle to demonstrate a difference between the treatment and control groups.
REFERENCES: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, p 7.
Kocher MS, Zurakowski D: Clinical epidemiology and biostatistics: A primer for orthopaedic surgeons. J Bone Joint Surg Am 2004;86:607-620.

Question 42

A 21-year-old pitcher reports shoulder pain with hard throwing. He notes that the pain occurs in the early acceleration phase of his throw. Given his history, what structures are at greatest risk for injury?

Explanation

DISCUSSION: Internal impingement in the thrower’s shoulder occurs in the abducted, externally rotated position as described by Walch and associates. The injury is thought to occur from repetitive contact between the posterosuperior portion of the labrum and glenoid against the articular side of the rotator cuff and greater tuberosity.
REFERENCES: Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40.
Jazrawi LM, McCluskey GM III, Andrews JR: Superior labral anterior and posterior lesions and internal impingement in the overhead athlete. Instr Course Lect 2003;52:43-63.
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study. J Shoulder Elbow Surg

1992;1:238-245.

Question 43

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Explanation

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,

ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 44

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Explanation

Figure A shows a minimally displaced Weber B ankle fracture. The need for operative treatment would be dependent on fracture stability. A gravity stress test would best demonstrate fracture displacement, syndesmotic injury and medial sided ligamentous integrity.
In patients who present with no medial widening on standard ankle radiographs and no clinical symptoms of deltoid ligament injury, the integrity of the deltoid ligament remains unknown. The gravity stress radiograph may be used to help identify a deltoid ligament injury in association with an isolated distal fibular fracture. Stage-IV supination-external rotation fractures, which involve the deltoid ligament, are more likely to be treated operatively as they are often considered unstable ankle fractures.
Egol et al. reviewed 101 patients with isolated fibular fracture and an intact mortise. They found that medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. Interestingly, they report that good functional results can be obtained in patients with widening of the medial clear space on a stress radiograph in the absence of medial signs.
Gill et al. compared the effectiveness of gravity stress radiograph as compared to manual stress radiograph for the detection of deltoid ligament injury in isolated fibular fracture. A total of twenty-five patients with SER type-II fracture and SER Type IV-equivalent fractures were enrolled. They found the gravity stress radiograph was equivalent to the manual stress radiograph for determining deltoid ligament injury.
Figure A shows a mortise radiograph displaying a minimally displaced Weber B ankle fracture. Illustration A shows the positioning for a gravity stress radiograph. The patient is in the lateral decubitus position with the injured leg dependent and off the end of the table, a mortise view is taken in 10° of internal rotation of the tibia.
Incorrect Answers:

Question 45

In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if

Explanation

DISCUSSION: With the notable exception of fusion for degenerative spondylolisthesis and scoliosis, there is a paucity of evidence on the indications for spinal fusion in patients undergoing laminectomy for spinal stenosis. However, it is generally recommended that if the spine is destabilized (for example by removal of one complete facet joint or by an iatrogenic pars fracture), spinal fusion should be considered. Although fusion can be considered for a very long laminectomy, a two-level laminectomy does not represent, by itself, a clear indication for the addition of a spinal fusion. The repair of a dural tear and the use of nicotine by the patient play no role in the determination of whether or not to add fusion to a laminectomy procedure.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 299-409.
Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812.

Question 46

A year-old man is about to undergo right total hip arthroplasty. A preoperative AP pelvis radiograph is shown in below. The final acetabular component and polyethylene liner are implanted. With the broach in place, the surgeon trials a standard offset neck and neutral length femoral head. The leg lengths are approximately equal, but the hip is unstable. What is the best next step?

Explanation

DISCUSSION:
The radiograph shows that this patient has a high offset varus femoral morphology of both hips. Preoperative templating would identify this, and the surgeon should choose an implant system that has extended offset options to help match the native anatomy and biomechanics and minimize the risk of instability. Trialing a high offset neck, rather than a standard offset neck, is the next most appropriate step. Depending on the design of the implant system, this step can be accomplished by direct medialization of the femoral head, which would not affect leg length, or by lowering the neck angle, which would affect the leg length and would require a longer femoral head, because the leg lengths had previously been equal. Placement of a longer femoral head would likely improve hip stability but would also make the leg length uneven, which is a common cause of dissatisfaction after total hip arthroplasty. An offset acetabular liner also increases the leg length and does not correct the issue, which is on the femoral side. Trochanteric
advancement is sometimes used as a treatment for instability but would be inappropriate as the next step in this setting.

Question 47

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted? Review Topic

Explanation

The radiograph shows a type V acromioclavicular joint injury. Type V injuries involve disruption of the acromioclavicular and coracoclavicular ligaments. Type I injuries involve a sprain of the acromioclavicular joint ligaments. Type II injuries involve disruption of the acromioclavicular joint ligaments; the coracoclavicular ligaments are partially injured. Sternoclavicular ligaments stabilize the medial clavicle and the sternum; they are not damaged with acromioclavicular joint dislocations.

Question 48

Figures 163a through 163c show the radiograph and MRI scans of a 45-year-old woman with severe right arm pain. She has had symptoms for 6 months without resolution despite multiple nonsurgical treatments. Examination reveals weakness in the right triceps and wrist flexors with decreased sensation in the middle finger and a positive Spurling's sign. What is the most appropriate treatment for the patient's symptoms? Review Topic

Explanation

The patient has symptoms and signs of cervical radiculopathy despite a long course of nonsurgical management. Therefore, surgical decompression is indicated and is best performed through an anterior cervical diskectomy and arthrodesis. Single level anterior cervical diskectomy and arthrodesis have been shown to produce significant improvements in arm pain and neurologic function. Anterior cervical foraminotomy, while reported, has insufficient data to support its use and it places the vertebral artery at significant risk. Posterior cervical foraminotomy is contraindicated given the ventral spinal cord compression; foraminotomy places the patient at risk for spinal cord injury. The patient has one-level cervical disease, therefore a corpectomy is unnecessary. Posterior laminoplasty is used to treat myelopathy, not radiculopathy.

Question 49

During total knee arthroplasty using a posterior cruciate-retaining design, excessive tightness in flexion is noted, while the extension gap is felt to be balanced. Which of the following actions will effectively balance the knee?

Explanation

DISCUSSION: Excessive flexion gap tightness can be addressed with a variety of techniques; including: (a) recess and release the posterior cruciate ligament; (b) resect a posterior slope in the tibia; (c) avoid an oversized femoral component that moves the posterior condyles more distally; (d) resect more posterior femoral condyle and use a smaller femoral component placed more anteriorly; and (e) release the tight posterior capsule and balance the collateral ligaments.
REFERENCE: Ayers DC, Dennis DA, Johanson NA, Pelligrini VD: Common complications of total knee arthroplasty. J Bone Joint Surg Am 1997;79:278-311.

Question 50

A 16-year-old right-hand dominant male pitcher has had increasing pain in his dominant shoulder for the past 6 months without treatment. A coronal T2-weighted MRI scan is shown in Figure 80. What is the most appropriate treatment plan? Review Topic

Explanation

The coronal MRI scan shows an undersurface partial-thickness rotator cuff tear. Initial treatment for this injury should include complete cessation of throwing (or other overhead activities dependent on the athlete). Despite the duration of symptoms, he has had no treatment to date; therefore, nonsurgical management should include activity cessation, a rotator cuff and periscapular strengthening program, and then a slow and supervised return to throwing with particular attention to proper pitching mechanics. Decreasing the pitch count or continued play with observation risks progression of the problem. Surgical intervention is not indicated for initial treatment.

Question 51

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

Explanation

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

Question 52

The patient returns 4 days after surgery and says he has noticed a red, swollen knee since yesterday. He reports a fever of 38.0°C since last evening and denies traumatic injury. He has an erythematous knee with a large, tense effusion; his range of motion is limited; and the surgical incisions are not draining. Radiographs taken in the office show no change from the immediate postsurgical images. Aspiration in the office returns 50 cc of cloudy, blood-tinged synovial fluid, and analysis of the fluid reveals a white blood cell count of 92000 (reference range 4500-11000 /µL). Which bacteria is most commonly responsible for this clinical scenario?

Explanation

Video 39 for reference
This patient has a history of failed primary and revision ACL reconstructions, both times with medial meniscus repairs. The clinical scenario suggests a recurrent ACL injury with a recurrent medial meniscus tear that is now locked. The most critical risk factor for ACL reconstruction is age younger than 20 years. The meniscal repair success rate using an all-inside device is between 80% and 90%. Traditionally, it was believed that healing rates were
higher in ACL reconstruction, but current literature demonstrates a similar rate of healing associated with ACL reconstruction and no reconstruction of stable knees.
The images show a vertical femoral tunnel resulting from this patient’s prior reconstruction and revision. The MR images reveal a locked bucket-handle tear of the medial meniscus, and the examination shows a positive Lachman test finding attributable to ACL graft failure. In the setting of a young individual who has failed 2 meniscal repairs, a third repair is not indicated. In addition to a revision ACL reconstruction to stabilize the knee, a partial medial meniscectomy is indicated. An attempt at revision medial meniscus repair would be indicated if the technique were poor in the first attempt, but a failed repair otherwise should indicate the need for partial meniscectomy. The postsurgical images reveal a much more anatomic position of the femoral tunnel that should provide better rotational control of the knee, thereby improving the pivot shift (compared to the vertical femoral tunnel).
This patient has an obvious postsurgical infection based on the timing, examination, and results of the aspiration. In multiple studies of septic arthritis following ACL reconstruction, the most common pathogen was coagulase-negative staph (Staphylococcus epidermidis), followed by S. aureus. If S. aureus is the causative pathogen, the rate of necessary graft removal is higher because of the aggressive nature of this specific bacteria.

Question 53

A 47-year-old woman with no history of trauma has had a painful, stiff shoulder for the past 3 months. Treatment consisting of subacromial injection and nonsteroidal anti-inflammatory drugs has been ineffective. Her active range of motion is painful and is limited to 90 degrees of abduction, 60 degrees of elevation, 30 degrees of external rotation, and internal rotation to the posterior superior iliac spine. Plain radiographs of the cervical spine and shoulder are normal. Management at this time should consist of

Explanation

Idiopathic adhesive capsulitis usually responds to nonoperative therapy or closed manipulation, but shoulder stiffness due to trauma or surgery may necessitate an arthroscopic or an open-release procedure. For most patients, a supervised physical therapy program will be successful in treating adhesive capsulitis.

Question 54

Figures 43a and 43b show the clinical photographs of a 4-month-old child with bilateral popliteal pterygium. The fixed knee contractures measure 100 degrees bilaterally. What future treatment is most likely to successfully correct this deformity?

Explanation

DISCUSSION: Congenital popliteal webbing with contractures of 60 degrees is a difficult deformity to correct. The anatomy of the web is of considerable importance. MRI can delineate the extent of the posterior fibrous band that often stretches from the ischium to the calcaneus. The sciatic nerve, usually shortened, most often runs just anterior to this fibrous band. For mild contractures of less than 20 degrees, nonsurgical management is usually adequate. Hamstring lengthening and postoperative splinting are usually sufficient for contractures of 20 degrees to

40 degrees. Moderate contractures of up to 60 degrees usually require Z-plasties in the popliteal fossa and postoperative serial casting to avoid undue tension on neurovascular structures. Contractures of more than 60 degrees require a femoral shortening osteotomy or gradual correction with an external fixator. However, rapid recurrence following fixator removal is common if formal soft-tissue procedures and postoperative splinting are not performed.
REFERENCES: Parikh SN, Crawford AH, Do TT, et al: Popliteal pterygium syndrome: Implications for orthopaedic management. J Pediatr Orthop B 2004;13:197-201.
Brunner R, Hefti F, Tgetgel JD: Arthrogrypotic joint contracture at the knee and foot: Correction with a circular frame. J Pediatr Orthop B 1997;6:192-197.

Question 55

Figure 22 shows the radiographs of a 16-year-old boy who injured his elbow in a fall 1 year ago. Although he has no pain, he reports restricted forearm rotation and elbow flexion. What is the most likely diagnosis?

Explanation

DISCUSSION: Congenital dislocation of the radial head is often confused with posttraumatic dislocation. The distinguishing feature here is the dome-shaped radial head. Some patients with congenital anomalies fail to recognize their limitations until an injury occurs. Soft-tissue contractures do not cause radial head dislocation nor do they usually cause this pattern of motion restriction (mainly flexion and rotation without significant loss of extension). There is no deformity of the ulna to suggest an old Monteggia lesion.
REFERENCES: Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 196.
Bell SN, Morrey BF, Bianco AJ Jr: Chronic posterior subluxation and dislocation of the radial head. J Bone Joint Surg Am 1991;73:392-396.

Question 56

Figures 122a and 122b are the radiographs of a 79-year-old woman with a 2-year history of progressively worsening right hip pain. She had a right total hip arthroplasty 7 years prior. An infection workup is negative. She opts for revision surgery; the most appropriate surgical plan to address her femoral component is

Explanation

DISCUSSION
The patient’s radiographs show loosening of the cemented femoral stem and varus remodeling of the femur. An extended trochanteric osteotomy is necessary because attempting to extract the existing prosthesis and implant another prosthesis without an osteotomy is likely to cause a proximal femoral fracture. Also, an osteotomy would facilitate atraumatic removal of the stem and cement. Cementless fixation is likely to produce a more predictable long-term outcome than cemented fixation for the revision implant.

Question 57

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Explanation

DISCUSSION: The biopsy specimens show a chondromyxoid fibroma with varying amounts of cartilage, benign fibrous tissue, giant cells, and loose myxoid areas. Chondromyxoid fibroma is a benign active bone lesion that is best treated with aggressive curettage and bone grafting. Although recurrences are common, more aggressive treatment is not warranted initially.
REFERENCES: Wilson AJ, Kyriakos M, Ackerman LV: Chondromyxoid fibroma: Radiographic appearance in 38 cases and in a review of the literature. Radiology 1991;179:513-518.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 167-189.

Question 58

Figure 35 shows the lateral radiograph of a 15-year-old basketball player who felt a dramatic pop in his knee when landing after a lay-up. The patient reports that he cannot bear weight on the injured extremity. Management should consist of

Explanation

DISCUSSION: Tibial tubercle avulsion is an injury of the adolescent knee that most often occurs just before the end of growth. The fracture usually occurs with jumping, either at push-off or landing. This patient has a type III injury. In type III injuries, the articular surface is disrupted, and meniscal injury and compartment syndrome can occur. Open reduction is the treatment of choice, and anterior fasciotomy should be considered prophylactically at the time of surgery. Although the fracture heals with an anterior epiphysiodesis of the proximal tibia, little growth remains in this patient and no special handling of the physis is warranted.
REFERENCES: Ogden JA, Tross RB, Murphy MJ: Fractures of the tibial tuberosity in adolescents. J Bone Joint Surg Am 1980;62:205-215.
Pape JM, Goulet JA, Hensinger RN: Compartment syndrome complicating tibial tubercle avulsion. Clin Orthop 1993;295:201-204.

Question 59

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Explanation

produce higher levels of SMN protein.
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.

Question 60

Ulnar collateral ligament (UCL) reconstruction using a modified Jobe technique

Explanation

DISCUSSION
Certain complications are more strongly associated with the approach and surgical procedure for elbow pathology. With a 2-incision distal biceps repair, heterotopic ossification
with a radial-ulnar synostosis is a concern. This complication can be minimized through irrigation of bone debris and care to avoid dissection between the radius and ulna. With a single-incision distal biceps repair, the lateral antebrachial cutaneous nerve is retracted during the procedure. Numbness on the lateral side of the forearm is common, although often temporary. During arthroscopic debridement for lateral epicondylitis, injury to the radial UCL can occur, leading to posterolateral rotatory instability of the elbow. The modified Jobe technique for UCL reconstruction typically involves an ulnar nerve transposition during the procedure. Numbness and tingling in the fourth and fifth digits are concerns when this procedure is performed.

Question 61

A year-old patient fell 3 weeks after undergoing a total hip arthroplasty using cementless fixation of the femoral component. She sustained a comminuted Vancouver type B-2 fracture with displacement of the calcar fragment. What is the best treatment option?

Explanation

DISCUSSION:
The patient has an acute postoperative fracture of the proximal femur with subsidence. It is also common that the stem retroverts relative to the femur. It is most often seen in proximally porous coated stems within 90 days of surgery, one paper found it to occur 0.7% of the time in modern implants. There is always a debate whether this is a missed intraoperative fracture, or a new fracture that has resulted from an event of increased hoop stresses. Removal of the primary stem, placement of a diaphyseal engaging
stem (most frequently a tapered-fluted stem), and cabling of the fracture is the most successful treatment.

Question 62

What is the most appropriate next step in the work-up of a patient with the asymptomatic lesion shown in Figure 23?

Explanation

DISCUSSION: The eccentric metaphyseal location, skeletal maturity, narrow zone of transition, and lack of symptoms suggest a benign process and are consistent with a healed nonossifying fibroma. These lesions typically fill in (ossify) with skeletal maturity, eventually remodeling and disappearing. Radiographic monitoring is indicated. Biopsy is not recommended unless the lesion changes radiographically.
REFERENCES: Marks KE, Bauer TW: Fibrous tumors of bone. Orthop Clin North Am 1989;20:377-393.
Bullough PG, Walley J: Fibrous cortical defect and non-ossifying fibroma. Postgrad Med J 1965;41:672-676.
Skrede O: Non-osteogenic fibroma of bone. Acta Orthop Scand 1970;41:362-380.

Question 63

Figure 92 is the radiograph of a 45-year-old man who was thrown from his horse and now reports groin pain. Which of the following is the most common long-term sequelae of this injury?

Explanation

The radiograph reveals an anterior posterior compression injury to the pelvic ring which is commonly seen after horseback riding injuries. In a large series of patients with this type of injury, 18 of 20 patients had sexual dysfunction after sustaining this injury. Posttraumatic osteoarthritis of the sacroiliac joints may occur, but is less common in this type of injury. Chronic low back pain, gait abnormalities, and quadriceps weakness are not typically seen with this type of injury.

Question 64

Which of the following statements is most accurate regarding undetected intraoperative surgical glove perforation?

Explanation

DISCUSSION: The incidence of undetected intraoperative surgical glove perforation has been demonstrated at approximately 8.5%, occurring most frequently on the index finger or left hand of the assistant surgeon. The frequency of glove perforation is higher in surgeries lasting longer than 3 hours.
REFERENCES: Al-Habdan I, Sadat-Ali M: Glove perforation in pediatric orthopaedic practice. J Pediatr Orthop 2003;23:791-793.
Sadat-Ali M, Al-Othman A: Glove perforations in orthopaedic practice. Saudi Med J 1996;17:811-813.

Question 65

Among patients with adolescent idiopathic scoliosis, a thoracolumbosacral orthosis is most effective for which type of curve?

Explanation

DISCUSSION
A thoracolumbosacral orthosis is most effective for bracing of curves when the apex is at T7 or below. Bracing is used for patients who are skeletally immature (Risser stage 0, 1, or 2), and it is recommended that the brace be worn 16 to 23 hours per day and continued until skeletal maturity or until the curve progresses to beyond 45 degrees, at which point bracing is no longer considered effective.
RECOMMENDED READINGS
Luhmann SJ, Skaggs DL: Pediatric spine conditions, in Lieberman JR (ed): AAOS Comprehensive Orthopaedic Review. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, pp 245-265.
Shaughnessy WJ. Advances in scoliosis brace treatment for adolescent idiopathic scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75, v. Review. PubMed PMID: 17945126. View Abstract at PubMed

Question 66

A 21-year-old woman is struck by a car and sustains a Gustillo IIIB fracture of the tibia. The wound was debrided and immobilized with an external fixator. Radiographs are shown in Figure A. The soft tissue defect was covered with a free flap. Her recovery was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli. One month after her injury, she underwent intramedullary nailing and placement of an antibiotic spacer measuring 15cm in length. Radiographs are shown in Figure B. At the next stage of surgery 6 weeks later, the surgeon should plan to do all of the following:

Explanation

The second stage of the Masquelet technique requires removal of the cement bolus, incision into the induced membranes and bone grafting. The existing hardware is preserved where possible as the fracture is still not stable. Bone graft is inserted INTO the membranous cavity, AROUND the nail.
The Masquelet staged technique of induced membranes is an option for filling large bone defects up to 25cm in length. This technique protects against autograft resorption, stimulates mesenchymal cell-to-osteoblast differentiation, maintains graft position, and prevents soft tissue interposition. Cement impregnation achieves high local antibiotic concentration without risk of systemic toxicity.
Ashman et al. discussed the techniques of addressing bone defects. Options include:
(1) acute limb shortening (up to 4cm in the tibia and humerus, and 7cm in the femur);
(2) distraction osteogenesis for defects up to 10cm long (at 1mm/day with consolidation period of 5days per mm, or total treatment time of up to 60days/cm), (3) autograft (up to 25cm of vascularized fibula, or 3cm of nonvascularized iliac crest),
and (4) Masquelet technique.
Taylor et al. reviewed the induced membranes technique. They found that the membrane is well vascularized and composed of type I collagen with fibroblasts with an inner epithelial cell layer. There is a high concentration of VEGF, RUNX2 (CBFA1), TGFß1, and BMP2. The membrane is sutured over bone graft to create a closed pouch. When a nail is present, they note a second internal membrane around the nail, potentially increasing local vascularity and osteoinductive factor concentration.
Figure A shows a Gustillo IIIB tibia fracture with a large bone defect held in a temporizing external fixator. Figure B shows the same defect following intramedullary nailing and with a cement spacer placed circumferentially around the nail in the defect.
Incorrect Answers

Question 67

Figure A shows immediate post-operative radiographs of a 75-year-old patient with primary osteoarthritis. She presents 3 years later with increasing pain and weakness in the shoulder despite home physical therapy. Examination reveals limited active range of motion, with forward elevation of 80 degrees and external rotation of 50 degrees. Her deltoid function is intact. Repeat radiographs are seen in Figure B.

Explanation

This patient presents with failed total shoulder arthroplasty. The best treatment option for functional outcome would be revision to reverse shoulder arthroplasty (rTSA).
RTSA is considered a viable treatment option for patients with failed shoulder arthroplasty. It allows for improved arm elevation and abduction in the setting of nonfunctional rotator cuff muscles, as seen in this example. Despite the expanding indications for rTSA, there are high complication rates in the revision setting. Complication rates for rTSA after failed shoulder arthroplasty have been reported to be between 11-36%. This procedure should, therefore, be performed by surgeons with extensive training in reconstructive shoulder arthroplasty.
Patel et al. retrospectively reviewed 31 patients (mean age, 68.7 years) who underwent rTSA for treatment of a failed shoulder arthroplasty. They found the greatest improvement with active forward elevation from 44° preoperatively to 108° postoperatively (P < .001). Complications occurred in 3 patients with periprosthetic fracture.
Hattrup et al. reviewed a series of 19 patients that underwent open rotator cuff repair after shoulder arthroplasty. Out of the 19 patients only 4 shoulders were successfully repaired. They concluded that successful rotator cuff repair after shoulder arthroplasty is possible but failure is more common.
Figure A shows a left total shoulder arthroplasty that is well reduced in the glenoid. Figure B shows antero-superior escape of the prosthesis, indicative of a massive rotator cuff tear.
Incorrect Answers:

Question 68

A 55-year-old woman with polyarticular rheumatoid arthritis has had progressively increasing left shoulder pain for the past 2 years despite nonsurgical management. No focal weakness is noted during examination of the shoulder. AP and axillary radiographs are shown in Figures 47a and 47b. Treatment should consist of

Explanation

DISCUSSION: Unconstrained total shoulder arthroplasty has been found to yield satisfactory results in a high percentage of patients with rheumatoid involvement of the glenohumeral joint. Pain relief has been more predictable with total shoulder arthroplasty than humeral arthroplasty, and a glenoid component is favored when there is sufficient glenoid bone stock and an intact rotator cuff. Constrained or fixed-fulcrum devices have an unacceptably high failure rate because of loosening. Glenohumeral arthrodesis is avoided when the deltoid or rotator cuff is functioning because the functional results after arthroplasty are superior when compared with results of arthrodesis. Arthroscopic synovectomy may be helpful in early stages of the disease before extensive cartilage damage has occurred.
REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg Br 1987;69:723-726.

Question 69

Figure 10 is an anteroposterior pelvis radiograph of an 82-year-old man who had right hip pain that began 2 weeks ago but has since resolved with use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs). Currently he has no pain. Examination of his hip shows decreased internal rotation and minimal pain at the extremes of motion. What is the most appropriate treatment at this point?

Explanation

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams 14
& Wilkins; 2007:514-533.

Question 70

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Explanation

DISCUSSION: An APC type 1 involves slight widening of pubic symphysis and/or anterior sacroiliac (SI) joint. An APC II is a continuation of this force, and additionally involves a disrupted anterior SI joint, as
well as sacrotuberous and sacrospinous ligaments. An APC III also involves disrupted posterior SI ligaments, causing complete SI joint disruption with potential translational and rotational displacement.
The reference by Young et al is a classic article that describes the Young and Burgess classification of pelvic ring injuries. They retrospectively analyzed pelvic ring radiographs and discussed four patterns of injury: anteroposterior compression, lateral compression, vertical shear, and a complex/combined pattern.
The reference by Burgess et al is a validation of the aforementioned classification and study, as they reviewed 210 consecutive patients who sustained a pelvic ring injury. They validated the classification scheme and found that overall blood replacement averaged: lateral compression, 3.6 units; anteroposterior compression, 14.8 units; vertical shear, 9.2 units; combined mechanical, 8.5 units. Overall mortality was: lateral compression, 7.0%; anteroposterior, 20.0%, vertical shear, 0%; combined mechanical, 18.0%.
Incorrect answers:
1,2,4,5: An APC - 2 pelvic ring injury involves injury to all of these structures.

Question 71

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 72

A 64-year-old man who underwent total shoulder arthroplasty 4 weeks ago is making satisfactory progress in physical therapy, but his therapist notes limitations in external rotation to neutral. A stretching program is started, and the patient suddenly gains 90 degrees of external rotation but now reports increased pain and weakness. What is the best course of action?

Explanation

DISCUSSION: Nearly all approaches to shoulder arthroplasty require detachment of the subscapularis tendon from the humerus and subsequent repair. Healing of this tenotomy is one of the limiting factors in postoperative recovery. Failure of the tenotomy repair must be recognized and treated early with repeat repair or pectoralis muscle transfer for optimal results. Failure of the subscapularis is diagnosed clinically as excessive external rotation and weakness, especially in the lift-off or belly press position. Muscle testing can be difficult in the postoperative period and may not be possible to assess in those positions. Although MRI might be useful to confirm the diagnosis, studies may be limited by artifact. CT or electromyography would not be diagnostic.
REFERENCES: Wirth MA, Rockwood CA Jr: Complications of total shoulder-replacement arthroplasty. J Bone Joint Surg Am 1996;78:603-616.
Miuer SL, Hazrati Y, Klepps S, et al: Loss of subscapularis function after shoulder replacement: A seldom recognized problem. J Shoulder Elbow Surg 2003;12:29-34.

Question 73

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

Explanation

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

Question 74

Examination of an obese 3-year-old girl reveals 30 degrees of unilateral genu varum. A radiograph of the involved leg with the patella forward is shown in Figure 10. Management should consist of

Explanation

DISCUSSION: The clinical scenario describes infantile tibia vara (Blount’s disease). The radiograph shows severe deformity with the characteristic Langenskiold stage 3 changes of the medial proximal tibial metaphysis that distinguish it from physiologic bowing. The preferred treatment is proximal tibiofibular osteotomy with acute correction into slight valgus to unload the damaged area of the physis. This method provides the best results in patients younger than age 4 years. Continued observation would result in progressive deformity. Bracing is most effective in younger children with less severe deformity. Lateral proximal tibial hemiepiphysiodesis relies on growth of the injured medial physis for correction and would result in severe tibial shortening in this young child. Complete epiphysiodesis also produces severe shortening and requires multiple lengthening procedures.
REFERENCES: Johnston CE II: Infantile tibia vara. Clin Orthop 1990;255:13-23.
Richards BS, Katz DE, Sims JB: Effectiveness of brace treatment in early infantile Blount’s disease. J Pediatr Orthop 1998;18:374-380.

Question 75

A 24-year-old man has right forearm pain after sliding head first into home plate. Examination reveals that the arm is swollen, but there are no neurovascular deficits or skin lacerations. Radiographs reveal a both-bone forearm fracture. The ulna has an oblique fracture with a 30% butterfly fragment, and the radius is comminuted over 75% of its circumference. In addition to reduction and plate fixation of both bones, management should consist of

Explanation

DISCUSSION: The patient has a both-bone fracture with a comminuted radial shaft. Open reduction and internal fixation of both bones is the treatment of choice. In the past, Chapman and associates recommended bone grafting radial shaft fractures with more than 30% comminution of the circumference. This has remained the recommendation in most textbooks. More recent studies, where modern biologic plating techniques were used, found that the addition of bone graft to comminuted fractures was not necessary because the union rate did not differ from that of nongrafted comminuted fractures.
REFERENCES: Anderson LD, Sisk TD, Tooms RE, Park WI III: Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-297.
Chapman MW, Gordon JE, Zissimos AG: Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71:159-169.
Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294.
Wei SY, Born CT, Abene A, Ong A, Hayda R, Delong WG Jr: Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46:1045-1048.

Question 76

...Figure 74 is the radiograph of an 11-year-old boy with pain in his left arm. Prognosis is most influenced by

Explanation

Question 77

A 66-year-old woman who previously underwent hemiarthroplasty 2 years ago for a fracture continues to have severe pain and loss of motion despite undergoing physical therapy. A radiograph is shown in Figure 2. What is the most likely reason that this patient has failed to improve her motion?

Explanation

DISCUSSION: The radiograph shows tuberosity malposition. The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than age 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement.
REFERENCES: Bigliani LU, Flatow EL, McCluskey G, et al: Failed prosthetic replacement for displaced proximal humeral fractures. Orthop Trans 1991;15:747-748.
Boileau P, Krishnan SG, Tinsi L, et al: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:401-412.
Tanner MW, Cofield RH: Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res 1983;179:116-128.

Question 78

A 26-year-old ballet dancer reports posterolateral ankle pain, especially with maximal plantar flexion. Examination reveals maximal tenderness just posterior to the lateral malleolus, and symptoms are heightened with forced passive plantar flexion. Radiographs are shown in Figures 42a and 42b. What is the most likely cause of the patient’s symptoms?

Explanation

DISCUSSION: The patient has a symptomatic os trigonum caused by impingement that occurs with maximal plantar flexion of the ankle in the demi-pointe or full-pointe position. Patients frequently report posterolateral pain localized behind the lateral malleolus that may be misinterpreted as a disorder of the peroneal tendon. Pain with passive plantar flexion (the plantar flexion sign) indicates posterior impingement, not a problem with the peroneal tendon. The symptoms are not characteristic of a stress fracture, nor do the radiographs show a stress fracture or an osteochondritis dissecans lesion. The os trigonum is modest in its dimensions. The incidence or magnitude of symptoms does not correlate with the size of the fragment. Large fragments may be asymptomatic, while small lesions may create significant symptoms.
REFERENCES: Marotta JJ, Micheli LJ: Os trigonum impingement in dancers. Am J Sports Med 1992;20:533-536.
Hamilton WG: Foot and ankle injuries in dancers, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1241-1276.

Question 79

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

Explanation

DISCUSSION: Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration. In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective. Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained.
REFERENCES: Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. Orthopedics 1996;19:465-475.
Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. J Bone Joint Surg Am 1999;81:535-538.

Question 80

A 36-year-old woman was injured in a train derailment. She has a significant open depressed skull fracture with active bleeding, a hemopneumothorax, and blood in the left upper quadrant and colic gutter by Focused Assessment with Sonography for Trauma (FAST) examination. Additionally, she has the pelvic injury seen on the CT scans in Figures 18a and 18b. The mortality rate for this patient approaches

Explanation

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.

J Trauma 1982;22:691-693.

Question 81

A 24-year-old man was thrown from a car and is seen in the emergency department with a Glasgow Coma Scale (GCS) score of 8. A CT scan of the head shows no significant bleeding. The patient is hemodynamically stable. The left femur has the closed injury shown on the radiographs in Figures 53a and 53b. What is the best treatment for this patient?

Explanation

DISCUSSION: Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggest that intramedullary nails done acutely with avoidance of intraoperative hypotension did not compromise the outcome related to the head injury. This was especially true for high-level GCS scores. A GCS score of lower than 8 and intraoperative hypotension have been associated with worsening outcomes following acute intramedullary nailing of the femur. Skin traction and distal femur skeletal traction in a young adult man with a femoral fracture is not well tolerated secondary to spasm and pain. External fixation is an option but an unnecessary step in the treatment of this patient. Ventriculostomy is not necessary in stable patients with no significant bleeding on a CT scan of the head.
REFERENCES: Starr AJ, Hunt JL, Chason DP, et al: Treatment of femur fracture with associated head injury. J Orthop Trauma 1998;12:38-45.
Nau T, Kutscha-Lissberg F, Muellner T, et al: Effects of a femoral shaft fracture on multiply injured patients with a head injury. World J Surg 2003;27:365-369.
McKee MD, Schemitsch EH, Vincent LO, et al: The effect of a femoral fracture on concomitant closed head injury in patients with multiple injuries. J Trauma 1997;42:1041-1045.
Brundage SI, McGhan R, Jurkovich GJ, et al: Timing of femur fracture fixation: Effect on outcome in patients with thoracic and head injuries. J Trauma 2002;52:299-307.

Question 82

The newborn foot deformity seen in Figures 64a and 64b should initially treated with

Explanation

DISCUSSION: Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American AcademAyL-oMfadOenrathCooppayedic Surgeons, 2006, pp 240-241.
Farsetti P, Weinstein SL, Ponseti IV: The Long-term functional and radiographic outcomes of untreated
and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265. Question 65
A 4-year-old girl has been limping for the past 2 months. There is no history of trauma, previous injury, fever, or other systemic complaints. Examination reveals a moderate right knee effusio n with a 10-degree knee flexion contracture. What is the next most appropriate step in evaluation?
Arthroscopy
Antinuclear antibody
MRI
Bone scan
HLA-B27
DISCUSSION: The patient presents with juvenile idiopathic arthritis manifestations. The American College of Rheumatology defines this as one or more joints involved with swelling of 6 weeks or longer. A positive antinuclear antibody test would be diagnostic. Consideration should be made to have the patient see an ophthalmologist for evaluation of possible uveitis. Although the patient could have Lyme disease, that choice is not an option. The presence of an elevated antinuclear antibody by itself should not necessarily be used for diagnosing arthritis; however, the test does have clinical utility as a screening test. The frequency of a positive antinuclear antibody test is greatest in younger girls with oligoarticular disease and carries an increased risk for anterior uveitis. Arthroscopy might be indicated if this patient was presenting with a discoid meniscus, but there is no history of clicking, which is often one of the classic signs of discoid meniscus. MRI would not be used to diagnose juvenile idiopathic arthritis, but
MRI would be useful to help diagnose discoid meniscus. A bone scan would show increased uptake in the patient’s knee but again, this would not help diagnose her condition. HLA-B27 has no role in diagnosing juvenile idiopathic arthritis, especially in females.
REFERENCES: Iesaka K, Kubiak EN, Bong LR, et al: Orthopaedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 2006;35:67-73.
Wright DA: Juvenile idiopathic arthritis, in Morrissey RT, Weinstein SL (eds): Love l and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia PA, Lippincott Williams and Wilkins, 2006, pp 405-438. Question 66
An 18-month-old girl is brought in by her parents because of concerns about intoeing, bowlegs, and tripping and fa ling. Prenatal and birth history are otherwise unremarkable. The child’s growth and
development appear to be normal and she has a normal neurologic exam, a straight spine with no defects, and the hips are stable. Examination reveals hip internal rotation of 40 degrees and hip external rotation of 60 degrees. The thigh-foot angle is internal 30 degrees. Feet are straight and supple. Gait is characterized by intoeing with occasional tripping and falling. Based on these findings, what is the most appropriate action?
No treatment because internal tibial torsion slowly resolves on its own
Immediate treatment with a Denis-Browne bar
Distal tibial osteotomies
Proximal femoral derotational osteotomies
Treatment with twister cables PREFERRED RESPONSE: 1
DISCUSSION: The child has classic internal tibial torsion that is very commonly seen in younger children who are just beginning to walk. The normal outcome is for slow resolution of this problem and it seldom requires any treatment. Treatment with a Denis-Browne bar or with twister cables has not been proven to be effective. Surgical treatment at this point is premature and clearly not indicated.
REFERENCES: Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.
Staheli LT, Corbett M, Wyss C, et al: Lower-extremity rotational problems in children: Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47.

Question 83

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

Explanation

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T₁-weighted MRI scans and with high signal intensity on T₂-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 84

A 75-year-old man presents with a displaced femoral neck fracture. During your surgical exposure for a hemiarthroplasty, the femoral neck has fractured through a pathologic lesion which is diagnosed as a lymphoma on frozen section. The lesion is located in the center of the femoral neck and the calcar femorale is not involved. Your treatment should include:

Explanation

This case presents a treatment dilemma for most orthopaedic surgeons. However, because lymphomas are very chemo-radiotherapy sensitive, treatment is straightforward. Lymphoma isolated to bone is treated by resection and reconstruction as indicated. In this case, the resection is accomplished with neck osteotomy and the reconstruction with a hemiarthroplasty. Postoperative adjuvant radiotherapy and chemotherapy can be used to treat the local and distant disease as necessary. You wouldn't close the wound without surgical fixation unless the chemotherapy would be used to improve your surgical margin (such as for a osteosarcoma). Radical resection or hip disarticulation are very aggressive and morbid procedures for a tumor that is very sensitive to chemo-radiotherapy. Bone marrow transplantation is not used in the initial treatment of lymphoma, but can be considered for relapsed disease.
The clinical and radiographic features specific to lymphoma of bone are outlined by Dürr but on the whole are not diagnostic.
Vose describes the current treatment protocols for patients with non-Hodgkin's lymphoma including patients with impending/sustained pathologic fractures.

Question 85

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Explanation

DISCUSSION: The MRI scan reveals a full-thickness rotator cuff tear with retraction and increased signal in the subacromial space indicating joint fluid.
REFERENCES: Herzog RJ: Magnetic resonance imaging of the shoulder. Instr Course Lect 1998;47:3-20.
Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 1991;73:17-29.

Question 86

A 46-year-old man reports occasional squeaking of his hip 2 years after undergoing an uneventful total hip arthroplasty. History reveals no pain, physical examination cannot reproduce audible squeaking, and radiographs show appropriate implant position. What is the most appropriate management?

Explanation

DISCUSSION: In the absence of component malpositioning, hip pain, or other compelling reasons to reoperate, a squeaking ceramic bearing is not an indication for revision surgery. The patient can be reassured and observed.
Hopefully, with a better understanding of acoustic phenomena following ceramic total hip arthroplasty, this complication can be minimized.
REFERENCES: Yang CC, Kim RH, Dennis DA: The squeaking hip: A cause for concem-disagrees. Orthopedics
2007;30:739-742.
Walter WL, O’Toole GC, Walter WK, et al: Squeaking in ceramic-on-ceramic hips: The importance of acetabular component orientation. J Arthroplasty 2007;22:496-503.

Figure 80a Figure 80b

Question 87

Within the menisci, the majority of the large collagen fiber bundles are oriented in what configuration?

Explanation

DISCUSSION: The majority of large collagen fibers within the menisci are oriented circumferentially. It is these fibers that develop the hoop stress with compressive loading of the menisci. Most meniscal tears are longitudinal and occur between these circumferential fibers.
REFERENCES: Mow VC, et al: Structure and function relationships of the menisci of the knee, in Mow VC, Arnoczky SP, Jackson DW (eds): Knee Meniscus: Basic and Clinical Foundations. New York, NY, Raven Press, 1992, pp 37-57.
DeHaven KE, Arnoczky SP: Meniscus repair: Basic science, indications for repair, and open repair. Instr Course Lect 1994;43:65-76.

Question 88

Which of the following is considered the appropriate initial management protocol for an unconscious football player without spontaneous respirations?

Explanation

DISCUSSION: The on-field evaluation and management of the seriously injured athlete requires advance preparation and planning. It is imperative that the health care team have a game plan in place and the proper equipment readily available. The initial step consists of stabilizing the head and neck by manually holding the head and neck in a neutral position. Then, in the following order, check for breathing, pulses, and level of consciousness. If the athlete is breathing, simply remove the mouth guard and maintain the airway. If the athlete is not breathing, the face mask must be removed and the chin strap left in place. An open airway must be established, followed by assisted breathing. CPR is only instituted when breathing and circulation are compromised. If the athlete is unconcious or has a suspected cervical spine injury, the helmet must not be removed until the athlete has been transported to an appropriate facility and the cervical spine has been completely evaluated.
REFERENCES: McSwain NE, Garnelli RL: Helmet removal from injured patients. Bull Am Coll Surg 1997;82:42-44.
Vegso JJ, Lehman RC: Field evaluation and management of head and neck injuries. Clin Sports Med 1987;6:1-15.
Arndt EA (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 93-101.

Question 89

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

Explanation

Functional recovery after nerve injury-The outcome of peripheral nerve injuries is quite variable. Variables hypothesized to have an important role in determining the outcome of nerve repair include: (1) the age of the patient; (2) the type of nerve injured; (3) the distance the regenerating axons must grow to reach the target organ; (4) the length of the injured zone; (5) the timing of the nerve repair; (6) the status of the target organ at the time it is reinnervated; and (7) the technical excellence of the surgeon.
Functional recovery is generally complete after a crush injury because the basement membrane and endoneurium are left intact, and the damaged axons can regenerate within their original endoneurial tubes and reinnervate their original target organ. After a complete lesion to the nerve, however, functional recovery of movement is often quite poor. The loss of functional recovery probably is related to the failure of the axons to regenerate and the misdirection of regenerating axons, which leads to inappropriate innervation of denervated muscles. Inappropriate innervation is thought to result in a loss in the ability to accurately recruit individual muscles and motor units within a muscle, resulting in the loss of motor control.

Question 90

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 91

Which of the following statements best describes labral tears in the hip? Review Topic

Explanation

Labral and chondral lesions are observed within the anterosuperior quadrant of the acetabulum. Tearing of the labrum markedly reduces resistance to joint motion, leading to instability. The most common associated lesions are chondral injuries. They can occur with or without abnormal bone morphology. The etiology for labral tears can be from traumatic and degenerative causes, structural abnormalities from femoroacetabular impingement, developmental abnormalities, and hip instability.

Question 92

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Explanation

Type I collagen fibers are most responsible for the tensile strength of a peripheral nerve. Type I collagen is the most abundant collagen of the human body which forms large, eosinophilic fibers known as collagen fibers. It is present in scar tissue, the end product when tissue heals by repair, as well as tendons, ligaments, the endomysium of myofibrils, the organic part of bone, the dermis, the dentin and organ capsules.
The COL1A1 gene produces a component of type I collagen, called the pro-alpha1(I) chain. This chain combines with another pro-alpha1(I) chain and also with a pro-alpha2(I) chain (produced by the COL1A2 gene) to make a molecule of type I procollagen. These triple-stranded, rope-like procollagen molecules must be processed by enzymes outside the cell. Once these molecules are processed, they arrange themselves into long, thin fibrils that cross-link to one another in the spaces around cells. The cross-links result in the formation of very strong mature type I collagen fibers.
Wong et al. provide a review of the basic science behind nerve healing and the recovery after nerve repair. They note the importance of minimizing additional surgical insult and careful handling of nerve tissue during repair to optimize outcomes.
Pertici et al. noted that autologous nerve implantation to bridge a long nerve gap presents the greatest regenerative performance in spite of substantial drawbacks. They were able to show improved nerve guided regrowth with a type I collagen matrix conduit as compared to a conduit made of a mix of type I and type III collagen.
Illustration A shows a diagram of type I collagen, showing the rope-like characteristics behind the tensile strength.
Incorrect Answers:

Question 93

An orthopaedic surgeon who is the developer of a knee arthroplasty system is discussing treatment options with a patient who has tricompartmental osteoarthritis. As a part of this discussion, the orthopaedic surgeon has an obligation to disclose

Explanation

This topic is listed in Appendix D of the Code of Ethics for Orthopaedic Surgeons/American Academy of Orthopaedic Surgeons under sections III B and C.
III. Conflicts of Interest
B. Where there are financial interests involved in the ownership of a pharmacy, rehabilitation center, imaging equipment, surgery center, or health care facility where the orthopaedic surgeon’s financial interest is not immediately obvious, the orthopaedic surgeon must disclose that financial interest to the patient and to colleagues.
C. When an orthopaedic surgeon receives anything of value, including royalties, from a manufacturer, the orthopaedic surgeon must disclose this fact to the patient and to colleagues. It is unethical for an orthopaedic surgeon to receive compensation (excluding royalties) from a manufacturer for using a particular device or medication. Reimbursement for administrative costs in conducting or participating in a scientifically sound research trial is acceptable.

Question 94

What is the most common result if the acetabulum is rotated too far anteriorly during a periacetabular osteotomy?

Explanation

DISCUSSION: In patients with hip dysplasia who undergo a periacetabular osteotomy, the authors note that the freed acetabular segment can be overcorrected for the deformity. If it is placed too anteriorly, then hip flexion is limited. Posterior dislocation is a rare complication. The other complications should not occur as a result of this procedure.
REFERENCES: Hussell JG, Rodriguez JA, Ganz R: Technical complications of the Bernese periacetabular osteotomy. Clin Orthop 1999;363:81-92.
Myers SR, Eijer H, Ganz R: Anterior femoroacetabular impingement after periacetabular osteotomy. Clin Orthop 1999;363:93-99.

Question 95

The patient decides to pursue surgical intervention. Which compartments should be released?

Explanation

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible for the patient's symptoms and falls below current thresholds for diagnosis.

Question 96

Figure 29a shows the clinical photograph of a 26-year-old woman who has had the leg deformity since birth. She reports difficulty with walking and weight bearing and notes increased discomfort and swelling when the leg is dependent. She denies any history of trauma or family history of a similar disorder. Examination reveals a fixed equinovarus deformity of the foot but no evidence of a limb-length discrepancy. No other cutaneous findings or soft-tissue masses are noted. Sagittal and axial T1- and T2-weighted MRI scans are shown in Figures 29b and 29c. What is the most likely diagnosis?

Explanation

DISCUSSION: Because the MRI scans show marked dilation and proliferation of lymphatic channels that completely involve all the leg muscles and the clinical photograph shows the severe swelling associated with this disease, the most likely diagnosis is lymphangiomatosis. Poliomyelitis affects the anterior horn cells and manifests as muscle atrophy. Neurofibromatosis can have a similar clinical appearance but usually is associated with other systemic and cutaneous findings. Congenital band syndrome results in amputated or shortened extremities. Chronic venous stasis disease usually is not associated with joint contractures, and typically it affects older individuals. Surgical excision is the only known treatment; this patient underwent an above-knee amputation.
REFERENCES: Berquist TH (ed): MRI of the Musculoskeletal System, ed 3. Philadelphia, PA, Lippincott Raven, 1997, p 771.
Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St. Louis, MO, Mosby Year Book, 1995, p 688.

Question 97

The thumb metacarpophalangeal (MCP) joint should be flexed to what degree to properly assess ligamentous stability?

Explanation

DISCUSSION: The collateral ligaments of the MCP joint of the thumb can be isolated by flexing the joint to 30 degrees. Full extension is best to assess the accessory collaterals and the palmar plate. The ulnar collateral ligament nearly always separates from the base of first phalanx of the thumb; it frequently becomes lodged between adductor pollicis aponeurosis and its normal position (Stener lesion). The creation of a Stener lesion requires significant radial deviation of the phalanx along with combined tears of the proper and accessory collateral ligaments in order for the ligament to be displaced above the adductor aponeurosis.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgery, 2002, pp 339-358.
Stener B: Displacement of the ruptured ulnar collateral ligament of the MP joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1962;44:869-879.
33 • American Academy of Orthopaedic Surgeons

Question 98

A 32-year-old man who works as a laborer has had left trapezius wasting and lateral scapular winging after injuring his shoulder when a cargo box fell onto his neck 8 months ago. He now reports posterior shoulder pain and fatigue, and he has difficulty shrugging his shoulder. Examination reveals marked scapular winging, impingement signs, and an asymmetrical appearance when the patient attempts a shoulder shrug. Primary scapular-trapezius winging is the result of damage to the

Explanation

DISCUSSION: The patient has primary scapular-trapezius winging. This condition can be caused by blunt trauma to the relatively superficial spinal accessory nerve that is located in the floor of the posterior cervical triangle in the subcutaneous tissue. Other causes of injury include penetrating trauma, traction, or surgical injury. With trapezius winging, the shoulder appears depressed and laterally translated because of an unopposed serratus anterior. This contrasts with primary serratus anterior winging, which is caused by injury to the long thoracic nerve. In this condition, the scapula assumes a position of superior elevation and medial translation, and the inferior angle is rotated medially. The thoracodorsal nerve supplies the latissimus dorsi and is not involved in primary scapular winging.
REFERENCES: Kuhn JE, Plancher KD, Hawkins RJ: Scapular winging. J Am Acad Orthop Surg 1995;3:319-325.
Wright TA: Accessory spinal nerve injury. Clin Orthop 1975;108:15-18.

Question 99

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

Explanation

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

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

Question 100

What is the second most common primary bone malignancy in children?

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.

Correct Answer: Use plasma expanders.

Explanation:

DISCUSSION: Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open would is not recommended nor would there likely be enough from an open tibial fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
REFERENCES: Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007.
Jehovah’s Witnessess Official Web Site: Medical Care and Blood, 2008, http://www.watchtower.org/e/medical_care_and_blood.htm

Question 2:

Options:

Alendronate
Indomethacin
Radiotherapy
Excision

Correct Answer: Alendronate

Explanation:

Question 3:

A “p value” of 4% (p=0.04) indicates that the

Options:

hypothesis is incorrect or invalid
interobserver error rate is 4%.
Standard deviation is 4% higher or lower than the mean.
Sample size is 4% larger than required to be clinically significant.
Probability that the differences noted between two study groups were due to chance alone is 4%.

Correct Answer: Probability that the differences noted between two study groups were due to chance alone is 4%.

Explanation:

Question 4:

Options:

Ehlers-Danlos syndrome
Traumatic anterior instability
Humeral head osteonecrosis
Internal impingement
Partial-thickness supraspinatus tear

Correct Answer: Internal impingement

Explanation:

Question 5:

Options:

Aseptic loosening
Mortality
Infection
Bleeding
Limited motion requiring manipulation

Correct Answer: Mortality

Explanation:

Question 6:

Options:

Observer bias
Type-II error
Alpha error
Type-I error
Confounding error

Correct Answer: Observer bias

Explanation:

Question 7:

What proteinaceous compound binds to hyaluronic acid to function as an effective boundary molecular layer in articular cartilage?

Options:

Lubricin
Vitronectin
Aggrecan
Chondroitin sulfate

Correct Answer: Lubricin

Explanation:

Question 8:

Options:

No external rotation stretching for the first 6 weeks.
No external rotation stretching for the first 3 weeks.
Limit external rotation to the side to 60 degrees for the first 6 weeks.
Limit external rotation to the side to 60 degrees for the first 3 weeks.
No restrictions on external rotation stretching.

Correct Answer: Limit external rotation to the side to 60 degrees for the first 6 weeks.

Explanation:

Question 9:

- Which of the following types of sarcoma of the bone is most sensitive to external beam radiation?

Options:

Ewings tumor
Parosteal osteosarcoma
Dedifferentiated chondrosarcoma
Low grade intramedullary chondrosarcoma
High grade intramedullary osteosarcoma

Correct Answer: Ewings tumor

Explanation:

Question 10:

Options:

observation.
a Pemberton osteotomy.
a periacetabular osteotomy.
a Chiari osteotomy.
total hip arthroplasty.

Correct Answer: a periacetabular osteotomy.

Explanation:

Question 11:

Options:

Observation and close follow-up
Dynamization of the intramedullary nail
Revision surgery, internally rotate distal fragment by 19 degrees
Revision surgery, externally rotate distal fragment by 8 degrees
Revision surgery, internally rotate proximal fragment by 11 degrees

Correct Answer: Dynamization of the intramedullary nail

Explanation:

Question 12:

Figures 23a and 23b show the radiographs of a 75-year-old woman who sustained an injury to her nondominant hand. Initial treatment should consist of

Options:

closed reduction and splinting.
open reduction and internal fixation through a volar approach.
external fixation and Kirschner wire fixation.
intrafocal pinning and casting.
acceptance of alignment and bracing.

Correct Answer: closed reduction and splinting.

Explanation:

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction.
REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.
Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

Question 13:

Options:

Allograft reconstruction with semitendinosis weave to the humerus
Latissimus dorsi tendon transfer
Electrical stimulation
Shoulder arthrodesis
Arthroscopic pectoralis major tendon repair

Correct Answer: Allograft reconstruction with semitendinosis weave to the humerus

Explanation:

Question 14:

What is the primary intracellular signaling mediator for bone morphogenetic protein (BMP) activity?

Options:

Interleukin-1 (IL-1)
Runx2
NFK-B
SMADS
P53

Correct Answer: SMADS

Explanation:

Question 15:

Anabolic steroid use has which of the following effects on serum lipoprotein levels?

Options:

Decrease in low-density lipoprotein only
Decrease in high-density lipoprotein only
Increase in high-density lipoprotein only
Increase in low-density lipoprotein only
Increase in both high- and low-density lipoproteins

Correct Answer: Decrease in high-density lipoprotein only

Explanation:

Question 16:

Options:

Vertebrectomy of L5
Posterior spinal fusion with or without instrumentation from L4 to S1
Posterior spinal fusion without instrumentation from L5 to S1
Anterior spinal fusion from L4 to L5
Direct repair of the spondylolysis defect

Correct Answer: Posterior spinal fusion with or without instrumentation from L4 to S1

Explanation:

Question 17:

What factor is associated with the highest risk for in-hospital complications for patients undergoing a lumbar fusion for degenerative spondylolisthesis? Review Topic

Options:

Hospital size
Gender
Race
Age
One comorbidity

Correct Answer: Age

Explanation:

Question 18:

Which of the following findings is considered the strongest indication for surgical treatment of a mallet fracture of the distal phalanx?

Options:

Fragment size of more than 20% of the articular surface
Displacement of more than 2 mm
Articular step-off of more than 2 mm
Articular impaction
Volar subluxation of the distal phalanx

Correct Answer: Volar subluxation of the distal phalanx

Explanation:

Question 19:

Options:

Nerve conduction velocity studies and electromyography
Exploration and grafting of the radial nerve
Tendon transfers
Observation for another 2 months
Removal of the plate, neurolysis of the radial nerve, and intramedullary rodding of the humerus

Correct Answer: Observation for another 2 months

Explanation:

DISCUSSION: Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified.
REFERENCES: Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.
Green DP: Radial nerve palsy, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 112.

Question 20:

Figure 1 shows a radiograph obtained from an active 30-year-old man who sustained an injury to his ring finger 1 week earlier. The most appropriate treatment is

Options:

open reduction and internal fixation (ORIF).
a mallet splint.
repair of the terminal tendon.
arthrodesis.

Correct Answer: open reduction and internal fixation (ORIF).

Explanation:

EXPLANATION:
Figure 1 reveals evidence of an intra-articular distal phalanx fracture with a distal interphalangeal (DIP) joint dorsal subluxation. This injury is unstable and requires surgical management for an active individual. Volar distal phalanx fractures are often associated with flexor digitorum profundus avulsion injuries, which are addressed concomitantly. This injury was treated with ORIF of the intra-articular fracture, pinning of the DIP joint, and repair of an avulsed flexor digitorum profundus tendon with a button on the dorsal nail plate, as shown in Figure 2. Splint immobilization would not maintain a reduction of this unstable injury. The terminal tendon is not injured in this patient but is often injured in a dorsal distal phalanx fracture with a volar dislocation. Arthrodesis of the DIP is a salvage procedure and would not be considered acutely.

Question 21:

The Coleman block test is used to test for Review Topic

Options:

flexibility of the forefoot.
flexibility of the hindfoot.
valgus deformity of the hindfoot.
tightness of tendo Achilles.

Correct Answer: flexibility of the hindfoot.

Explanation:

Question 22:

What malignant disease most commonly develops in conjunction with chronic osteomyelitis?

Options:

Fibrosarcoma
Basal cell carcinoma
Lymphoma
Osteosarcoma
Squamous cell carcinoma

Correct Answer: Squamous cell carcinoma

Explanation:

Question 23:

Options:

Halo-vest orthosis
C1-C2 posterior cervical fusion
Occiput to C2 posterior cervical fusion
Cervical traction and closed reduction
Open reduction and internal fixation of C1

Correct Answer: C1-C2 posterior cervical fusion

Question 24:

Options:

Piriformis
Obturator internus
Superior gemellus
Quadratus femoris

Correct Answer: Quadratus femoris

Explanation:

Question 25:

What is the most appropriate treatment for a 50-year-old woman who sustains the injury shown in Figures 14a and 14b?

Options:

Total elbow arthroplasty
Functional hinge bracing
Long arm casting
Crossed Kirschner wires
Dual column plates

Correct Answer: Dual column plates

Explanation:

DISCUSSION: This intra-articular distal humerus fracture with displacement at the joint surface is best treated with surgical fixation. The most biomechanically sound construct is two plates applied to either column 180 degrees from one another. Elbow arthroplasty is most appropriate for low demand elderly patients.
REFERENCES: Schemitsch EH, Tencer AF, Henley MB: Biomechanical evaluation of methods of internal fixation of the distal humerus. J Orthop Trauma 1994;8:468-475.
McCarty LP, Ring D, Jupiter JB: Management of distal humerus fractures. Am J Orthop 2005;34:430-438.
Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: Surgical technique. J Bone Joint Surg Am 2005;87:41-50.

Question 26:

Options:

Breech delivery
Absence of an ipsilateral clavicle fracture
Horner's sign and an APGAR score of 10 at 1 minute
Return of active biceps before 3 months and preservation of full passive shoulder range of motion
Absent Moro and Babinski reflexes

Correct Answer: Return of active biceps before 3 months and preservation of full passive shoulder range of motion

Explanation:

Question 27:

- Which of the following advantages does the use of a vascularized fibula graft have over a nonvascularized fibula graft?

Options:

Begins to remodel and hypertrophy more quickly
Provides a better scaffold for osteoconduction
Reduces the risk of early fracture
Reduces technical difficulty
Lowers donor site morbidity

Correct Answer: Begins to remodel and hypertrophy more quickly

Explanation:

Question 28:

Figure 21 shows the radiograph of a 32-year-old patient with right hip pain that has failed to respond to nonsurgical management. What is the most appropriate surgical treatment at this time?

Options:

Femoral derotational osteotomy
Total hip arthroplasty
Arthrodesis
Surgical dislocation of the hip
Periacetabular osteotomy

Correct Answer: Periacetabular osteotomy

Explanation:

DISCUSSION: The radiograph reveals developmental dysplasia of both hips. The patient has classic anterolateral undercoverage of the femoral head on the right side as demonstrated by a high acetabular index (measured at 27 degrees). Anterior undercoverage can be determined by drawing the marking for the anterior wall that fails to overlap the femoral head in this patient. Currently in North America, the most accepted surgical management for symptomatic dysplasia of the hip with good joint space is a Bernese (Ganz) periacetabular osteotomy. Surgical dislocation of the hip and femoroacetabular osteoplasty may be considered for patients with symptomatic femoroacetabular impingement of the hip.
REFERENCES: Ganz R, Klaue K, Vinh TS, et al: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
Trousdale RT, Ekkernkamp A, Ganz R, et al: Periacetabular and intertrochanteric osteotomy for the treatment of osteoarthrosis in dysplastic hips. J Bone Joint Surg Am 1995;77:73-85.

Question 29:

A 29-year-old quarterback falls onto his dominant shoulder and sustains the injury shown in Figures 14a and 14b. Management should consist of

Options:

an arm sling.
nonsteroidal anti-inflammatory drugs and a rapid return to activity.
arthroscopic partial claviculectomy.
acromioclavicular joint reduction and stabilization.
acromionectomy.

Correct Answer: acromioclavicular joint reduction and stabilization.

Explanation:

Question 30:

Options:

Long thoracic nerve
Cranial nerve XI (spinal accessory nerve)
Suprascapular nerve
Axillary nerve

Correct Answer: Long thoracic nerve

Explanation:

Question 31:

What is the most important factor in determining recovery after surgical repair of a complete laceration of a nerve at the wrist?

Options:

Timing of repair
Technique of repair
Patient’s age
Use of a fibrin tissue sealant
Use of a nerve conduit

Correct Answer: Patient’s age

Explanation:

DISCUSSION: All other factors being equal, a patient’s age is the most important factor in determining outcome after peripheral nerve injury. Repair of a nerve laceration within the first 2 weeks is generally considered appropriate. Fascicular repair may be of benefit in larger proximal nerves to reapproximate appropriate nerve bundles; distally perineural or epineural repair is sufficient. Use of a fibrin tissue sealant for nerve repair does not result in improved outcomes over suture repair. Nerve conduits have shown promise in digital nerves but do not have proven benefit in larger caliber nerves.
REFERENCES: Sunderland S: Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY, Churchill Livingstone, 1991.
Wilgis ES, Brushart TM: Nerve repair and grafting, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1325.
Narakas A: The use of fibrin glue in repair of peripheral nerves. Orthop Clin North Am 1988;19:187-199.
Weber RA, Breidenbach WC, Brown RE, et al: A randomized prospective study of
polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg 2000;106:1036-1045.

Question 32:

Options:

Continued observation
Open reduction and internal fixation of the fracture
Excision of the hook of the hamate
Carpal tunnel release
Guyon’s canal release

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 33:

The most common neurologic injury following an anterior cervical diskectomy and fusion (ACDF) is injury to which of the following structures? Review Topic

Options:

Recurrent laryngeal nerve
Superior laryngeal nerve
C5 root
Spinal cord
Sympathetic chain

Correct Answer: Recurrent laryngeal nerve

Explanation:

Question 34:

Options:

Observation and patient education regarding hip dislocation precautions
Revision to a larger-diameter femoral head
Revision to a constrained acetabular component
Application of a hip orthosis for 3 months

Correct Answer: Observation and patient education regarding hip dislocation precautions

Explanation:

Question 35:

Options:

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

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 36:

In the spine, osteoblastomas usually originate in the

Options:

anterior vertebral body.
posterior vertebral body.
posterior longitudinal ligament.
posterior elements.
paraspinal muscles.

Correct Answer: posterior elements.

Explanation:

Question 37:

Options:

Calcific tendinitis
Poliomyelitis
Diskogenic cervical spine disease
Impingement
Brachial neuritis

Correct Answer: Brachial neuritis

Explanation:

DISCUSSION: The patient has symptoms and examination findings of acute brachial neuritis which is often a diagnosis of exclusion. The recent viral flu-like symptoms have shown a correlation with the development of this disorder. The acute, severe shoulder weakness excludes calcific tendinitis, impingement, and poliomyelitis. A normal cervical spine examination makes cervical disk disease unlikely.
REFERENCES: Turner JW, Parsonage MJ: Neuralgic amyotrophy (paralytic brachial neuritis). Lancet 1957;2:209-212.
Omer GE, Spinner M, Van Beek AL (eds): Management of Peripheral Nerve Problems, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 101-104.

Question 38:

An acute posterolateral disk herniation at the L4-5 level will most likely affect what nerve root? Review Topic

Options:

Correct Answer: L5

Explanation:

Question 39:

Which of the following is considered the most appropriate shoe modification following transmetatarsal amputation?

Options:

Foam filling of the forefoot void
Custom last shoe of a smaller size
Solid ankle polypropylene ankle-foot orthosis
Silicone partial foot prosthesis with cosmetic toes
Cushioned molded insole and toe filler over a carbon fiber footplate

Correct Answer: Cushioned molded insole and toe filler over a carbon fiber footplate

Explanation:

Question 40:

A 20-year-old man sustains the injury shown in Figures 1a and 1b in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by

Options:

a subtalar arthrodesis.
screw fixation of the talar neck.
repair of the medial subtalar capsule.
temporary transarticular pin fixation.
evaluation for and excision or fixation of osteochondral fractures.

Correct Answer: evaluation for and excision or fixation of osteochondral fractures.

Explanation:

Question 41:

Options:

Repeated measures analysis of variance
F test
Power analysis
Analysis of variance
Kruskal-Wallis test

Correct Answer: Power analysis

Explanation:

Question 42:

Options:

Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff
Posterior glenoid, humeral head, bursal side of the rotator cuff
Biceps anchor, articular side of the rotator cuff, supraspinatus tendon
Biceps tendon, bursal side of the rotator cuff, superior labrum
Subscapularis, anterior labrum, humeral head

Correct Answer: Posterosuperior labrum, greater tuberosity, articular side of the rotator cuff

Explanation:

Question 43:

Figure 43 shows an arthroscopic view of a right shoulder through a lateral portal in the beach chair position. The arrow is pointing to what structure?

Options:

Biceps tendon
Coracohumeral ligament
Superior glenohumeral ligament
Middle glenohumeral ligament
Inferior glenohumeral ligament

Correct Answer: Biceps tendon

Explanation:

DISCUSSION: This view from the lateral portal shows a full-thickness rotator cuff tear. The glenohumeral joint can be visualized through this tear. The glenoid, labrum, and biceps tendon attaching to the superior aspect of the glenoid are easily viewed from this portal, and the arrow is pointing to the biceps tendon. Arthroscopic rotator cuff repair can be performed while visualizing from this portal and using anterior and posterior working portals.
REFERENCES: Mazzocca AD, Noerdlinger M, Cole B, et al: Arthroscopy of the shoulder: Indications and general principles of techniques, in McGinty JB (ed): Operative Arthroscopy,
ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 412-427.
Burkhart, SS: Arthroscopic management of rotator cuff tears, in McGinty JB (ed): Operative Arthroscopy, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2003, pp 508-546.

Question 44:

A 29-year-old female has sustained the acute injury shown in Figure A. Which of the following is an indication for open reduction internal fixation in this patient?

Options:

Medial sided tenderness
Medial sided swelling
Positive cotton test
Medial clear space widening with gravity stress radiographs
Positive squeeze test

Correct Answer: Medial sided tenderness

Explanation:

Question 45:

In patients without spondylolisthesis or scoliosis undergoing laminectomy for lumbar spinal stenosis, spinal fusion is generally recommended if

Options:

a dural tear is repaired.
more than one level requires decompression.
less than one half of each facet is removed bilaterally.
the pars interarticularis is fractured.
the patient is a smoker.

Correct Answer: the pars interarticularis is fractured.

Explanation:

DISCUSSION: With the notable exception of fusion for degenerative spondylolisthesis and scoliosis, there is a paucity of evidence on the indications for spinal fusion in patients undergoing laminectomy for spinal stenosis. However, it is generally recommended that if the spine is destabilized (for example by removal of one complete facet joint or by an iatrogenic pars fracture), spinal fusion should be considered. Although fusion can be considered for a very long laminectomy, a two-level laminectomy does not represent, by itself, a clear indication for the addition of a spinal fusion. The repair of a dural tear and the use of nicotine by the patient play no role in the determination of whether or not to add fusion to a laminectomy procedure.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 299-409.
Fischgrund JS, Mackay M, Herkowitz HN, et al: 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine 1997;22:2807-2812.

Question 46:

Options:

Choosing a longer femoral head and accepting a resulting leg-length discrepancy
Trialing a lateralized femoral neck component
Removing the acetabular liner and implanting an offset liner instead
Performing a trochanteric osteotomy with advancement

Correct Answer: Trialing a lateralized femoral neck component

Explanation:

Question 47:

A 46-year-old woman fell from her bicycle and sustained the injury shown in Figure 24. Which of the following ligaments has been disrupted? Review Topic

Options:

Acromioclavicular
Acromioclavicular and coracoclavicular
Coracoclavicular
Coracoacromial and sternoclavicular
Sternoclavicular

Correct Answer: Acromioclavicular and coracoclavicular

Explanation:

Question 48:

Options:

Posterior laminoplasty
Posterior cervical foraminotomy
Anterior cervical foraminotomy
Anterior cervical diskectomy and arthrodesis
Anterior corpectomy and arthrodesis

Correct Answer: Anterior cervical diskectomy and arthrodesis

Explanation:

Question 49:

Options:

Resect more distal femur.
Resect more anterior tibia.
Use a larger femoral component.
Use a smaller polyethylene insert.
Recess the posterior cruciate ligament.

Correct Answer: Recess the posterior cruciate ligament.

Explanation:

Question 50:

Options:

Decreased pitch count for 4 weeks
Continued play with close observation
Cessation of all throwing for 6 weeks
Arthroscopic repair
Mini-open repair

Correct Answer: Cessation of all throwing for 6 weeks

Explanation:

Question 51:

Options:

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

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

Explanation:

Question 52:

Options:

Staphylococcus epidermidis
Staphylococcus aureus (S. aureus)
Propionibacterium acnes (P. acnes)
Beta-hemolytic Streptococcus

Correct Answer: Staphylococcus epidermidis

Explanation:

Question 53:

Options:

arthroscopic capsular release
manipulation under anesthesia
a physical therapy program
an intra-articular corticosteroid injection
administration of high-dose oral corticosteroids

Correct Answer: a physical therapy program

Explanation:

Question 54:

Options:

Serial casting of both knees weekly
Physiotherapy and dynamic splinting
Soft-tissue releases of the knees, including Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies
Femoral shortening osteotomies combined with soft-tissue releases of the knees (Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies)
Gradual correction with a circular external fixator without soft-tissue release

Correct Answer: Femoral shortening osteotomies combined with soft-tissue releases of the knees (Z-plasties of skin, excision of fibrotic bands, hamstring lengthenings, and posterior knee capsulotomies)

Explanation:

DISCUSSION: Congenital popliteal webbing with contractures of 60 degrees is a difficult deformity to correct. The anatomy of the web is of considerable importance. MRI can delineate the extent of the posterior fibrous band that often stretches from the ischium to the calcaneus. The sciatic nerve, usually shortened, most often runs just anterior to this fibrous band. For mild contractures of less than 20 degrees, nonsurgical management is usually adequate. Hamstring lengthening and postoperative splinting are usually sufficient for contractures of 20 degrees to
40 degrees. Moderate contractures of up to 60 degrees usually require Z-plasties in the popliteal fossa and postoperative serial casting to avoid undue tension on neurovascular structures. Contractures of more than 60 degrees require a femoral shortening osteotomy or gradual correction with an external fixator. However, rapid recurrence following fixator removal is common if formal soft-tissue procedures and postoperative splinting are not performed.
REFERENCES: Parikh SN, Crawford AH, Do TT, et al: Popliteal pterygium syndrome: Implications for orthopaedic management. J Pediatr Orthop B 2004;13:197-201.
Brunner R, Hefti F, Tgetgel JD: Arthrogrypotic joint contracture at the knee and foot: Correction with a circular frame. J Pediatr Orthop B 1997;6:192-197.

Question 55:

Options:

Posttraumatic soft-tissue contractures
Congenital dislocation of the radial head
Chronic posttraumatic dislocation of the radial head
Combined annular and lateral collateral ligament injury
An unrecognized Monteggia variant type of injury

Correct Answer: Congenital dislocation of the radial head

Explanation:

Question 56:

Options:

extended trochanteric osteotomy and revision to a cementless long-stem prosthesis.
extended trochanteric osteotomy and revision to a cemented long-stem prosthesis.
revision to a cementless long-stem prosthesis without use of an extended trochanteric osteotomy.
revision to a cemented long-stem prosthesis without use of an extended trochanteric osteotomy.

Correct Answer: extended trochanteric osteotomy and revision to a cementless long-stem prosthesis.

Explanation:

Question 57:

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Options:

wide resection and salvage of the physis.
resection and hemicondylar osteoarticular allograft.
cryosurgery.
radiation therapy.
curettage and bone grafting.

Correct Answer: curettage and bone grafting.

Explanation:

Question 58:

Options:

closed reduction and casting in extension.
open reduction with suture fixation of the proximal fragment.
closed reduction, followed by functional bracing.
open reduction and internal fixation with screws and complete proximal tibial epiphysiodesis.
open reduction and internal fixation with screws.

Correct Answer: open reduction and internal fixation with screws.

Explanation:

Question 59:

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

Options:

Peripheral myelin protein 22 (PMP22)
Survival motor neuron I (SMN1)
Survival motor neuron II (SMN2)
Dystrophin

Correct Answer: Survival motor neuron II (SMN2)

Explanation:

Question 60:

Ulnar collateral ligament (UCL) reconstruction using a modified Jobe technique

Options:

Paresthesias in the fourth and fifth digits
Numbness on the lateral side of the forearm
Heterotopic ossification
Posterolateral rotatory instability of the elbow
Medial antebrachial cutaneous neuroma

Correct Answer: Paresthesias in the fourth and fifth digits

Explanation:

Question 61:

Options:

Revision using a proximal femoral replacement prosthesis
Revision using a diaphyseal engaging femoral prosthesis along with cerclage fixation
Open reduction internal fixation using a locking plate with strut graft
Protected weight bearing with abduction bracing

Correct Answer: Revision using a diaphyseal engaging femoral prosthesis along with cerclage fixation

Explanation:

Question 62:

What is the most appropriate next step in the work-up of a patient with the asymptomatic lesion shown in Figure 23?

Options:

Open biopsy
Needle biopsy
Observation
CT-guided radiofrequency ablation
Antibiotics

Correct Answer: Observation

Explanation:

Question 63:

Figure 92 is the radiograph of a 45-year-old man who was thrown from his horse and now reports groin pain. Which of the following is the most common long-term sequelae of this injury?

Options:

Gait abnormality
Sexual dysfunction
Chronic low back pain
Quadriceps weakness
Posttraumatic osteoarthritis

Correct Answer: Sexual dysfunction

Explanation:

Question 64:

Which of the following statements is most accurate regarding undetected intraoperative surgical glove perforation?

Options:

Undetected intraoperative surgical glove perforation is rare.
The index finger and left hand are the most common sites of surgical glove perforation.
The primary surgeon is more likely to sustain an undetected surgical glove perforation, as opposed to the scrub nurse or surgical assistant.
Surgical time is not related to the frequency of surgical glove perforation.
Undetected surgical glove perforation is rare in surgeries lasting 3 hours or longer.

Correct Answer: The index finger and left hand are the most common sites of surgical glove perforation.

Explanation:

Question 65:

Among patients with adolescent idiopathic scoliosis, a thoracolumbosacral orthosis is most effective for which type of curve?

Options:

Apex of the curve is at T3
Apex of the curve is at T8
Apex of the curve is at L1
Apex of the curve is at L2

Correct Answer: Apex of the curve is at T8

Explanation:

DISCUSSION
A thoracolumbosacral orthosis is most effective for bracing of curves when the apex is at T7 or below. Bracing is used for patients who are skeletally immature (Risser stage 0, 1, or 2), and it is recommended that the brace be worn 16 to 23 hours per day and continued until skeletal maturity or until the curve progresses to beyond 45 degrees, at which point bracing is no longer considered effective.
RECOMMENDED READINGS
Luhmann SJ, Skaggs DL: Pediatric spine conditions, in Lieberman JR (ed):
AAOS Comprehensive Orthopaedic Review. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2009, pp 245-265.
Shaughnessy WJ. Advances in scoliosis brace treatment for adolescent idiopathic scoliosis. Orthop Clin North Am. 2007 Oct;38(4):469-75, v. Review. PubMed PMID: 17945126.
View Abstract at PubMed

Question 66:

Options:

Excise the spacer
Excise the spacer, debride all membranous tissue, perform exchange nailing
Excise the spacer, debride all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity, remove the nail

Correct Answer: Excise the spacer

Explanation:

Question 67:

Options:

Open tendon transfer
Corticosteriod injection and supervised physical therapy
Open rotator cuff repair, subacromial decompression and distal clavical excision
Revision to reverse shoulder arthroplasty
Revision to cuff arthropathy hemiarthroplasty

Correct Answer: Revision to cuff arthropathy hemiarthroplasty

Explanation:

Question 68:

Options:

arthroscopic synovectomy.
humeral arthroplasty.
unconstrained total shoulder arthroplasty.
constrained total shoulder arthroplasty with a fixed-fulcrum prosthesis.
glenohumeral arthrodesis.

Correct Answer: unconstrained total shoulder arthroplasty.

Explanation:

Question 69:

Options:

Observation and NSAID use as needed
MRI scan
Bone biopsy
Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP).

Correct Answer: Observation and NSAID use as needed

Explanation:

DISCUSSION
The radiograph shown is consistent with Paget disease of the bone. It demonstrates classic findings of widened lamellae and disorganized sclerotic and lytic areas. The cause is not clearly defined, but may be linked to a viral infection and subsequent alterations of osteoblastic and osteoclastic activity. Most patients are asymptomatic, and Paget disease is often found incidentally on radiographs. In this case, the patient’s symptoms likely were caused by hip arthritis, but Paget disease can cause diffuse bone pain in some cases. Considering the patient’s mild and short-term symptoms, observation and NSAID use is most appropriate. An MRI scan or biopsy is indicated if sarcomatous transformation is suspected, but this condition is rare and is associated with a substantial, unrelenting increase in pain. SPEP and UPEP are tests for multiple myeloma, of which the radiographs show no signs.
RECOMMENDED READINGS
Ralston SH. Pathogenesis of Paget's disease of bone. Bone. 2008 Nov;43(5):819-25. doi: 10.1016/j.bone.2008.06.015. Epub 2008 Jul 11. Review. PubMed PMID: 18672105.
View Abstract at PubMed
Bonenberger E, Einhorn T. Metabolic bone diseases. In: Callaghan JJ, Rosenberg
AG, Rubash HE, eds. The Adult Hip. 2nd ed. Philadelphia, PA: Lippincott Williams
14
& Wilkins; 2007:514-533.

Question 70:

Based on the Young and Burgess classification of pelvic ring injuries, an anterior-posterior compression type II injury does not result in disruption of which of the following?

Options:

pubic symphysis
anterior sacroiliac ligaments
posterior sacroiliac ligaments
sacrospinous ligament
sacrotuberous ligament

Correct Answer: pubic symphysis

Explanation:

Question 71:

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 72:

Options:

Early surgical exploration and repair of the torn subscapularis tendon
Observation and reassurance that the pain will resolve
A slow progressive resistance program to restore strength
CT to assess for component malrotation
Electromyography to evaluate for possible nerve injury

Correct Answer: Early surgical exploration and repair of the torn subscapularis tendon

Explanation:

Question 73:

Options:

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

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

Explanation:

Question 74:

Examination of an obese 3-year-old girl reveals 30 degrees of unilateral genu varum. A radiograph of the involved leg with the patella forward is shown in Figure 10. Management should consist of

Options:

continued observation until skeletal maturity.
fitting for a valgus-producing hinged knee-ankle-foot orthosis.
lateral proximal tibial hemiepiphysiodesis.
proximal tibiofibular osteotomy and acute correction.
proximal tibiofibular epiphysiodesis and osteotomy with lengthening.

Correct Answer: proximal tibiofibular osteotomy and acute correction.

Explanation:

DISCUSSION: The clinical scenario describes infantile tibia vara (Blount’s disease). The radiograph shows severe deformity with the characteristic Langenskiold stage 3 changes of the medial proximal tibial metaphysis that distinguish it from physiologic bowing. The preferred treatment is proximal tibiofibular osteotomy with acute correction into slight valgus to unload the damaged area of the physis. This method provides the best results in patients younger than age 4 years. Continued observation would result in progressive deformity. Bracing is most effective in younger children with less severe deformity. Lateral proximal tibial hemiepiphysiodesis relies on growth of the injured medial physis for correction and would result in severe tibial shortening in this young child. Complete epiphysiodesis also produces severe shortening and requires multiple lengthening procedures.
REFERENCES: Johnston CE II: Infantile tibia vara. Clin Orthop 1990;255:13-23.
Richards BS, Katz DE, Sims JB: Effectiveness of brace treatment in early infantile Blount’s disease. J Pediatr Orthop 1998;18:374-380.

Question 75:

Options:

bone grafting the radius only.
bone grafting both the radius and ulna.
bone graft substitute for both the radius and ulna.
no additional grafting.
no additional grafting but postoperative electrical stimulation.

Correct Answer: no additional grafting.

Explanation:

Question 76:

...Figure 74 is the radiograph of an 11-year-old boy with pain in his left arm. Prognosis is most influenced by

Options:

stage at presentation.
grade at presentation.
response to neoadjuvant chemotherapy.
histologic subtype. DISCUSSION… The imaging is characteristic for high-grade osteosarcoma. In patients with osteosarcoma, stage at presentation has the most prognostic impact; clinically detectable mestastases at presentation has a very poor prognosis. The other factors all influence prognosis in patients without metastatic disease. Low-grade nonmetastatic tumors have the best prognosis and are treated with surgery alone. In high-grade tumors, histologic response to neoadjuvant chemotherapy is predictive of survival. Response to chemotherapy, distal appendicular sites, and female gender were associated with improved survival in the study by Whelan and associates of 1067 patients with localized extremity osteosarcoma. Increased tumor volume after chemotherapy had an adverse effect on survival independent of histologic response to chemotherapy. Age, high levels of alkaline phosphatase, tumor volume, 2-drug regimen, surgical margins, and histologic response to chemotherapy were important prognostic factors.

Correct Answer: stage at presentation.

Question 77:

Options:

She was noncompliant in physical therapy.
The original surgery should have included resurfacing the glenoid.
The humeral head was too large.
The humeral component was placed too proud.
The tuberosities are malpositioned.

Correct Answer: The tuberosities are malpositioned.

Explanation:

DISCUSSION: The radiograph shows tuberosity malposition. The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than age 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement.
REFERENCES: Bigliani LU, Flatow EL, McCluskey G, et al: Failed prosthetic replacement for displaced proximal humeral fractures. Orthop Trans 1991;15:747-748.
Boileau P, Krishnan SG, Tinsi L, et al: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:401-412.
Tanner MW, Cofield RH: Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res 1983;179:116-128.

Question 78:

Options:

Posterior impingement of the os trigonum
Subluxation of the peroneal tendon
Posterior tibial stress fracture
Osteochondritis dissecans of the lateral dome of the talus
Stenosis of the peroneal tendon sheath

Correct Answer: Posterior impingement of the os trigonum

Explanation:

Question 79:

Options:

an extra-depth shoe with an accommodative orthosis.
surgical debridement and metatarsal head resection.
posterior tibial tendon transfer through the interosseous membrane.
Achilles tendon lengthening and total contact casting.
hyperbaric oxygen therapy.

Correct Answer: Achilles tendon lengthening and total contact casting.

Explanation:

Question 80:

Options:

less than 10%.
30%.
50%.
70%.
greater than 90%.

Correct Answer: greater than 90%.

Explanation:

DISCUSSION: Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries.
REFERENCES: Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000.
Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.
Gilliland MD, Ward RE, Barton RM, et al: Factors affecting mortality in pelvic fractures.
J Trauma 1982;22:691-693.

Question 81:

Options:

Skin traction for the femur, with a follow-up CT scan of the head in the morning
Distal femur skeletal traction, with a follow-up CT scan of the head in the morning
External fixation of the femur with delayed intramedullary nailing
Intramedullary nailing of the femur
Ventriculostomy and external fixation of the femur

Correct Answer: Intramedullary nailing of the femur

Explanation:

DISCUSSION: Treatment of patients with a closed head injury and a femoral fracture remains controversial but recent data suggest that intramedullary nails done acutely with avoidance of intraoperative hypotension did not compromise the outcome related to the head injury. This was especially true for high-level GCS scores. A GCS score of lower than 8 and intraoperative hypotension have been associated with worsening outcomes following acute intramedullary nailing of the femur. Skin traction and distal femur skeletal traction in a young adult man with a femoral fracture is not well tolerated secondary to spasm and pain. External fixation is an option but an unnecessary step in the treatment of this patient. Ventriculostomy is not necessary in stable patients with no significant bleeding on a CT scan of the head.
REFERENCES: Starr AJ, Hunt JL, Chason DP, et al: Treatment of femur fracture with associated head injury. J Orthop Trauma 1998;12:38-45.
Nau T, Kutscha-Lissberg F, Muellner T, et al: Effects of a femoral shaft fracture on multiply injured patients with a head injury. World J Surg 2003;27:365-369.
McKee MD, Schemitsch EH, Vincent LO, et al: The effect of a femoral fracture on concomitant closed head injury in patients with multiple injuries. J Trauma 1997;42:1041-1045.
Brundage SI, McGhan R, Jurkovich GJ, et al: Timing of femur fracture fixation: Effect on outcome in patients with thoracic and head injuries. J Trauma 2002;52:299-307.

Question 82:

The newborn foot deformity seen in Figures 64a and 64b should initially treated with

Options:

observation with possible stretching.
serial casting.
medial surgical release.
posterior medial surgical release.
dynamic ankle-foot orthosis.

Correct Answer: serial casting.

Explanation:

DISCUSSION: Mild to moderate metatarsus adductus is best treated with observation and possible passive stretching exercises because most of these feet will self correct. Numerous types of shoes, braces, and splints have been devised but the efficacy of these have not been determined. Serial casting is reserved for severe metatarsus adductus in the infant, although a medial surgical release may be indicated if the deformity is symptomatic and persists beyond age 4 years.
REFERENCES: Abel MF (ed): Orthopaedic Knowledge Update: Pediatrics 3. Rosemont, IL, American Academ
A
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L-
o
M
f
ad
O
en
r
a
th
C
o
o
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y
edic Surgeons, 2006, pp 240-241.
Farsetti P, Weinstein SL, Ponseti IV: The Long-term functional and radiographic outcomes of untreated
and non-operatively treated metatarsus adductus. J Bone Joint Surg Am 1994;76:257-265. Question 65
A 4-year-old girl has been limping for the past 2 months. There is no history of trauma, previous injury, fever, or other systemic complaints. Examination reveals a moderate right knee effusio n with a 10-degree knee flexion contracture. What is the next most appropriate step in evaluation?
Arthroscopy
Antinuclear antibody
MRI
Bone scan
HLA-B27
DISCUSSION: The patient presents with juvenile idiopathic arthritis manifestations. The American College of Rheumatology defines this as one or more joints involved with swelling of 6 weeks or longer. A positive antinuclear antibody test would be diagnostic. Consideration should be made to have the patient see an ophthalmologist for evaluation of possible uveitis. Although the patient could have Lyme disease, that choice is not an option. The presence of an elevated antinuclear antibody by itself should not necessarily be used for diagnosing arthritis; however, the test does have clinical utility as a screening test. The frequency of a positive antinuclear antibody test is greatest in younger girls with oligoarticular disease and carries an increased risk for anterior uveitis. Arthroscopy might be indicated if this patient was presenting with a discoid meniscus, but there is no history of clicking, which is often one of the classic signs of discoid meniscus. MRI would not be used to diagnose juvenile idiopathic arthritis, but
MRI would be useful to help diagnose discoid meniscus. A bone scan would show increased uptake in the patient’s knee but again, this would not help diagnose her condition. HLA-B27 has no role in diagnosing juvenile idiopathic arthritis, especially in females.
REFERENCES: Iesaka K, Kubiak EN, Bong LR, et al: Orthopaedic surgical management of hip and knee involvement in patients with juvenile rheumatoid arthritis. Am J Orthop 2006;35:67-73.
Wright DA: Juvenile idiopathic arthritis, in Morrissey RT, Weinstein SL (eds): Love
l
and Winter’s Pediatric Orthopaedics, ed 6. Philadelphia PA, Lippincott Williams and Wilkins, 2006, pp 405-438. Question 66
An 18-month-old girl is brought in by her parents because of concerns about intoeing, bowlegs, and tripping and fa
l
ing. Prenatal and birth history are otherwise unremarkable. The child’s growth and
development appear to be normal and she has a normal neurologic exam, a straight spine with no defects, and the hips are stable. Examination reveals hip internal rotation of 40 degrees and hip external rotation of 60 degrees. The thigh-foot angle is internal 30 degrees. Feet are straight and supple. Gait is characterized by intoeing with occasional tripping and falling. Based on these findings, what is the most appropriate action?
No treatment because internal tibial torsion slowly resolves on its own
Immediate treatment with a Denis-Browne bar
Distal tibial osteotomies
Proximal femoral derotational osteotomies
Treatment with twister cables PREFERRED RESPONSE: 1
DISCUSSION: The child has classic internal tibial torsion that is very commonly seen in younger children who are just beginning to walk. The normal outcome is for slow resolution of this problem and it seldom requires any treatment. Treatment with a Denis-Browne bar or with twister cables has not been proven to be effective. Surgical treatment at this point is premature and clearly not indicated.
REFERENCES: Lincoln TL, Suen PW: Common rotational variations in children. J Am Acad Orthop Surg 2003;11:312-320.
Staheli LT, Corbett M, Wyss C, et al: Lower-extremity rotational problems in children: Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47.

Question 83:

Options:

aspiration and steroid injection.
rest.
acromioplasty.
arthroscopic repair and decompression.
rehabilitation.

Correct Answer: arthroscopic repair and decompression.

Explanation:

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T
1
-weighted MRI scans and with high signal intensity on T
2
-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 84:

Options:

Closure of the wound and chemotherapy
Radical resection of the proximal femur and megaprothesis hemiarthroplasty
Hemiarthroplasty with postoperative staging and chemo-radiotherapy as indicated
Bone marrow transplantation
Hip disarticulation

Correct Answer: Hemiarthroplasty with postoperative staging and chemo-radiotherapy as indicated

Explanation:

Question 85:

A 47-year-old man has acute right shoulder pain after falling off a ladder. The MRI scan shown in Figure 9 reveals

Options:

aseptic necrosis of the humeral head.
a nondisplaced anatomic neck fracture.
a partial-thickness rotator cuff tear.
a full-thickness rotator cuff tear.
a bony Bankart defect.

Correct Answer: a full-thickness rotator cuff tear.

Explanation:

Question 86:

Options:

Revise the cup bearing to polyethylene
Revise the cup bearing to polyethylene and replace the femoral head with a metal design
Increase the cup abduction angle
Decrease the cup abduction angle
Continue routine follow-up and observation

Correct Answer: Continue routine follow-up and observation

Explanation:

Question 87:

Within the menisci, the majority of the large collagen fiber bundles are oriented in what configuration?

Options:

Radially
Circumferentially
Vertically
Obliquely
Randomly

Correct Answer: Circumferentially

Explanation:

Question 88:

Which of the following is considered the appropriate initial management protocol for an unconscious football player without spontaneous respirations?

Options:

Log roll to a supine position, remove the helmet, and begin assisted breathing
Stabilize the head and neck, log roll to a supine position, remove the helmet, and begin assisted breathing
Log roll to a supine position, stabilize the head and neck, remove the face mask, and begin cardiopulmonary respiration (CPR)
Log roll onto a spine board, stabilize the head and neck, remove the face mask, and begin CPR
Stabilize the head and neck, log roll to a supine position, remove the face mask, and begin assisted breathing

Correct Answer: Stabilize the head and neck, log roll to a supine position, remove the face mask, and begin assisted breathing

Explanation:

Question 89:

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

Options:

Retrograde collapse of the endoneurial tubes
Irreversible atrophy of the denervated muscles
Elongation of the axons across the zone of injury
Sprouting of the axons at the neuromuscular junction
Misdirection of the axons across the zone of injury

Correct Answer: Misdirection of the axons across the zone of injury

Explanation:

Question 90:

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 91:

Which of the following statements best describes labral tears in the hip? Review Topic

Options:

They are unrelated to degenerative joint disease.
They lead to increased movement of the femur relative to the acetabulum.
They usually result from lesions of the ligamentum teres.
They only occur with abnormal bone morphology.
They commonly occur in the posteroinferior quadrant of the hip.

Correct Answer: They lead to increased movement of the femur relative to the acetabulum.

Explanation:

Question 92:

Type I collagen fibers in peripheral nerves are primarily responsible for which of the following?

Options:

Conduction strength
Tensile strength
Conduction velocity
Compressive strength
Cross-linkage

Correct Answer: Conduction velocity

Explanation:

Question 93:

- An orthopaedic surgeon who is the developer of a knee arthroplasty system is discussing treatment options with a patient who has tricompartmental osteoarthritis. As a part of this discussion, the orthopaedic surgeon has an obligation to disclose

Options:

The name of the manufacturer
The manufacturer’s potential liability
The physician’s clinical performance
The physician’s materials testing data
Any royalties the physician receives from the manufacturer

Correct Answer: Any royalties the physician receives from the manufacturer

Explanation:

Question 94:

What is the most common result if the acetabulum is rotated too far anteriorly during a periacetabular osteotomy?

Options:

Posterior dislocation
Limited hip flexion
Heterotopic ossification
Femoral nerve injury
Fracture of the posterior column

Correct Answer: Limited hip flexion

Explanation:

Question 95:

The patient decides to pursue surgical intervention. Which compartments should be released?

Options:

Anterior and lateral
Anterior, lateral, and deep posterior
Anterior, lateral and superficial posterior
Lateral and superficial posterior

Correct Answer: Anterior and lateral

Explanation:

The diagnostic criteria for chronic exertional compartment syndrome is pressure >15 mm Hg at rest, or
>30 mm Hg at 1 minute post exercise, or >20 mm Hg at 5 minutes post-exercise. The anterior and lateral compartments are the only ones that meet strict diagnostic criteria for chronic exertional compartment syndrome. The superficial posterior compartment, although close to meeting criteria, is not responsible
for the patient's symptoms and falls below current thresholds for diagnosis.

Question 96:

Options:

Poliomyelitis
Neurofibromatosis (von Recklinghausen disease)
Lymphangiomatosis
Congenital band syndrome
Chronic venous stasis disease

Correct Answer: Lymphangiomatosis

Explanation:

Question 97:

The thumb metacarpophalangeal (MCP) joint should be flexed to what degree to properly assess ligamentous stability?

Options:

30 degrees of flexion to test the proper collateral ligament and full extension to test the accessory collateral ligament and the palmar plate
30 degrees of flexion to test the accessory collateral ligament and full extension to test the proper collateral ligament and the palmar plate
45 degrees of flexion to test the accessory collateral ligament, the proper collateral ligament, and the palmar plate
90 degrees of flexion to test the proper collateral ligament and full extension to test the acces sory collateral ligament and the palmar plate
90 degrees of flexion to test the accessory collateral ligament and full extension to test the proper collateral ligament and the palmar plate

Correct Answer: 30 degrees of flexion to test the proper collateral ligament and full extension to test the accessory collateral ligament and the palmar plate

Explanation:

Question 98:

Options:

spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
spinal accessory nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.
long thoracic nerve, causing shoulder elevation with the scapula translated medially and the inferior angle rotated medially.
long thoracic nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.
thoracodorsal nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Correct Answer: spinal accessory nerve, causing shoulder depression with the scapula translated laterally and the inferior angle rotated laterally.

Explanation:

Question 99:

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

Options:

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

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

Explanation:

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

Question 100:

What is the second most common primary bone malignancy in children?

Options:

Rhabdomyosarcoma
Osteosarcoma
Ewing’s sarcoma
Fibrosarcoma
Adamantinoma

Correct Answer: Ewing’s sarcoma

Explanation:

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

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

Orthopedic Board Prep MCQs: Arthroplasty & Trauma | Part 152

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 152

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index