Orthopedic MCQs: Trauma, Shoulder, Elbow, Hip - Part 154

About This Board Review Set

This is Part 154 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Topics Covered in Part 154

This module focuses heavily on: Dislocation, Elbow, Fracture, Hip, Shoulder.

Sample Questions from This Set

Sample Question 1: A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month followup appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is...

Sample Question 2: A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees great...

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

Sample Question 4: 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...

Sample Question 5: During preparation for the NCAA wrestling championships, a participant reports the development of vesicular lesions on his right chest wall that are mildly painful; however, they have not affected his ability to wrestle. How should this ath...

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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 woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month followup appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 21. What is the most likely diagnosis? Review Topic

Explanation

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

Question 2

A 22-year-old wrestler who underwent an open anterior shoulder reconstruction to repair a dislocated shoulder 6 months ago now reports shoulder pain after attempting a takedown. Examination reveals external rotation that is 15 degrees greater than the contralateral side. He has pain associated with abduction and external rotation but no apprehension. Which of the following tests would most likely reveal positive findings?

Explanation

DISCUSSION: Postoperative subscapularis detachment can be identified with a positive lift-off test that reveals weakness in internal rotation. This complication does not necessarily compromise the anterior capsule repair. The load-and-sift maneuver and articular contrast studies may be normal. Supraspinatus tests for impingement and weakness should be negative.
REFERENCES: Gerber C, Krushell RJ: Isolated ruptures of the tendon of the subscapularis muscle: Clinical fractures in 16 cases. J Bone Joint Surg Br 1991;73:389-394.
Hawkins RJ, Bokor DJ: Clinical evaluation of the shoulder, in Rockwood CA, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 149-177.

Question 3

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

Explanation

EXPLANATION:
The axial T2-weighted MRIs demonstrate a distal biceps rupture. The increased signal is noted superficial to the brachialis muscle and adjacent to the biceps tuberosity. The distal biceps tendon is not seen in the distal cuts and has retracted proximally. The physical examination of patients with these injuries show abnormal contour of the arm and tenderness in the antecubital fossa. The hook test is a provocative maneuver that documents biceps integrity. When performing the maneuver, the examiner attempts to hook a finger around the distal biceps tendon while the patient actively supinates with the elbow held in flexion. Nonsurgical treatment has been documented to result in an average loss of 40% of supination strength and 30% of elbow flexion strength. Repair is optimal within several weeks of injury. The alternative options would not occur with a distal biceps rupture.

Question 4

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?

Explanation

DISCUSSION: 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.
REFERENCES: Lalonde F, Letts M, Yang JP, et al: An analysis of burst fractures of the spine in adolescents. Am J Orthop 2001;30:115-120.
Clark P, Letts M: Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg 2001;44:337-345.
Been HD, Bouma GJ: Comparison of two types of surgery for thoraco-lumbar burst fractures: Combined anterior and posterior stabilization vs posterior instrumentation only. Acta Neurochir (Wien) 1999;141:349-357.

Question 5

During preparation for the NCAA wrestling championships, a participant reports the development of vesicular lesions on his right chest wall that are mildly painful; however, they have not affected his ability to wrestle. How should this athlete be managed? Review Topic

Explanation

Herpes simplex virus (HSV) can cause serious outbreaks on athletic teams, especially wrestling. HSV is highly contagious; it is secreted from active blisters, saliva, and mucous membranes. For wrestlers, the NCAA states that the athlete must be free from systemic symptoms and any new blisters for 72 hours before being allowed to participate. Also, all lesions must be dry and crusted and at least 120 hours of antiviral therapy should have been instituted.

Question 6

Figure 7 shows the CT scan of a 25-year-old soccer player who has had posterior ankle pain with plantar flexion for the past 2 years. Immobilization has failed to provide relief. He is ambulatory. Management should consist of

Explanation

DISCUSSION: An os trigonum is usually asymptomatic, but this accessory bone has been associated with persistent posterior ankle pain, which has been described as os trigonum syndrome. This usually affects athletes and ballerinas. Forced plantar flexion leads to impingement of the os trigonum against the posterior tibial plafond, and flexor hallucis tendinitis may develop. It may be difficult to differentiate a fractured trigonal process from the os trigonum. MRI may reveal bone marrow edema that may aid in the diagnosis of os trigonum syndrome. Steroid injections may lead to tendon rupture. The results of excision of a symptomatic os trigonum through a posteromedial or lateral approach are favorable, with a rapid return to full function. The main complication of this procedure is sural nerve injury with a lateral approach.
REFERENCES: Hedrick MR, McBryde AM: Posterior ankle impingement. Foot Ankle Int 1994;15:2-8.
Abramowitz Y, Wollstein R, Barzilay Y, et al: Outcome of resection of a symptomatic os trigonum. J Bone Joint Surg Am 2003;85:1051-1057.

Question 7

An osteoprogenitor cell is expected to commit to a bone lineage in the presence of what transcription factor?

Explanation

Mesenchymal stem cells are pluripotent cells that can differentiate into many lineages including osteoblasts, adipocytes, myoblasts, chondroblasts, and fibroblasts. Runx2 and Osx appear to be required for differentiation to osteoblastic lines. PPARy2 and
C/EBPa are transcription factors leading to adipocytes, MyoD promotes myoblasts, and Sox 9 corresponds to chondroblasts.

Question 8

Figures 20a and 20b show the AP and lateral radiographs of a 62-year-old man who has had hip pain for the past 3 weeks. Figure 20c shows a CT scan of the abdomen and pelvis. A needle biopsy specimen is shown in Figure 20d. Preoperative management should include which of the following?

Explanation

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 9

A 47-year-old landscaper presents with worsening left shoulder pain and weakness. Three years ago, he injured the left shoulder in a fall and elected for nonoperative management to minimize time off from work. Physical therapy was effective until 6 months ago when his shoulder function worsened to the point that he is now unable to work. Examination of his active range of motion reveals forward elevation 120° with pain, abduction 100°, IR at neutral to T8 and ER at neutral 5°. He has a positive ER lag sign and Hornblower's sign. Belly press and lift-off tests are normal. A recent radiograph is shown in Figures A. MRI images are shown in Figures B and C. Which of the following is the best treatment option? Review Topic

Explanation

This patient has a chronic massive posterosuperior rotator cuff tear with marked atrophy, tendon retraction and loss of external rotation strength that is impacting his daily life. The best treatment option for this middle-aged laborer with an irreparable posterosuperior rotator cuff tear is a latissimus dorsi transfer to restore external rotation strength and motion.
Irreparable rotator cuff tears are marked by: (1) Superior displacement of the humeral head (AHI < 5-7mm), (2) Fatty infiltration of the rotator cuff muscles (Goutallier stage 3-4), (3) Increased duration of the tendon tear and (4) Profound external rotation weakness. These findings are predictive of poor-quality tissue and stiffness of the muscle-tendon unit, not amenable to primary repair. In this setting, a latissimus dorsi
transfer can be utilized to restore shoulder strength, function and improve pain. Relative contraindications include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis.
Gerber et al. performed a case series analysis of 67 patients with irreparable rotator cuff tears managed with latissimus dorsi transfer. Patients with an intact subscapularis demonstrated improvement in pain, range of motion and strength postoperatively, while no improvement was noted in patients with subscapularis deficiency. The authors conclude that latissimus dorsi transfer should not be performed in the setting of poor subscapularis function.
Iannotti et al. found that better clinical results following latissimus dorsi transfer were associated with: preserved active shoulder range of motion and strength (specifically forward elevation > 90° and external rotation > 20°), synchronous firing of the transferred latissimus dorsi muscle and male gender.
Figure A is an AP radiograph of the left shoulder with superior migration of the humeral head (AHI < 5mm) and no evidence of glenohumeral arthritis. Figures B and C show a retracted posterosuperior rotator cuff tear and Goutallier stage 4 atrophy (more fat than muscle) of the supraspinatus, infraspinatus and teres minor, rendering this tear irreparable. Illustration A shows a latissimus dorsi transfer. The latissimus dorsi tendon is positioned over the top of the humeral head, covering most of the rotator cuff defect. The tendon is then secured to the subscapularis tendon edge and lesser tuberosity anteriorly, the remnant supraspinatus and infraspinatus tendons medially, and the greater tuberosity laterally.
Incorrect Answers:

Question 10

What is the most common malignancy involving the hand?

Explanation

DISCUSSION: Skin cancers far outnumber primary musculoskeletal malignancies of the hand and the most common of these is squamous cell carcinoma. Metatastic lung carcinoma, while classic for the carcinoma that metastasizes to the hand, does so at an extremely low rate.
REFERENCES: Fink JA, Akelman E: Nonmelanotic malignant skin tumors of the hand. Hand Clin 1995;11:255-264.
Fleegler EJ: Skin tumors, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 2184-2205.

Question 11

A 47-year-old male tennis player has pain in his nondominant shoulder that has failed to respond to 4 months of nonsurgical management. Examination reveals acromial tenderness and pain at the supraspinatus tendon insertion. He has a positive impingement sign, pain on forward elevation, and minimal cuff weakness. The MRI scans are shown in Figures 30a and 30b. To completely resolve his symptoms, treatment should consist of

Explanation

DISCUSSION: The MRI scans show a mesoacromion with tendonopathy of the supraspinatus. The history and physical findings indicate that the patient has a symptomatic os acromiale. Simple excision of the unstable os acromiale has not yielded consistently good results. Meticulous internal fixation using tension banding with cannulated screws and autologous bone grafting has shown good results for this problem.
REFERENCES: Hutchinson MR, Veenstra MA: Arthroscopic decompression of shoulder impingement secondary to os acromiale. Arthroscopy 1993;9:28-32.
Warner JJ, Beim GM, Higgins L: The treatment of symptomatic os acromiale. J Bone Joint Surg Am 1998;80:1320-1326.

Question 12

A 32-year-old woman has an isolated left posterior wall acetabular fracture in which about 25% of the wall surface is involved. Which of the following criteria would indicate the need for surgical reduction and fixation?

Explanation

DISCUSSION: Fractures with a posterior wall fragment that makes up less than one third of the surface generally are stable. Conversely, fractures with a fragment making up more than 50% of the surface are unstable. Patients with an intermediate fracture fragment should undergo a fluoroscopic examination under sedation or anesthesia to determine if the fragment is truly stable. If so, the patient can be treated nonoperatively and safely mobilized.
REFERENCES: Tornetta P III: Non-operative management of acetabular fractures: The use of dynamic stress views. J Bone Joint Surg Br 1999;81:67-70.
Keith JE Jr, Brashear HR Jr, Guilford WB: Stability of posterior fracture-dislocations of the hip: Quantitative assessment using computed tomography. J Bone Joint Surg Am 1988;70:711-714.

Question 13

A 22-year-old woman injures her neck in a motor vehicle accident. Examination reveals no sensory or motor function below T8. Radiographs and an MRI scan show a burst fracture at T7. Forty-eight hours later, the bulbocavernosus reflex is present but there is no evidence of motor or sensory recovery in the lower extremities. What is the most likely diagnosis?

Explanation

DISCUSSION: Spinal shock typically ends after 48 hours with the return of reflexes, including the bulbocavernosus reflex. Lack of motor or sensory recovery in the lower extremities with the return of reflexes generally indicates a complete cord syndrome.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1132-1133.

Question 14

Which of the following processes does not account for decreased hematopoiesis in patients with metastatic disease?

Explanation

DISCUSSION: Paucytopenia is a common problem in patients with metastatic disease. Causes include chemotherapy, external beam radiation, marrow replacement by tumor, and anemia of chronic disease. There is no correlation with decreased calcium and a decrease in hematopoiesis. Supportive care with granulocyte-colony stimulating factor (G-CSF) and neupogen can stimulate hematopoiesis.
REFERENCE: Frassica FJ, Gitelis S, Sim FH: Metastic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.

Question 15

A 56-year-old man sustained a nondisplaced extra-articular fracture of the proximal aspect of the third metatarsal after dropping a heavy object on his left foot. Management should consist of

Explanation

DISCUSSION: This injury pattern is one of a direct trauma to the mid aspect of the foot. Without additional forces involved, capsular ligamentous injury is not anticipated; therefore, the injury should be a stable pattern. Treatment should consist of protected weight bearing as tolerated in a walking boot or walking cast. Surgical intervention with open reduction and internal fixation, percutaneous pinning, or open reduction and internal fixation with primary tarsometatarsal joint fusion is not indicated with this pattern of injury. The use of external bone stimulation in this acute fracture setting is not indicated. With injuries to the midfoot area where the exact mechanism of injury is uncertain, there should be a high index of suspicion for an associated injury to the tarsometatarsal joint, and standing radiographs or stress radiographs should be obtained.
REFERENCES: Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1265-1296.
Early JS: Fractures and dislocations of the midfoot and forefoot, in Rockwood and Green’s Fractures in Adults, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001,

pp 2181-2245.

Question 16

A 22-year-old patient underwent successful reduction of a posterolateral elbow dislocation. Management should now consist of

Explanation

DISCUSSION: The elbow usually is stable after reduction in most elbow dislocations. Ross and associates reported that supervised motion begun immediately after reduction was effective in uncomplicated dislocations. The elbow will become stiff if immobilization is applied for an extended period of time. Immediate open treatment is not indicated for a simple elbow dislocation.
REFERENCES: Ross G, McDevitt ER, Chronister R, et al: Treatment of simple elbow dislocation using an immediate motion protocol. Am J Sports Med 1999;27:308-311.
O’Driscoll SW, Jupiter JB, King GJ, et al: The unstable elbow. J Bone Joint Surg Am 2000;82:724-738.

Question 17

Figures 1 through 6 reveal the radiographs and MR images of a 30-year-old man who has a 1-year history of atraumatic medial-sided left knee pain refractory to nonsurgical measures. What is the most appropriate treatment?

Explanation

The images illustrate a large unstable osteochondral lesion of the medial femoral condyle. Radiographs and MR images clearly show deep subchondral bone involvement. The appropriate choice of surgery is OCA transplantation, which is indicated for primary treatment of large cartilage lesions, osteochondral lesions, and salvage procedure from failed prior cartilage surgery. Correction of mechanical axis malalignment, ligamentous insufficiency, and meniscal deficiency should also be addressed. ACI alone or an arthroscopic microfracture procedure would not address the bone defect, leaving an uneven articular surface. Although an osteotomy may be a viable choice, a distal femoral varus osteotomy would increase the contact pressure in the medial compartment and worsen the situation. The histologic anatomy of articular cartilage is well described. The superficial layer or lamina splendens contains a small amount of proteoglycan with collagen fibrils arranged parallel to the articular surface. In contrast, the deep zone contains the largest-diameter collagen fibrils, oriented perpendicular to the joint surface, and the highest concentration of proteoglycans.

Question 18

An 18-year-old man has acute respiratory distress after sustaining injuries in a motorcycle accident. He has a blood pressure of 80/60 mm Hg and a pulse rate of 110/min. Examination reveals chest tympany to percussion, distended neck veins, and deviation of the trachea away from his right hemithorax where the breath sounds are diminished. Heart sounds are regular and normal on auscultation. Initial management should consist of

Explanation

DISCUSSION: Tension pneumothorax occurs when air trapped in the pleural space between the lung and chest wall achieves sufficient pressure to compress the lungs and shift the mediastinum. Urgent needle decompression of the pleural space air followed by definitive chest tube placement is the treatment of choice.
REFERENCE: Mattox KL, Feliciano DV, Moore EE (eds): Management of Shock, ed 4. New York, NY, McGraw Hill, 2000, p 215.

Question 19

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

Explanation

DISCUSSION: Naranja and associates reviewed 37 knees (35 patients, with 28 women and 7 men) without any motion that were converted to total knee arthroplasties. After an average follow-up of 90 months, the patients lacked an average of 7° of extension and had 62° of flexion. Results showed a short-term complication rate of 24% (stiffness requiring manipulation, delayed wound healing, and recurrent hemarthrosis), a major complication rate of 35% (patellar tendon or tibial tubercle avulsion, persistent pain requiring arthrodesis, loosening, and joint stiffness requiring arthrotomy for excision of scar tissue), and an infection rate of 14%. The total complication rate was 57%. A satisfactory outcome (no pain and an unlimited ambulation distance) was obtained in only 10 patients (29%). There was no relationship between results and the angle at which the knee was ankylosed preoperatively. This study revealed that although success in reconstructing a previously ankylosed or arthrodesed knee is possible, the lack of consistent adequate motion and the complication rate may suggest that the surgeon reconsider the risks and benefits of this difficult procedure.
REFERENCE: Naranja RJ Jr, Lotke PA, Pagnano MW, Hanssen AD: Total knee arthroplasty in a previously ankylosed or arthrodesed knee. Clin Orthop 1996;331:234-237.

Question 20

Figures 4a and 4b show the radiographs of a 32-year-old man who has right groin pain with activity or prolonged standing. Which of the following factors would not prohibit consideration of acetabular liner exchange and grafting of the defects?

Explanation

DISCUSSION: Polyethylene particles generated as mechanical wear debris can be phagocytized by macrophages and enter a metabolically active state that releases cytokines, causing periprosthetic bone resorption. Significant osteolysis can occur in the pelvis with a porous-coated cementless socket without loosening of the component. If the acetabular component is modular, well positioned, well-designed with a good survivorship record, and remains undamaged after liner removal, the polyethylene liner can be exchanged and the lytic defects can be debrided and bone grafted. This implant is well positioned, has a good survivorship record, a good locking mechanism, and is modular. The hip arthroplasty needs to be aseptic for consideration of liner exchange.
REFERENCES: Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 21

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Explanation

Marfan syndrome is a challenging disease for the orthopaedic surgeon. Most problems of joint laxity, acetabular protrusio, and minor scoliosis curves are treated nonsurgically. Pseudarthrosis of the tibia is not seen in Marfan syndrome; it is more common in patients with neurofibromatosis (NF-1). Treating kyphosis is risky for vertebral subluxation. Rapidly progressive scoliosis in immature patients is associated with higher surgical complications, but surgery is indicated. Overcorrection is associated with significant cardiovascular complications and should be avoided.

Question 22

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

Explanation

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

Question 23

A 65-year-old woman with rheumatoid arthritis is unable to actively extend her index, middle, ring, and little fingers secondary to tendon rupture. In performing a flexor digitorum sublimis (FDS) of the middle/ring finger to extensor digitorum communis (EDC) transfer to restore active metacarpophalangeal (MCP) joint extension, the FDS should be passed

Explanation

Although the early use of FDS as a transfer to restore finger extension in patients with radial nerve palsy was performed by passing the tendon through the interosseous membrane, Nalebuff and Patel later modified this procedure for the rheumatoid arthritis patient by passing the FDS radially, around the radius in a dorsal direction. They felt that this provided a number of advantages, including: 1. technical ease, 2. avoidance of synovial disease on the dorsum of the wrist, and 3. correction of ulnar deviation of the fingers through the line of pull from the radial side of the forearm.

Question 24

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

Explanation

DISCUSSION: Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury.
REFERENCES: Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Gerber C, Sebesta A: Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report. J Shoulder Elbow Surg 2000;9:483-490.

Question 25

Figure 24 shows the AP radiograph of a 22-year-old woman who has pain with activity and crepitus at he second metatarsophalangeal joint. Despite nonsurgical treatment, the pain has become progressively worse over the past year. Treatment should include

Explanation

The use of NSAIDs along with soft metatarsal insoles may alleviate the stress on MTP joint. Occasionally, an intraarticular injection may alleviate symptoms. Failed conservative treatment should be followed by synovectomy of the MTP joint. When the proximal phalanx is hyperextended, a flexor tendon transfer may also be used to produce some plantar flexion. Early synovectomy may prevent the development of subluxation, dislocation, or hammer-toe development. The other treatment options given are much more invasive and are typically salvage procedures.

Question 26

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by

Explanation

CTE is a neurodegenerative disease that occurs years or decades after recovery from acute or postacute effects of head trauma. The exact relationship between concussion and CTE is not entirely clear; however, early behavioral manifestations of CTE have been described by family and providers to include apathy, irritability, and suicidal ideation. For some patients, cognitive difficulty such as poor episodic memory and executive function may be the first signs of CTE. Onset most often occurs in midlife after athletes have completed their sports careers, with mean age of onset at 42 years. The effects on the brain are degenerative, leading to a permanent state of derangement. Autopsy findings demonstrate multiple gross pathological findings. The condition is more common among contact athletes.

Question 27

At the level of tibial bone resection in total knee arthroplasty, where does the common peroneal nerve lie?

Explanation

DISCUSSION: At the level of tibial bone resection in total knee arthroplasty, the common peroneal nerve lies superficial to the lateral head of the gastrocnemius and is therefore protected by this structure. In an MRI study of 60 knees, the mean distance from the bony posterolateral corner of the tibia to the nerve was 1.49 cm, with no distance less than 0.9 cm. The distance from the bone to nerve was greater in larger legs.
REFERENCES: Clarke HD, Schwartz JB, Math KR, et al: Anatomic risk of peroneal nerve injury with the “pie crust” technique for valgus release in total knee arthroplasty. J Arthroplasty 2004;19:40-44.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-52, 4-53.

Question 28

A baseball pitcher has intractable posterior and superior shoulder pain. The arthroscopic view seen in Figure 25 shows no Bankart or Hill-Sachs lesion and a negative drive-through sign. There are no signs of ligamentous laxity, but active compression and anterior slide tests are positive. Treatment should consist of

Explanation

DISCUSSION: According to Morgan and associates, a type II SLAP lesion can create or is associated with a superior instability pattern. They suggest that this can exist without a co-existing anteroinferior instability pattern. They reported that repair of the SLAP lesion alone resulted in satisfactory outcomes in 90% of patients and a return to throwing in more than 90% of pitchers. The arthroscopic findings in this patient do not support a diagnosis of anteroinferior laxity or instability; therefore, thermal capsular shift or capsular placation is not necessary.
REFERENCES: Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14:553-565.
Mileski RA, Snyder RJ: Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131.
Levitz CL, Dugas J, Andrews JR: The use of arthroscopic thermal capsulorrhaphy to treat internal impingement in baseball players. Arthroscopy 2001;17:573-577.

Question 29

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Explanation

DISCUSSION: The Weber and Lauge-Hansen fracture classifications suggest that the interosseous membrane (IOM) is torn with certain fracture patterns. In a recent study that evaluated ankle fractures with MRI, Nielson and associates identified 30 patients with IOM tears. Ten of the tears did not correspond with the level of the fibular fracture. The authors concluded that stability of the syndesmosis should not be based on the level of the fibular fracture alone but should also include an intraoperative stress test. Transsyndesmotic fixation should be considered for those fractures where the intraoperative stress test demonstrates instability. A widened medial clear space may occur with a deltoid injury and distal fibular fracture in the absence of a significant tear of the interosseous membrane.
REFERENCE: Nielson JH, Sallis JG, Potter HG, et al: Correlation of interosseous membrane tears to the level of the fibular fracture. J Orthop Trauma 2004;18:68-74.

Question 30

Which of the following pharmacologic agents is most likely to adversely affect the success rate of bony union after lumbar arthrodesis?

Explanation

DISCUSSION: Glassman and associates reported a significantly higher pseudarthrosis rate when ketorolac was used postoperatively compared to a similar group of patients who were not given ketorolac. Animal studies from the same institution support these clinical findings. To reduce narcotic dosage, nonsteroidal anti-inflammatory drugs (NSAIDs) have been promoted as an adjunct for postoperative analgesia in patients undergoing spinal fusion. However, a high failure rate of arthrodesis has been associated with postoperative use of NSAIDs. The analgesics oxycodone hydrochloride, hydrocodone/acetaminophen, and tramadol, as well as the tricyclic antidepressant imipramine, have not been shown to inhibit fusion.
REFERENCES: Glassman SD, Rose SM, Dimar JR, et al: The effect of postoperative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine 1998;23:834-838.
Dimar JR II, Ante WA, Zhang YP, et al: The effects of nonsteroidal anti-inflammatory drugs on posterior spinal fusions in the rat. Spine 1996;21:1870-1876.

Question 31

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

Explanation

DISCUSSION: The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop

2000;20:7-14.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

Question 32

Figures 44a and 44b show the radiographs of a 28-year-old woman who has had progressive hip pain for the past 3 months. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has multiple hereditary exostoses and a secondary chondrosarcoma arising from a proximal femoral exostosis. The radiograph of the knee shows multiple osteochondromas typical in a patient with multiple hereditary exostoses. Patients with this diagnosis are at an increased risk for malignant degeneration of an osteochondroma. The lateral radiograph of the hip shows a bony lesion emanating from the anterior aspect of the femoral neck that is not well defined in the surrounding soft tissues. There are punctate calcifications and a large soft-tissue mass. The most likely diagnosis is a secondary chondrosarcoma developing from a benign osteochondroma. An enchondroma is an intramedullary benign cartilage lesion. Ollier’s disease and Maffucci’s syndrome involve multiple enchondromas.
REFERENCES: Scarborough M, Moreau G: Benign cartilage tumors. Orthop Clin North Am 1996;27:583-589.
Garrison R, Unni K, McLeod RA, Pritchard DJ, Dahlin DC: Chondrosarcoma arising in osteochondroma. Cancer 1982;49:1890-1897.

Question 33

Figures A and B show radiographs of a 24-year-old female with a soccer injury. A physical examination reveals an isolated, closed injury with no clinical features of neurovascular injury or compartment syndrome. She has been consented to be treated with intramedullary nail fixation. A pre-operative note by the anaesthesiology team makes reference to the patients fair skin and natural red-hair color. How will this information affect the post-operative management of this patient?

Explanation

Female patients with natural red-hair may require higher dosages of post-operative analgesia compared to other hair types.
Melanocortin-1-receptor (MC1R) is one of the key proteins involved in hair color and skin tone. Mutations of the MC1R alleles can render this protein non-functional, which results in a phenotype of red-hair and fair skin. Mutations of the MC1R have shown to modulate the pain response and opioid efficacy in these patients. Women are
more commonly affected and often require more anaesthetic and higher dosages of opioid to achieve comparable MAC level and pain-relief, respectively, as women with other hair types.
Liem et al. showed that a greater concentration of induction and maintenance agents (sevoflurane and desflurane, respectively) were required to sustain comparable MAC levels in red-haired patients as dark haired patients.
Fillingim et al. reviewed the affect of gender, sex and pain. They concluded there is a biopsychosocial element of pain that is perceived differently by men and women. In terms of postoperative and procedural pain, the outcome might be more severe in women than men.
Delaney et al. looked at the involvement of the melanocortin-1 receptor in acute pain in mice. They found that while the MC1R is better known as a gene involved in mammalian hair colour, it was shown to be involved in the pain pathway of inflammatory but not neuropathic origin. Mutations of MC1R showed increased tolerance to noxious pain stimulus in mice.
Figures A and B are AP and lateral radiographs of a left tibia. There is a low energy, distal third shaft fracture with no cortical apposition on the AP view.
Incorrect Answers:

Question 34

Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?

Explanation

DISCUSSION: Ankle arthrodesis for posttraumatic ankle arthrosis provides reliable pain relief. However, the long-term sequela of joint arthrodesis is the development of arthrosis in the surrounding joints. Over time, following ankle arthrodesis, the ipsilateral hindfoot and midfoot joints show signs of joint space wear, and this may be symptomatic. With a stable ankle arthrodesis, progressive limb-length discrepancy or talar osteonecrosis is not expected. Ankle arthrodesis has not been definitively linked to ipsilateral knee arthritis or contralateral ankle arthritis.
REFERENCES: Coester LM, Saltzman CL, Leupold J, Pontarelli W: Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am 2001;83:219-228.
Mazur JM, Schwartz E, Simon SR: Ankle arthrodesis: Long-term follow-up with gait analysis. J Bone Joint Surg Am 1979;61:964-975.

Question 35

A 12-year-old boy reports the acute onset of pain and a pop over the right side of his pelvis while swinging a baseball bat during a Little League game. Radiographs reveal an avulsion of the anterior superior iliac spine with 2 cm of displacement. Management should consist of

Explanation

DISCUSSION: Anterior superior iliac spine avulsion fractures are caused by sudden, forceful contractions of the sartorius and tensor fascia lata. These injuries occur in young athletes through the growth plate with the hip extended and the knee flexed, such as while sprinting or swinging a baseball bat. The athlete will often report a pop or snap at the time of injury. Displaced fractures usually can be seen on radiographs. CT or MRI can be obtained to confirm the diagnosis. In most patients, nonsurgical management consisting of rest and protected weight bearing yields satisfactory outcomes. Surgery is usually reserved for fractures with displacement of more than 3 cm and painful nonunions.
REFERENCES: Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 139-153.
White KK, Williams SK, Mubarack SJ: Definition of two types of anterior superior iliac spine avulsion fractures. J Pediatr Orthop 2002;22:578-582.

Question 36

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Explanation

DISCUSSION: In this age group of patients with arthrogryposis, open reduction through a medial approach is generally recommended. Open reduction through an anterior approach is reserved for patients in which a medial approach has failed or for older patients who require simultaneous femoral shortening and/or pelvic osteotomy. Closed treatment of unilateral hip dislocation in association with arthrogryposis is rarely successful. In bilateral hip dislocation associated with arthrogrypsis, the consensus is that the hips are best left unreduced because of the difficulty in obtaining excellent clinical and radiographic results bilaterally.
REFERENCES: Staheli LT, Chew DE, Elliot JS, Mosca VS: Management of hip dislocations in children with arthrogryposis. J Pediatr Orthop 1987;7:681-685.
Szoke G, Staheli LT, Jaffe K, Hall JG: Medial-approach open reduction of hip dislocation in amyoplasia-type arthrogryposis. J Pediatr Orthop 1996;16:127-130.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996.

Question 37

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

Explanation

DISCUSSION: The superior cluneal nerves (L1, L2, and L3) are most at risk when harvesting iliac crest bone graft during a posterior decompression and fusion. These nerves pierce the lumbodorsal fascia and cross the posterior iliac crest, beginning 8 cm lateral to the posterior superior iliac spine. The ilioinguinal nerve is more at risk during exposure of the anterior ilium during retraction of the iliacus and abdominal wall muscles. Iliohypogastric nerve injury may arise in a similar fashion to ilioinguinal neuralgia. The lateral femoral cutaneous nerve lies in close proximity to the anterior superior iliac spine and is also at risk with anterior iliac crest bone graft harvesting. The superior gluteal nerve courses through the sciatic notch and supplies motor branches to the gluteus medius, minimus, and tensor fascia lata muscles. Injury results in hip abduction weakness.
REFERENCES: An HS: Principles and Techniques of Spine Surgery. Baltimore, MD, Williams and Wilkins 1998, pp 770-773.
Kurz LT, Garfin SR, Booth RE Jr: Harvesting autogenous iliac bone grafts: A review of complications and techniques. Spine 1989;14:1324-1331.
Mrazik J, Amato C, Leban S, et al: The ilium as a source of autogenous bone grafting: Clinical considerations. J Oral Surg 1980;38:29-32.

Question 38

An 11-year-old girl has had pain in the medial arch of her foot for the past 3 months. She reports that pain is present even with daily activities such as walking to class at school, and ibuprofen provides some relief. She denies any history of trauma. Examination reveals a flexible pes planus with focal tenderness over a prominent tarsal navicular tuberosity. Radiographs show a prominent accessory navicular. Management should consist of

Explanation

DISCUSSION: The patient has the classic symptoms, examination findings, and radiographs for a painful accessory navicular. Initial treatment should always be nonsurgical, specifically cast immobilization. Surgery should be reserved for those patients who fail nonsurgical management. Corticosteroids should not be injected into a posterior tibial tendon or insertion point because they can weaken the tendon and possibly cause tendon rupture. Triple arthrodesis and biopsy have no role in the management of a painful accessory navicular.
REFERENCE: Bordelon RL: Flatfoot in children and young adults, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 717-756.

Question 39

A 13-year-old girl has had right groin pain for the past 3 weeks. She denies any history of trauma. Examination of the hip reveals no palpable soft-tissue mass or lymphadenopathy, and there is full range of motion. A plain radiograph and MRI scan are shown in Figures 15a and 15b. Biopsy specimens are shown in Figures 15c and 15d. What is the most likely diagnosis?

Explanation

DISCUSSION: Fibrous dysplasia frequently occurs in the proximal femur. Microfractures and remodeling can lead to the classic “Shepherd’s crook deformity.” The lesion has a ground-glass appearance on plain radiographs. The histologic appearance shows proliferating fibroblasts in a loose spindle cell background. Dysplastic metaplastic trabeculae are arranged in an irregular or “Chinese letter” appearance.
REFERENCES: Enneking WF, Gearen PF: Fibrous dysplasia of the femoral neck: Treatment by cortical bone grafting. J Bone Joint Surg Am 1986;68:1415-1422.
Simon MA, Springfield DS, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-200.

Question 40

50%

Explanation

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 41

What percentage of bone weight is collagen?

Explanation

Bone is a composite of both inorganic and organic material. The inorganic component of bone comprises 60% to 70% of the tissue, water accounts for 5% to 8%, and the organic matrix makes up the remainder. Collagen accounts for 90% of the organic component and thus 20% to 25% of bone weight. Collagen accounts for the flexibility of bone. The inorganic component of bone is made primarily of calcium and phosphorous, in the analogue of hydroxyapatite, and other ions including sodium, magnesium, and carbonate.

Question 42

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

Explanation

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

Question 43

A 35-year-old construction worker has developed isolated lateral compartment arthritis. He has lost 50 pounds, now has a body mass index of 30, and still has pain that limits his activities of daily living and work despite receiving a 4-month course of nonsteroidal anti-inflammatory medications and 2 intra-articular cortisone injections. His range of motion is 5 to 110 degrees, and his mechanical axis is 18 degrees of valgus. What is the most appropriate surgical treatment for this patient?

Explanation

DISCUSSION
Knee arthritis in a young laborer is challenging to address. A surgeon could perform an arthroplasty, but there is concern for early failure and the subsequent need for multiple revisions during this patient’s lifespan. Indications for distal femoral varus osteotomy include at least a 12- to 15-degree valgus mechanical axis and range of motion of at least 15 to 90 degrees. Contraindications for this procedure include inflammatory arthritis and restricted knee motion.
RESPONSES FOR QUESTIONS 138 THROUGH 141
Acute periprosthetic infection
Chronic periprosthetic infection
Joint dislocation
Periprosthetic fracture
Pseudotumor
Femoral nerve palsy
Sciatic nerve palsy
Aseptic prosthetic loosening
Select the total hip arthroplasty (THA) complication listed above that most commonly is associated with the clinical scenario described below.

Question 44

A 62-year-old active man returns for routine follow-up 16 years after hip replacement. He has no hip pain. Radiographs reveal a well-circumscribed osteolytic lesion around a single acetabular screw. All hip components are perfectly positioned. Comparison radiographs obtained 6 months later show an increase in the size of the osteolytic lesion. CT depicts a well-described lesion that is 3 cm at its largest diameter and is localized around one screw hole with an eccentric femoral head. What treatment is appropriate, assuming that well-fixed cementless total hip components are in place?

Explanation

DISCUSSION:
Given a well-fixed acetabular metal shell and a localized osteolytic lesion, good outcomes can be expected from liner revision in this clinical scenario with retention of the metal socket, assuming no damage to the components or other unexpected findings arise during revision surgery. Here, complete cup revision is not warranted, considering the appropriate implant position. Beaulé and associates reviewed 83 consecutive patients (90 hips) in whom a well-fixed acetabular component was retained in a clinical scenario such as the one described. No hip showed recurrence or expansion of periacetabular osteolytic lesions. If the metal cup is unstable, acetabular component revision may be indicated.

Question 45

Which soft-tissue sarcoma is most likely to develop lymphatic metastasis?

Explanation

Question 46

Figure 90 is the radiograph of this patient 5 months later when he returned for his preseason football physical. He is asymptomatic. What is the best next step?

Explanation

DISCUSSION
This patient has a closed midshaft clavicle fracture with significant displacement that has healed and remodeled nicely with nonsurgical treatment. Functional disability or nonunion after nonsurgical treatment of clavicle fractures in adolescents is rare. Schulz and associates showed no differences in pain, strength, range of motion, or subjective outcome scores between injured and uninjured limbs treated nonsurgically to address displaced, shortened midshaft clavicle fractures in adolescents. Bae and associates demonstrated that clavicle fracture malunions in adolescents do not cause loss of motion or strength.

RESPONSES FOR QUESTIONS 91 THROUGH 96
Chromosome 17 mutation
MYH3 mutation
Embryonic vascular interruption
Infantile vascular interruption
Chromosome 11 mutation
Sporadic inheritance
Select the appropriate etiology listed above for each pictured syndrome.

Question 47

An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

Explanation

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 48

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Explanation

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.

Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 49

Osteoporotic vertebral compression fractures are associated with Review Topic

Explanation

Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.

Question 50

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Explanation

DISCUSSION: Although osteochondromas can occur in almost every bone in patients with MHE, proximally located lesions are more likely to undergo malignant transformation. Annual radiographs of the shoulder girdles and pelvis are indicated in patients with MHE. Any enlarging osteochondromas are a concern as possible malignancies.
REFERENCES: Peterson HA: Multiple hereditary osteochondromata. Clin Orthop 1989;239:222.
McCornack EB: The surgical management of hereditary multiple exostosis. Orthop Rev 1981;10:57.

Question 51

The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Explanation

After plain radiographs of the affected area have been obtained, magnetic resonance imaging modality is the best imaging modality for detecting and characterizing the lesion, regarding definition of normal muscle, fascial boundaries, and the tumor mass. Although MR imaging is not specific in determining whether lesions are benign or malignant, it can be useful in evaluation
other characteristics, such as size, pattern of growth, integrity of natural boundaries, and homogeneity.
Intravenous contrast agents are not necessary to evaluate neurovascular structures. Both the T1 & T2 weighted images are essential to detect and characterize soft tissue lesions.
Most Tumors have long T1 and T2 relaxation times, therefore, in most instances signal intensity alone is of limited benefit. Exceptions are lipoma, hematoma, intra-lesional hemorrhage.
Hemorrhage may occur in some soft tissue lesions, especially sarcomas, leading to the low T1 and high T2 intensity sound on MR. Miller, indicates that Water, CSF, acute hemorrhage and soft tissue tumors appear dark on T1 and light on T2.

Question 52

A 79-year-old woman with a massive rotator cuff tear presents to the emergency department with pain and difficulty moving her arm 7 weeks after undergoing reverse TSA for a displaced 4-part proximal humerus fracture.

Explanation

DISCUSSION
The complication rate is high after surgical treatment of proximal humerus fractures, particularly in elderly patients with osteoporotic bone. In patients treated with ORIF, common complications include varus malunion (16%), avascular necrosis (10%), screw penetration (8%), and infection (4%). In cases involving a dislocation of the humeral head, avascular necrosis is more common. In patients treated with hemiarthroplasty or TSA, complications include component loosening, infection, and dislocation. TSA is associated with
glenoid loosening in patients with rotator cuff incompetence and should be avoided in these patients. Reverse TSA is a potential solution for this population. Dislocation and postoperative infection are potential complications after reverse TSA.
RECOMMENDED READINGS
Krappinger D, Bizzotto N, Riedmann S, Kammerlander C, Hengg C, Kralinger FS. Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011 Nov;42(11):1283-

Question 53

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Explanation

DISCUSSION: An MRI scan is both highly sensitive and specific for the evaluation of osteonecrosis. The measurement of increased intraosseous pressure can be technically difficult and the results have been variable. Plain radiographs can be normal early in the progression of osteonecrosis of the femoral head. The technetium Tc 99m bone scan is a very sensitive test. However, it is not specific; increased uptake can be noted in patients with arthritis, neoplastic disease, fracture, or sepsis. In addition, because of bilaterality, the frequency of false-negative scans is relatively high.
REFERENCES: Steinberg ME: Early diagnosis, evaluation, and staging of osteonecrosis, in Jackson DW (ed): Instructional Course Lectures 43. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 513-518.
Glickstein MF, Burk DL Jr, Schiebler ML, et al: Avascular necrosis versus other diseases of the hip: Sensitivity of MR imaging. Radiology 1988;169:213-215.

Question 54

.What is the most common detrimental impact of an unplanned excision of a high-grade soft-tissue sarcoma?

Explanation

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 66
Figures 64a through 64c are the radiograph, MRI scan, and histology of a 53-year-old man with medial knee pain and swelling below the knee.

Question 55

Nerve conduction velocity is slowed by

Explanation

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no association between hand dominance and nerve conduction velocity.

Question 56

Which of the following changes is seen with age and degeneration in the intervertebral disk? Review Topic

Explanation

The intervertebral disk consists of annulus fibrosus, nucleus pulposus, and endplate. Nucleus cells have a critical need for glucose because they obtain their energy primarily by glycolysis, even in the presence of oxygen. Disk cells do not require oxygen to remain alive, but they die at low glucose levels or acidic pH. Nutrients are supplied from the blood vessels at the margins of the disk and have to traverse the cartilaginous endplate and the fibrous annulus in order to reach the disk cells. The loss of the nutrient supply through the vertebral body will starve the cells in the disk center and may be a major factor in disk degeneration. The gross appearance of the nucleus pulposus is clear watery gelatinous matrix in the very young disk, but with age the nucleus pulposus becomes more opaque, and less hydrated and firm. The cellular composition of the young disk consists of many notochordal cells, but after 10 years of age, notochordal cells are not seen in the disk. Notochordal cells are the remnant of embryonal cells in the nucleus pulposus.

Question 57

An inverted radial reflex is associated with

Explanation

DISCUSSION: An inverted radial reflex is a hypoactive brachioradialis reflex in combination with involuntary finger flexion. It is a spinal cord “release” sign and is associated with upper motor neuron pathology as seen in cervical stenosis with myelopathy. Radiculopathy is characterized by a diminished reflex but no finger flexion. Peripheral neuropathy is not associated with any reflex change. Parsonage-Turner syndrome is an idiopathic brachial neuritis.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 1998, p 762.
Vaccaro AR, Betz RR, Zeidman SM (eds): Principles and Practice of Spine Surgery. St Louis, MO, Mosby, 2002, p 323.

Question 58

A 17-year-old boy underwent open reduction and internal fixation of a navicular fracture 5 days ago. A follow-up examination now reveals a tensely swollen foot with erythema and multiple skin bullae. The patient is febrile and has marked pain with palpation of the entire forefoot and hindfoot. What is the next step in management?

Explanation

DISCUSSION: Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%. Debridement of the bullae and observation are not indicated. Although elevation and close follow-up may be warranted early on, in this patient, surgical debridement is the next step.
REFERENCES: Ault MJ, Geiderman J, Sokolov R: Rapid identification of group A streptococcus as the cause of necrotizing fasciitis. Ann Emerg Med 1996;28:227-230.
McHenry CR, Piotrowski JJ, Pentrinic D, Malangoni MA: Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558-563.

Question 59

Which of the following injuries is most commonly associated with a fracture of the scapular body?

Explanation

Ada and Miller reviewed 148 fractures in 113 scapulae. Ninety-six percent had associated injuries, the most common being fracture of an upper thoracic rib. Other associated injuries included lung trauma, head injury, cervical spine injury, clavicle fractures and brachial plexus injury.

Question 60

A 37-year-old recreational athlete has osteoarthritis of the glenohumeral joint. He has failed nonsurgical measures and is interested in surgical intervention but would like to avoid arthroplasty. When performing shoulder arthroscopy for glenohumeral arthritis, which radiographic parameter is most predictive of clinical failure?

Explanation

Multiple studies have evaluated the utility of arthroscopy in the treatment of shoulder arthritis. Despite differing levels of success, a few common characteristics have been shown to lead to a higher probability of clinical failure. Mitchell and associates showed that shoulders with less joint space (1.3 mm vs 2.6 mm) and Walch type B2 and C glenoids were significantly more likely to fail than were Walch types A1, A2, and B1. Additionally, older patients (age >50 years) tended to have worse outcomes. Skelley and associates found that isolated capsular release and debridement had a high failure rate (conversion to total shoulder arthroplasty in 42% within 9 months) and postulated that patients undergoing concomitant procedures, such as biceps tenodesis, may fare better. Van Theil and associates found significant risk factors for failure included the presence of grade 4 bipolar disease, joint space <2 mm, and the presence of large osteophytes. They had a
22% conversion to total shoulder arthroplasty at 10.1 months.

Question 61

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 62

Figures 21a and 21b show the clinical photograph and radiograph of a 15-year-old girl who has a deformity of her feet. Her parents are concerned because there is a family history of Charcot-Marie-Tooth disease. The patient reports some mild instability of the ankle and has noticed mild early callosities; however, she is not having any significant pain. Coleman block testing reveals a forefoot valgus and supple hindfoot. She has weakness to eversion and dorsiflexion. Initial management should consist of

Explanation

DISCUSSION: Initial management of a young patient with a cavovarus deformity of the foot and a family history of Charcot-Marie-Tooth disease should focus on mobilization and strengthening of the weakening muscular units and an accommodative insert. Surgical intervention should be delayed until progression of the deformity begins to cause symptoms and/or weakness of the muscular units, resulting in contractures of the antagonistic muscle units.
REFERENCES: Pinzur MS: Charcot’s foot. Foot Ankle Clin 2000;5:897-912.
Holmes JR, Hansen ST Jr: Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14:476-486.
Thometz JG, Gould JS: Cavus deformity, in The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 343-353.

Question 63

A 14-year-old boy sustained a femoral neck fracture in a fall from a tree and underwent open reduction and internal fixation 6 months ago. Follow-up examination now reveals an antalgic Trendelenburg gait and painful range of motion. A radiograph is shown in Figure 23, and a CT scan shows a nonunion. Treatment should consist of

Explanation

DISCUSSION: The coxa vara deformity and fracture nonunion should be treated simultaneously; therefore, the treatment of choice is curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation. In addition, valgus osteotomy will convert the shear forces across the nonunion to compression, aiding in healing of the nonunion. None of the other procedures addresses both issues, and hip fusion is inappropriate under these conditions.
REFERENCES: Lam SF: Fractures of the neck of the femur in children. J Bone Joint Surg Am 1971;53:1165-1179.
Canale ST, Beaty JH: Pelvic and hip fractures, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1109-1193.

Question 64

Figure 55 shows the radiograph of a 30-year-old man who sustained a closed comminuted fracture of the right clavicle. Examination reveals decreased sensation in the radial nerve distribution. Weakness is noted with shoulder abduction, internal rotation, and wrist extension. A displaced bone fragment is most likely pressing on what portion of the brachial plexus? Review Topic

Explanation

Clavicular fractures are occasionally complicated by injury to the brachial plexus. A displaced bone fragment pressing on the posterior cord proximal to the upper subscapularis nerve would account for these findings.

Question 65

A 7-year-old boy sustained a head contusion and small bowel injuries in a motor vehicle accident in which he was wearing a lap belt. He subsequently required a bowel resection. Six weeks after the accident, his parents note a painful mass in his lower back. His neurologic examination is normal. A radiograph and CT scans are shown in Figures 47a through 47c. Definitive management should now consist of

Explanation

DISCUSSION: The posttraumatic lumbar kyphotic deformity will not remodel and is likely to worsen with time because the central line of gravity lies anterior to the deformity and the ligamentous disruption will not heal. The worsening deformity also puts the patient at some risk for future neurologic damage.
REFERENCES: Ebraheim NA, Savolain ER, Southworth SR, et al: Pediatric lumbar seat belt injuries. Orthopedics 1991;14:1010-1013.
Taylor JA, Eggli KD: Lap belt inhuries of the lumbar spine in children: A pitfall in CT diagnosis. Am J Rad 1988;150:1355-1358.

Question 66

Which of the follow scenarios is most likely to be amenable to a complete repair of a massive rotator cuff tear? Review Topic

Explanation

Whereas a rotator cuff tear associated with an acute anterior dislocation in 45-year old patient may be massive, its acute nature typically means that significant retraction and atrophy of the musculature has not occurred. Therefore, repair is often complete and tension-free. A massive tear associated with rheumatoid arthritis is likely one of chronic attrition with poor tendon tissue because of the underlying disease and chronic corticosteroid use. Repairs of massive chronic rotator cuff tears have been reported to have a 50% rate of retear and this rate would be expected to be higher in the revision setting and with evident supraspinatus atrophy on physical examination. Superior humeral migration on static upright radiographs indicates loss of the superior glenoid rim, leading to rotator cuff tear arthropathy.

Question 67

An 18-month-old boy with obstetric brachial plexus palsy is being evaluated for limited right shoulder motion. Physical therapy for the past 6 months has failed to result in improvement of the contracture. Which of the following studies is necessary prior to any shoulder reconstruction?

Explanation

DISCUSSION: The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.
REFERENCES: Waters PM: Update on management of pediatric brachial plexus palsy.

J Pediatr Orthop B 2005;14:233-244.
Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am

2005;87:320-325.
Moukoko D, Ezaki M, Wilkes D, et al: Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86:787-793.

Question 68

Figures 6a and 6b are the radiographs of a thin 23-year-old man who sustained a closed injury to his left arm in a fall. He has no other injuries and his

Explanation

The patient is a thin man with an isolated left humerus fracture. The fracture has bony apposition and should be amenable to closed treatment; therefore the most appropriate treatment is coaptation splinting with conversion to a fracture brace. A hanging arm cast is not recommended for a transverse fracture because of the propensity to distract the fragments, especially if left in place for a long period of time. A shoulder immobilizer is not an appropriate treatment for a humeral shaft fracture. A transverse fracture line is sometimes considered a relative indication for surgical treatment if the fragments are distracted, but in this patient, immediate surgical fixation is not warranted in the absence of other indications for surgical treatment.

Question 69

Which of the following best describes the relative content of the components of articular cartilage in decreasing order?

Explanation

DISCUSSION: Water is the most abundant component of articular cartilage with a wet weight of 65% to 80%. Of the water, 80% is at the surface and 65% at the deep zone. Collagen accounts for 10% to 20% of the wet weight, with type II collagen accounting for 90% to 95% of the total collagen content. Small amounts of types V, VI, IX, X, and XI collagen are also present. Proteoglycans comprise 10% to 15% of the wet weight of collagen. The remainder of the wet weight is made up of other collagens, noncollagenous proteins, and chondrocytes.
REFERENCE: Schiller AL: Pathology of osteoarthritis, in Kuettner KE, Goldberg VM: Osteoarthritic Disorders. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995,

pp 95-101.

Question 70

A 30-year-old man has pain in the left arm after a motor vehicle accident. His neurovascular examination is intact, and radiographs are shown in Figures 25a and 25b. What is the best course of management?

Explanation

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Yokoyama K, Itoman M, Kobayashi A, et al: Functional outcomes of “floating elbow” injuries in adult patients. J Orthop Trauma 1998;12:284-290.

Question 71

An 18-year-old football player reports acute pain and swelling after a direct injury to his plantar flexed foot. Examination reveals midfoot swelling and tenderness. Nonstanding radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return

to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 72

A 13-year-old boy has pain and a firm mass in his left knee. A radiograph and MRI scan are shown in Figures 2a and 2b, and a biopsy specimen is shown in Figure 2c. Based on these findings, what is the most likely diagnosis?

Explanation

DISCUSSION: The most likely diagnosis is osteosarcoma. The imaging studies show an aggressive primary tumor of bone, and the histology slide shows a typical chondroblastic osteosarcoma, with osteoid deposited along the surface of bone trabeculae. Ewing’s sarcoma histologically consists of small round blue cells. Osteochondroma and periosteal chondroma can occur near the knee but have different radiographic and histologic patterns. Chondrosarcoma rarely occurs in children.
REFERENCES: Simon M, Springfield D, et al: Osteogenic sarcoma: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 267.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990,
pp 14-15.

Question 73

A 7-year-old boy sustained an acute puncture wound of the foot after stepping barefoot on a piece of glass 1 day ago. His mother states that she is not sure if she got the piece of glass out; however, she reports that his immunizations are up-to-date. Examination reveals that the wound is slightly erythematous, less than 1 mm in length on the heel, and is not currently draining. What is the next most appropriate step im management?

Explanation

DISCUSSION: The child has an up-to-date tetanus; therefore, a booster is not recommended. Pseudomonas coverage is most likely not needed because the child was barefoot. It is too early to evaluate for abscess or osteomyelitis with MRI, and a formal debridement is rarely indicated without signs of an abscess or a retained foreign body. Radiographs with soft-tissue penetration should be obtained to check for a retained foreign body.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 199-205.
DeCoster TA, Miller RA: Management of traumatic foot wounds. J Am Acad Orthop Surg 1994;2:226-230.

Question 74

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

Explanation

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

Question 75

.Figures 75a through 75d are the radiograph, CT scan, bone scan, and biopsy of a 45-year-old man who has had a several-month history of progressive pain in his right hip and groin region. Based on these images and histology, what is the most appropriate treatment?

Explanation

Question 76

A 57-year-old man involved in a motor vehicle accident sustains an injury to his right shoulder. A spot AP radiograph is shown in Figure 34. What is the next most appropriate step in the orthopaedic management of this patient?

Explanation

DISCUSSION: The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
REFERENCE: Simon JA, Puopolo SM, Capla EL, et al: Accuracy of the axillary projection to determine fracture angulation of the proximal humerus. Orthopedics 2004;27:205-207.

Question 77

Figures 1 and 2 are the radiograph and MRI scan of a 16-year-old boy who injured his right knee by a lateral side impact while playing football. The MRI indicates what structure was most likely injured?

Explanation

This is a rupture of the anterolateral ligament complex and a portion of the IT band. This injury is highly correlated with a complete ACL injury. In the MRI, the curvilinear or elliptic bone fragment (Segond fracture) projected parallel to the lateral aspect of the tibial plateau, the lateral capsular sign, is seen. The lateral capsular sign is also associated with ACL tears. Thus, this is an MRI showing a complete ACL tear.

Question 78

A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of

Explanation

DISCUSSION: There is a spectrum of heat-related conditions. Heat cramps are the mildest form of heat illness. In heat exhaustion, cramps are associated with headache and weakness, and the skin is pale and moist. Treatment of heat cramps or heat exhaustion consists of removing and loosening excess clothing, applying ice to the axilla and groin, ingestion of cool water, and cool water sprays. This patient demonstrates symptoms of heat stroke which is a medical emergency. The core body temperature may be as high as 106 to 110 degrees F (41.1 to 43.3 degrees C). In heat stroke, the patient may no longer be sweating, and the skin may be hot and red. The athlete is usually confused, weak, nauseated, and may have seizure activity. Central nervous system depression has been called the most important marker of heat stroke, and progresses from confusion and bizarre behavior to collapse, delirium, and coma. Bizarre behavior is often the first sign of heat stroke. The patient needs to be treated and moved to a medical facility rapidly. During transfer, IV fluids and cooling of the athlete should be initiated. The best treatment of heat-related illness appears to be prevention with adequate hydration and monitoring of conditions (temperature and humidity), with cancellation of competition when conditions do not comply with guidelines.
REFERENCES: Griffin LY: Emergency preparedness: Things to consider before the game starts. J Bone Joint Surg Am 2005;87:894-902.
Barker TA, Motz HA, Gersoff WK: Environmental factors in athletic performance, in Fu FH, Stone DA (eds): Sports Injuries, ed 2. Philadelphia, PA, Lippincott, 2001, pp 67-68.
Roberts WO: Environmental concerns, in Kibler WB (ed): ACSM’s Handbook for the Team Physician. Baltimore, MD, Williams & Wilkins, 1996, p 172.

Question 79

-Figure 39 is the anteroposterior radiograph of a marathon runner who has left groin pain that prevents her from running. She recently got back into her usual running routine after an ankle injury preventedbher from running for several months. She now has pain with any weight bearing. What is the most appropriate treatment option?

Explanation

Question 80

A 41-year-old right-hand-dominant man has been treated nonsurgically for right elbow arthritis. His radiographs reveal end-stage ulnohumeral arthritis with complete loss of the joint space. He reports pain during the mid-arc of elbow flexion and extension. During the last 8 years, he has attempted activity modification, medication, physical therapy, and multiple cortisone injections. His symptoms have progressed, resulting in constant pain, loss of a functional range of motion, and an inability to perform many activities of daily living. Secondary to his age and activity demands, he undergoes a soft-tissue interposition arthroplasty of his elbow with an Achilles allograft. Which presurgical finding correlates with elevated risk for postsurgical complications?

Explanation

End-stage posttraumatic or inflammatory elbow arthritis in active, high-demand patients remains difficult to treat. Traditional total elbow arthroplasty is discouraged in this demographic secondary to concerns about implant longevity. Soft-tissue interposition arthroplasty does not necessitate the same activity and weight
restrictions for patients after surgery and remains a reasonable salvage procedure. Larson and Morrey published their findings on 38 patients with a mean age of 39 years following soft-tissue interposition arthroplasty for posttraumatic and inflammatory end-stage elbow arthritis. These investigators reported a significant improvement in Mayo Elbow Performance Score in addition to improvement in the flexion- extension arc from 51° to 97° after surgery. They reported worse results and elevated incidence of complications for patients with presurgical elbow instability upon examination; retained hardware from prior
surgery was not deemed a contraindication.

Question 81

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Explanation

Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 82

A 53-year-old man complains of recurrent lateral elbow pain. He was surgically treated approximately one year ago with some improvement in his direct lateral elbow pain. He now reports new-onset discomfort at the posterolateral elbow, as well as difficulty when pushing himself up from a chair. On examination, he has a well-healed 6-cm incision over the lateral epicondyle with full active and passive range of motion. He has pain with palpation along the posterior lateral elbow and a positive posterior drawer test. Radiographs are unremarkable. What is the best next step?

Explanation

Lateral elbow tendinopathy remains a frequently encountered pathology of the elbow. Open or arthroscopic lateral epicondyle debridement can be considered for patients with refractory symptoms. With either technique, the lateral collateral ligament complex of the elbow is at risk for compromise, with excessive debridement distal and posterior to the center of rotation of the capitellum. When injured, patients often complain of pain around the posterior lateral elbow, which is commonly misdiagnosed as recurrent lateral epicondylitis. The push-up test (apprehension using the supinated forearm to push up from a chair) is a typical examination finding, along with a positive posterior drawer test. Patients may also develop posterior lateral
instability of the elbow, for which the recommended treatment is lateral collateral ligament reconstruction.

Question 83

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Explanation

Advanced glycation end-products (AGEs) are found in aging and osteoarthritis (OA) and result in increased articular cartilage stiffness and increased brittleness.
AGEs are produced from spontaneous nonenzymatic glycation of proteins when sugars (glucose, fructose, ribose) react with lysine or arginine residues. Because of the low turnover, cartilage is susceptible to AGEs accumulation. The accumulation of AGEs has been thought to play a role in the development of OA of the knee and ankle.
Li et al. reviewed age-related changes in cartilage. They state that with aging, there is excessive collagen cross-linking increases cartilage stiffness, while shortening/degradation of aggrecan leads to loss of sugar side chains and water-binding ability, while increased levels of AGEs are associated with a decline in anabolic activity. There is also increased chondrocyte death and/or apoptosis.
Anderson et al. reviewed the relationship between osteoarthritis and aging. They state that knee cartilage thins with aging (especially on the femoral and patellar sides, suggesting a gradual loss of cartilage matrix. AGEs formation leads to modification of type II collagen by cross-linking of collagen molecules, increasing stiffness and brittleness and increasing susceptibility to fatigue failure.
Incorrect Answers:

Question 84

Which of the following nerves supply the muscles on each side of internervous plane identified when performing the anterior (Smith-Petersen) approach to the hip?

Explanation

The anterior (Smith-Peterson) approach to the hip utilizes the superficial internervous plane between the sartorius (femoral nerve) and the tensor fascia lata (superior gluteal nerve). The deep internervous plane is between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Question 85

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Explanation

DISCUSSION: Left-sided unstable intertrochanteric hip fractures are at increased risk of malreduction compared to unstable right-sided fractures fixed with dynamic hip screws. In left-sided fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. With these left sided injuries, the rotational torque can cause an anterior spike, whereas with right-sided injuries the rotational torque causes compression and reduction of the fracture. In addition, if a nail is used for these injuries and the proximal fracture fragment is not being held by the nail itself, this phenomenon can be seen as well.
Mohan et al conducted a study to assess the effect of clockwise rotational torque onto the fracture configuration in unstable and stable intertrochanteric fractures fixed with a dynamic hip screw construct. They found that 11 out of 30 unstable fractures showed an anterior spike (flexion malreduction) in left-sided fixations due to clockwise torque. This malreduction was not present in right-sided or stable fractures.

Question 86

A 35-year-old woman reports worsening pain after undergoing a neurectomy in the third interspace for a Morton’s neuroma 12 months ago. She states that the pain is sharp and electrical, worse than before her surgery, and prevents her from participating in her usual work and exercise activities. Use of wider shoes and pads used before her surgery have failed to provide relief. Examination does not reveal any deformity or inflammation. Tenderness along with neuritic pain occurs with compression of the plantar aspect of the foot between the third and fourth metatarsal head area. To most reliably alleviate her pain, management should consist of

Explanation

DISCUSSION: Most patients with a significant recurrent neuroma will not obtain relief with conservative methods. Pain results from a stump neuroma at the weight-bearing area from too short of a resection of the nerve or from regrowth of the remaining nerve end. Although steroid injection may be helpful in localizing symptoms or providing temporary relief, it rarely cures a stump neuroma. Orthotics with a metatarsal pad will likely increase pressure and pain at the neuroma site. Physical therapy could temporize the symptoms but will not address the underlying problem. Similarly, bone decompression alone will not alter the location of the neuroma stump. Revision of the nerve to a more proximal level off of the weight-bearing area is the most likely method to succeed. A plantar approach facilitates identification and ability to revise the nerve to a more proximal level.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.
Johnson JE, Johnson KA, Unni KK: Persistent pain after excision of an interdigital neuroma: Results of reoperation. J Bone Joint Surg Am 1988;70:651-657.
Beskin JL, Baxter DE: Recurrent pain following interdigital neurectomy: A plantar approach. Foot Ankle 1988;9:34-39.
Amis JA, Siverhus SW, Liwnicz BH: An anatomic basis for recurrence after Morton’s neuroma excision. Foot Ankle 1992;13:153-156.

Question 87

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Explanation

DISCUSSION: A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces.
According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.

Question 88

Figure 91 is the radiograph of a 20-year-old man who kicked a door while intoxicated. At the emergency department, his leg is placed into a long-leg cast. After 2 hours, he reports increasing pain, numbness, and tingling in his toes. What is the most appropriate initial treatment?

Explanation

Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 89

A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity?

Explanation

DISCUSSION: Contracture of the intrinsic flexor muscles of the foot can be the result of unrecognized foot compartment syndrome. Foot compartment syndrome is a known complication of calcaneus fractures.
Myerson reported 3/43 patients in his series below had chronic foot compartment syndrome. There are 9 compartments in the foot: (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The plantar fascia limits the space available for hematoma and swelling, causing damage to the intrinsic flexors of the foot (particularly the lumbricals and interossei), resulting in clawtoes.

Question 90

Figure 88 is the radiograph of a 68-year-old man who fell 3 weeks after undergoing a successful left primary total hip arthroplasty. He is experiencing a substantial increase in pain and an inability to bear weight. What is an appropriate treatment plan?

Explanation

DISCUSSION
Based on the fact that the fracture is occurring around the stem (type B) and the stem is clearly loose (type B2), the appropriate treatment is removal of the in situ stem (which is loose), ORIF of the femur (cerclage wires, cables, or a plate would be acceptable), and insertion of a longer revision stem (a tapered fluted modular titanium or fully porous coated cylindrical stem) to bypass the fracture. All other responses are incorrect because they provide inappropriate treatment options for a Vancouver B2 fracture.

Question 91

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Explanation

DISCUSSION: It is generally accepted that reconstructions of the proximal tibia are associated with the highest incidence of failure, probably because of poor soft-tissue coverage, the need for extensor mechanism reconstruction, and other anatomic issues. It also may be related to the fact that patients with tumors of the proximal tibia, in general, have a better prognosis and better survival rates than patients with tumors located elsewhere in the body. Reconstructions of the proximal humerus may be more durable because they are not involved in weight-bearing activities.
REFERENCE: Horowitz SM, Glasser DB, Lane JM, Healey JH: Prosthetic and extremity survivorship after limb salvage for sarcoma: How long do the reconstructions last? Clin Orthop 1993;293:280-286.

Question 92

Hamstring lengthening and posterior transfer of the rectus femoris will be most successful in a patient with cerebral palsy who has which of the following gait abnormalities?

Explanation

DISCUSSION: Children with cerebral palsy typically ambulate with a crouched gait characterized by excessive flexion of the hips and knees during stance. Many patients exhibit co-contracture of the quadriceps and hamstrings, causing a stiff-knee gait. Normally, the rectus femoris fires at the initiation of swing and in terminal swing through initial contact. Prolonged activity of the rectus femoris throughout the swing phase interferes with normal knee flexion. This contributes to a stiff knee during swing phase and prevents clearance of the foot. Lengthening of the hamstrings alone will not improve foot clearance. Hamstring lengthening is contraindicated when there is hyperextension during stance. Transfer of the rectus femoris to one of the knee flexors has been shown to improve knee flexion during swing by an average of 15°. This allows improved foot clearance.
REFERENCES: Gage JR, Perry J, Hicks RR, Koop S, Werntz JR: Rectus femoris transfer to improve knee function of children with cerebral palsy. Dev Med Child Neurol 1987;29:159-166.
Sutherland DH, Santi M, Abel MF: Treatment of stiff-knee gait in cerebral palsy: A comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release. J Pediatr Orthop 1990;10:433-441.

Question 93

A 38-year-old woman has persistent elbow pain but is unable to recall a specific traumatic event. Examination reveals that the patient exhibits apprehension when the elbow is placed in valgus with forearm supination and axial loading. Because of chronicity and failure to respond to nonsurgical management, what is the most appropriate treatment? Review Topic

Explanation

The maneuver described is the lateral pivot-shift test, where valgus and axial loads are applied to the extended and supinated forearm while the elbow is gradually flexed. The presence of apprehension in an awake patient suggests posterolateral rotatory instability, indicating insufficiency of the lateral ulnar collateral ligament. Treatment for chronic cases involves reconstruction using a palmaris longus tendon graft combined with plication of the lateral capsuloligamentous structures. Direct ligament repair and isolated plication are less reliable. The long-term effects of thermal shrinkage are still unclear. Because of the failure to respond to nonsurgical management, continued bracing is unlikely to resolve the patient's symptoms.

Question 94

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 95

An 83-year-old man has a painful mass of the great toe. Radiographs and a biopsy specimen are seen in Figures 22a and 22b. What is the most likely diagnosis?

Explanation

DISCUSSION: Gouty arthritis, pseudogout, and infection can all present with inflammatory arthritis and periarticular erosions. Strongly negative birefringent crystals are seen in gout. The histologic image shows elongated “needle-like” crystals of gout. Epidermal inclusion cysts are rarely painful and usually have a history of localized penetrating trauma.
REFERENCES: Hamilton W, Breedman KB, Haupt HM, Lackman R: Knee pain in a 40-year-old man. Clin Orthop 2001;383:282-285,290-292.
Mizel M, Miller R, Scioli M (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 301-302.

Question 96

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

Explanation

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

Question 97

A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Explanation

To establish negligence, certain criteria must be met. 1) A duty was owed by the surgeon (in this case, yes, a relationship was established). 2) The duty was breached, where the provider failed to meet the standard of care (there was a technical error, but it was corrected). 3) The breach caused an injury. In this case, the patient had an outcome that was very acceptable, as documented with outcome studies, for femur fractures. Also, the rotational error and locking distally would have had little impact on the hip, whereas antegrade nailing itself is expected to result in some objective impairment of the hip in some patients. 4) Damages were incurred as a result. In this case, the patient returned to work and could not rock climb which could be reasonably expected with a femur fracture in some patients, and cannot be causally linked to the corrective surgery. For all practical purposes, the patient had a very acceptable outcome. Thus, settling the case for an error would be rather permissive and the important issue is that the surgeon recognized the problem, addressed it, and fulfilled his or her postoperative responsibility. The case is very defendable, and thus it is unlikely to be lost. Defending the case and alleging no error is incorrect because there was an error. The surgeon should never function outside of his or her legal counsel once a suit is filed.

Question 98

Figures 8a through 8d show the radiographs and CT scans of a 14-year-old girl who has a painful, rigid planovalgus foot. Management consisting of arch supports and anti-inflammatory drugs failed to provide relief. A below-knee walking cast resulted in pain resolution, but she now reports that the pain has recurred. Management should now consist of

Explanation

DISCUSSION: Tarsal coalitions commonly present in the preadolescent age group as a rigid, planovalgus foot. Small coalitions of the calcaneonavicular joint or the middle facet of the talocalcaneal joint can be excised with interposition of fat or muscle tissue. Isolated calcaneocuboid joint coalitions are very rare. This patient has an associated large talocalcaneal coalition; therefore, resection is contraindicated. Surgery is warranted after failure of nonsurgical management, and because of the involvement of two joints, the only viable option for the severely symptomatic foot is triple arthrodesis.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Olney BW: Tarsal coalition, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 169-181.

Question 99

An infant is born with a mass that involves both the volar and dorsal compartments of the left arm. A clinical photograph and biopsy specimen are shown in Figures 41a and 41b. What is the best initial course of action?

Explanation

DISCUSSION: The patient has infantile fibrosarcoma. For unresectable lesions, the treatment of choice is chemotherapy with vincristine, actinomycin-D, and cyclophosphamide, followed by excision if there is an adequate decrease in the size of the lesion.
REFERENCE: Kurkchubasche AG, Halvorson EG, Forman EN, Terek RM, Ferguson WS: The role of preoperative chemotherapy in the treatment of infantile fibrosarcoma. J Pediatr Surgery 2000;35:880-883.

Question 100

A 32-year-old motorcycle rider is involved in a motor vehicle accident and radiographs show a burst fracture at L2 with 20 degrees of kyphosis. The neurologic examination is consistent with unilateral motor and sensory involvement of the L5, S1, S2, S3, and S4 nerve roots. He has no other injuries. CT demonstrates 20% anterior canal compromise with displaced laminar fractures at the level of injury. What is the best option for management of this patient?

Explanation

DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.
REFERENCES: Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Flexor pollicis longus rupture
Median nerve palsy
Ulnar nerve palsy
Anterior interosseous nerve palsy
Posterior interosseous nerve palsy

Correct Answer: Ulnar nerve palsy

Explanation:

The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures.
(SBQ12TR.54) A 37-year-old male cashier is shot in the leg. He sustains the injury shown in Figures A and B, and is subsequently taken to the operating room for intramedullary nailing. Figure C shows a radiograph of the nail starting point (*). What complication is most likely to result?
Varus malunion
Nonunion
Valgus malunion
Malrotation
Superficial peroneal nerve injury
This patient is presenting with a comminuted fracture of the proximal third of the tibia. He is appropriately undergoing intramedullary nail fixation, however, the start point illustrated in Figure C is too medial and often leads to a valgus malunion.
Intramedullary nail fixation is more technically demanding in proximal tibial fractures than diaphyseal fractures. The valgus deformity is due to imbalanced muscle forces on the proximal fragment, which are then accentuated by a start point that is too medial. An apex anterior (procurvatum) deformity can also occur and results from the pull of the patellar tendon or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment. The ideal starting point for proximal tibial fractures is slightly lateral to the medial aspect of the lateral tibial spine on a true AP x-ray and very proximal and just anterior to the anterior margin of the articular surface.
Nork et al. reported the results of intramedullary nailing of proximal tibial fractures with emphasis on techniques of reduction. Various techniques were found to be successful including attention to the proper starting point, the use of unicortical plates, and the use of a femoral distractor applied to the tibia.
Lowe et al. describe surgical techniques for complex proximal tibial fractures. They describe the extended leg position, use of a femoral distractor, temporary plate fixation, blocking (Poller) screws, and use of percutaneous clamps as means to achieve reduction during fixation.
Figure A and B show an AP and lateral radiograph of a comminuted extra-articular fracture through the proximal third of the tibia. Figure C demonstrates a start point that is too medial (represented by the asterisk) for intramedullary nail fixation. Illustration A and B show the ideal start point for intramedullary nail fixation of the tibia on AP and lateral radiographs.
Incorrect Answers:
Varus malunion is more likely to occur in midshaft tibia fractures with an intact fibula.
Nonunion after a proximal tibial fracture treated with intramedullary nailing is less common than malunion.
Malrotation occurs most commonly after IM nailing of fractures through the distal third of the tibia.
The superficial peroneal nerve is at risk during distal screw fixation using a LISS plating technique for fracture fixation.

Question 2:

Options:

Impingement injection test
Lift-off test
Weakness with “empty-can” abduction test
Load-and-sift maneuver
MRI with contrast

Correct Answer: Lift-off test

Explanation:

Question 3:

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

Options:

finger flexion.
elbow extension.
finger extension.
forearm supination.

Correct Answer: forearm supination.

Explanation:

Question 4:

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:

DISCUSSION: 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.
REFERENCES: Lalonde F, Letts M, Yang JP, et al: An analysis of burst fractures of the spine in adolescents. Am J Orthop 2001;30:115-120.
Clark P, Letts M: Trauma to the thoracic and lumbar spine in the adolescent. Can J Surg 2001;44:337-345.
Been HD, Bouma GJ: Comparison of two types of surgery for thoraco-lumbar burst fractures: Combined anterior and posterior stabilization vs posterior instrumentation only. Acta Neurochir (Wien) 1999;141:349-357.

Question 5:

Options:

He may wrestle if his lesions are covered.
He may wrestle if he is on oral antiviral agents for 48 hours.
He may wrestle immediately with no other treatment.
He cannot wrestle until the lesions are scabbed over and there are no new lesions for at least 72 hours.
He cannot wrestle for 2 weeks.

Correct Answer: He cannot wrestle until the lesions are scabbed over and there are no new lesions for at least 72 hours.

Explanation:

Question 6:

Options:

a local steroid injection into the flexor hallucis longus tendon sheath.
range-of-motion exercises.
open reduction and internal fixation.
nonsteroidal anti-inflammatory drugs.
excision of the fragment.

Correct Answer: excision of the fragment.

Explanation:

Question 7:

An osteoprogenitor cell is expected to commit to a bone lineage in the presence of what transcription factor?

Options:

PPARy2
MyoD
Sox 9
C/EBPa
Runx2

Correct Answer: Runx2

Explanation:

Question 8:

Options:

Lymphocentigraphy
Colonoscopy
Bronchoscopy
Embolization of the femoral lesion
Bone marrow aspiration

Correct Answer: Embolization of the femoral lesion

Explanation:

DISCUSSION: The histology shows findings consistent with metastatic renal cell carcinoma. Renal cell carcinoma metastases are extremely vascular. Preoperative embolization helps minimize the amount of blood loss during curettage of these lesions.
REFERENCES: Chatziioannou AN, Johnson ME, Pneumaticos SG, et al: Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol 2000;10:593-596.
Sun S, Lang EV: Bone metastases from renal cell carcinoma: Preoperative embolization. J Vasc Interv Radiol 1998;9:263-269.

Question 9:

Options:

Continue physical therapy
Latissimus dorsi transfer
Arthroscopic rotator cuff repair
Pectoralis major transfer
Reverse total shoulder arthroplasty

Correct Answer: Pectoralis major transfer

Explanation:

Question 10:

What is the most common malignancy involving the hand?

Options:

Epithelioid sarcoma
Synovial sarcoma
Metastatic lung carcinoma
Chondrosarcoma
Squamous cell carcinoma

Correct Answer: Squamous cell carcinoma

Explanation:

DISCUSSION: Skin cancers far outnumber primary musculoskeletal malignancies of the hand and the most common of these is squamous cell carcinoma. Metatastic lung carcinoma, while classic for the carcinoma that metastasizes to the hand, does so at an extremely low rate.
REFERENCES: Fink JA, Akelman E: Nonmelanotic malignant skin tumors of the hand. Hand Clin 1995;11:255-264.
Fleegler EJ: Skin tumors, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, vol 2, pp 2184-2205.

Question 11:

Options:

rigid open reduction and internal fixation of the os acromiale with autologous bone graft.
arthroscopic repair of the rotator cuff and acromioplasty.
arthroscopic excision of the os acromiale.
arthroscopic decompression of the supraglenoid cyst.
open distal clavicle excision (Mumford procedure).

Correct Answer: rigid open reduction and internal fixation of the os acromiale with autologous bone graft.

Explanation:

Question 12:

Options:

Fracture comminution
Displacement of 1 mm at the fracture site
Involvement of the ischial facet
Femoral head subluxation during fluoroscopic examination
Presence of a bilateral pneumothorax

Correct Answer: Femoral head subluxation during fluoroscopic examination

Explanation:

Question 13:

Options:

Spinal shock
Anterior cord syndrome
Cauda equina syndrome
Complete cord syndrome
Brown-Sequard syndrome

Correct Answer: Complete cord syndrome

Explanation:

DISCUSSION: Spinal shock typically ends after 48 hours with the return of reflexes, including the bulbocavernosus reflex. Lack of motor or sensory recovery in the lower extremities with the return of reflexes generally indicates a complete cord syndrome.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 179-187.
Herkowitz HN, Garfin SR, Eismont FJ: Rothman-Simone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 1132-1133.

Question 14:

Which of the following processes does not account for decreased hematopoiesis in patients with metastatic disease?

Options:

External beam radiation
A decrease in cellular calcium
Cytotoxic systemic chemotherapy
Decreased iron use secondary to anemia of chronic disease
Marrow replacement by tumor cells

Correct Answer: A decrease in cellular calcium

Explanation:

Question 15:

A 56-year-old man sustained a nondisplaced extra-articular fracture of the proximal aspect of the third metatarsal after dropping a heavy object on his left foot. Management should consist of

Options:

open reduction and internal fixation.
external bone stimulation.
percutaneous pin fixation.
weight bearing in a walking boot or walking cast.
open reduction and internal fixation and primary tarsometatarsal joint fusion.

Correct Answer: weight bearing in a walking boot or walking cast.

Explanation:

Question 16:

A 22-year-old patient underwent successful reduction of a posterolateral elbow dislocation. Management should now consist of

Options:

splinting for 5 weeks.
active range-of-motion exercises after 1 to 3 days.
delayed passive stretching at 2 weeks.
open medial collateral ligament reconstruction.
open lateral collateral ligament reconstruction.

Correct Answer: active range-of-motion exercises after 1 to 3 days.

Explanation:

Question 17:

Options:

Distal femoral varus osteotomy
Autologous chondrocyte implantation (ACI)
Fresh osteochondral allograft (OCA) transplantation
Arthroscopic microfracture

Correct Answer: Fresh osteochondral allograft (OCA) transplantation

Explanation:

Question 18:

Options:

administration of 2 L of saline solution.
subxiphoid pericardial aspiration.
rapid infusion of 500 mL of colloid solution.
insertion of a large-bore needle in the right third or fourth intercostal space.
intubation followed by mechanical ventilation.

Correct Answer: insertion of a large-bore needle in the right third or fourth intercostal space.

Explanation:

Question 19:

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

Options:

Less than 5%
Less than 50%
60%
80%
90%

Correct Answer: Less than 50%

Explanation:

Question 20:

Options:

Malposition of the components
A poor survivorship record of the implant
A high-powered intraoperative frozen section that reveals a count of 20 WBCs per high-powered field
A nonmodular acetabular component
A well-fixed modular acetabular component

Correct Answer: A well-fixed modular acetabular component

Explanation:

Question 21:

Which of the following conditions routinely requires early surgical intervention in patients with Marfan syndrome? Review Topic

Options:

Kyphosis
Ankle instability
Protrusio acetabula
Progressive scoliosis
Pseudarthrosis of the tibia

Correct Answer: Progressive scoliosis

Explanation:

Question 22:

Options:

Clostridium
Acinetobacter
Pseudomonas
Mycobacterium
Staphylococcus aureus

Correct Answer: Clostridium

Explanation:

Question 23:

Options:

ulnarly, around the ulna in a dorsal direction.
radially, around the radius in a dorsal direction.
through the interosseous membrane.
through the intermetacarpal spaces between the index, middle, ring, and little fingers.
through the lumbrical canals of the index, middle, ring, and little fingers.

Correct Answer: radially, around the radius in a dorsal direction.

Explanation:

Question 24:

Options:

Inferior glenohumeral ligament
Middle glenohumeral ligament
Superior labrum
Subscapularis tendon
Supraspinatus tendon

Correct Answer: Subscapularis tendon

Explanation:

Question 25:

- Figure 24 shows the AP radiograph of a 22-year-old woman who has pain with activity and crepitus at he second metatarsophalangeal joint. Despite nonsurgical treatment, the pain has become progressively worse over the past year. Treatment should include

Options:

silicone implant joint replacement
metatarsophalangeal joint arthrodesis
metatarsophalangeal joint debridement
resection of the metatarsal head
resection of the base of the proximal phalanx

Correct Answer: metatarsophalangeal joint debridement

Explanation:

Question 26:

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease that is characterized by

Options:

onset most often by age 30.
a temporary state of neuronal and axonal derangement.
manifestations of affect such as apathy, irritability, and suicidal ideation.
absence of gross pathological brain changes upon autopsy.

Correct Answer: manifestations of affect such as apathy, irritability, and suicidal ideation.

Explanation:

Question 27:

At the level of tibial bone resection in total knee arthroplasty, where does the common peroneal nerve lie?

Options:

Deep to the arcuate ligament
Closer to bone in larger legs
On the muscle belly of the popliteus
On the bony posterolateral corner of the tibia
Superficial to the lateral head of the gastrocnemius

Correct Answer: Superficial to the lateral head of the gastrocnemius

Explanation:

DISCUSSION: At the level of tibial bone resection in total knee arthroplasty, the common peroneal nerve lies superficial to the lateral head of the gastrocnemius and is therefore protected by this structure. In an MRI study of 60 knees, the mean distance from the bony posterolateral corner of the tibia to the nerve was 1.49 cm, with no distance less than 0.9 cm. The distance from the bone to nerve was greater in larger legs.
REFERENCES: Clarke HD, Schwartz JB, Math KR, et al: Anatomic risk of peroneal nerve injury with the “pie crust” technique for valgus release in total knee arthroplasty. J Arthroplasty 2004;19:40-44.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-52, 4-53.

Question 28:

Options:

open fixation of the SLAP lesion with a screw that can be removed later.
arthroscopic repair of the SLAP lesion with suture anchors.
arthroscopic repair of the SLAP lesion with suture anchors with a thermal capsular shift.
arthroscopic repair of the SLAP lesion with suture anchors and a rotator cuff interval closure.
arthroscopic repair of the SLAP lesion with suture anchors and an arthroscopic capsular placation.

Correct Answer: arthroscopic repair of the SLAP lesion with suture anchors.

Explanation:

Question 29:

A 35-year-old patient sustained a bimalleolar ankle fracture. What is the most reliable method of predicting a tear of the interosseous membrane?

Options:

Level of the fibular fracture
Lauge-Hansen fracture class
Intraoperative stress testing
Widening of the medial clear space
Talar dislocation

Correct Answer: Intraoperative stress testing

Explanation:

Question 30:

Which of the following pharmacologic agents is most likely to adversely affect the success rate of bony union after lumbar arthrodesis?

Options:

Oxycodone hydrochloride
Hydrocodone/acetaminophen
Tramadol
Imipramine
Ketorolac

Correct Answer: Ketorolac

Explanation:

Question 31:

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

Options:

open reduction.
closed reduction and transarticular pinning.
closed reduction.
a sling and early range of motion.
radial head excision.

Correct Answer: closed reduction.

Explanation:

DISCUSSION: The patient has a displaced radial neck fracture. Displaced radial neck fractures with angulation of more than 30° to 45° require reduction. Methods of attempted closed reduction include wrapping the arm with an Esmarch’s bandage and applying direct pressure over the maximum deformity of the radial head. More aggressive methods include a Kirschner wire used as a joystick or intramedullary reduction as described by the Metaizeau technique. Open reduction should be avoided because of complications such as stiffness or osteonecrosis. Indications for open reduction are irreducible displacement of more than 45° with severe restriction of forearm rotation.
REFERENCES: Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop
2000;20:7-14.
Radomisli TE, Rosen AL: Controversies regarding radial neck fractures in children. Clin Orthop 1998;353:30-39.
Skaggs DL, Mirzayan R: The posterior fat pad sign in association with occult fracture of the elbow in children. J Bone Joint Surg Am 1999;81:1429-1433.
Gonzalez-Herranz P, Alvarez-Romera A, Burgos J, et al: Displaced radial neck fractures in children treated by closed intramedullary pinning (Metaizeau technique). J Pediatr Orthop 1997;17:325-331.

Question 32:

Figures 44a and 44b show the radiographs of a 28-year-old woman who has had progressive hip pain for the past 3 months. What is the most likely diagnosis?

Options:

Enchondroma
Osteochondroma
Chondrosarcoma
Ollier’s disease
Maffucci’s syndrome

Correct Answer: Chondrosarcoma

Explanation:

Question 33:

Options:

Longer duration of anticoagulation due to increased risk of DVT
Avoiding anticoagulation medications due to increased risk of bleeding
Require higher dosages of post-operative analgesia
Longer period of non-weight bearing on surgical limb
Avoiding opioids due to higher risk of unrecognized allergies

Correct Answer: Longer duration of anticoagulation due to increased risk of DVT

Explanation:

Question 34:

Which of the following is a long-term complication of ankle arthrodesis for posttraumatic arthritis?

Options:

Progressive limb-length discrepancy
Contralateral ankle arthritis
Ipsilateral hindfoot and midfoot arthritis
Ipsilateral knee arthritis
Talar osteonecrosis

Correct Answer: Ipsilateral hindfoot and midfoot arthritis

Explanation:

Question 35:

Options:

open reduction and internal fixation of the fragment along with the rectus femoris.
open reduction and internal fixation of the fragment along with the sartorius.
open reduction and internal fixation of the fragment along with the iliopsoas.
rest and protected weight bearing with crutches.
excision of the fragment.

Correct Answer: rest and protected weight bearing with crutches.

Explanation:

Question 36:

A 5-month-old girl with arthrogryposis has a limb-length discrepancy. Examination and radiographs reveal unilateral hip dislocation. Management should consist of

Options:

a Pavlik harness.
observation.
closed reduction and a spica cast.
open reduction and femoral shortening.
open reduction.

Correct Answer: open reduction.

Explanation:

Question 37:

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

Options:

Ilioinguinal nerve
Superior gluteal nerve
Superior cluneal nerves
Iliohypogastric nerves
Lateral femoral cutaneous nerve

Correct Answer: Superior cluneal nerves

Explanation:

Question 38:

Options:

cast immobilization for 4 to 6 weeks.
posterior tibial tendon advancement and repair (Kidner procedure).
corticosteroid injection of the posterior tibial tendon insertion.
triple arthrodesis.
needle biopsy of the trochar.

Correct Answer: cast immobilization for 4 to 6 weeks.

Explanation:

Question 39:

Options:

Fibrous dysplasia
Osteosarcoma
Ewing’s sarcoma
Periosteal chondroma
Aneurysmal bone cyst

Correct Answer: Fibrous dysplasia

Explanation:

Question 40:

50%

Options:

greater than 50%
None, by 5 years the allograft cartilage will be completely acellular

Correct Answer: greater than 50%

Explanation:

By 5 years, the allograft cartilage will be completely acellular, so there will be no residual donor chondrocytes.
Enneking et al. conducted both radiographic and histologic studies of sixteen massive retrieved human allografts four to sixty-five months after implantation. Analysis of the articular cartilage revealed no evidence that any chondrocytes had survived, even when the graft had been cryoprotected before it was preserved by freezing.
A 64-year-old woman with a longstanding history of rheumatoid arthritis complains of finger dysfunction for the past 6 months. Figure A displays her hand during active extension of all fingers. Figure B displays her hand maintaining her fingers extended following passive extension. What is the next most appropriate treatment for the ring finger?
Spiral oblique retinacular ligament reconstruction
Sagittal band reconstruction
Lateral band reconstruction
Central slip reconstruction
Triangular ligament and transverse retinacular ligament reconstruction
Sagittal band disruption is often associated with rheumatoid arthritis. When this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an extensor lag. If one passively extends the finger fully, the patient is able to maintain this position, as the tendon is intact.
Sagittal band reconstruction can be performed with Watson's technique of creating a distally based tendon graft harvested from the central third of the extensor tendon, passed deep to the intermetacarpal ligament and sutured back to itself. Illustration A depicts an intraoperative view of the tendon before reconstruction and Illustration B displays tendon following sagittal band reconstruction. Illustration C displays all of the anatomic locations
of the options listed above.
A splenectomy is performed in a 7-year-old boy following a motor vehicle accident. All of the following are recommended for long-term management EXCEPT:
Pneumococcal vaccination
Haemophilus influenza type B vaccination
Meningococcal group C vaccination
Lifelong prophylactic antibiotics
Hepatitis A vaccination
All of the responses are correct except the need for Hepatitis A vaccine. Hepatitis A is a virus with tropism for hepatocytes which causes infection from fecal-oral contaminated food/water, and shows no increased rate of either infectivity or morbidity in patients with hyposplenism.
Basic recommendations for splenectomized patients include:
All splenectomized patients and those with functional hyposplenism should receive pneumococcal immunization.
Patients not previously immunized should receive haemophilus influenza type B vaccine.
Patients not previously immunized should receive meningococcal group C conjugate vaccine.
Influenza immunization should be given.
Lifelong prophylactic antibiotics are still recommended (oral phenoxymethylpenicillin or erythromycin). This is seemingly despite lack of good data demonstrating a role for lifelong chemoprophylaxis and the acknowledgement that long-term compliance may be problematic.
Davies et al review the current level of evidence supporting these guidelines
for infection prevention in patients with hyposplenism. New to these guidelines are issues regarding occupational exposure and the use of the meningococcal group C and the seven-valent pneumococcal vaccine in non-immunized hyposplenic patients.
Gandhi et al evaluated their nonoperative management of blunt splenic injury in pediatric trauma care. They found compared to historical controls, children with blunt splenic injuries who were hemodynamically stable could be safely monitored with a protocol which required 4 days of inpatient care, 3 weeks of quiet home activities, and 3 months of light activity. This protocol seems to allow for safe return to unrestricted activity.
Incorrect Answer:
Ligaments attach to bone by both direct insertion and indirect insertion. Which of the following most accurately describes the order of the four transition zones of direct insertion?
Ligament > fibrocartilage > mineralized fibrocartilage > bone
Ligament > mineralized fibrocartilage > fibrocartilage > bone
Ligament > mineralized fibrocartilage > periosteum > bone
Ligament > Sharpey's fiber > periosteum > bone
Ligament > periosteum > fibrocartilage > bone
There are two types of tendon/ligament insertion into bone: direct and indirect insertion. The more common, indirect insertion, occurs when the superficial ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2) fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
While flexing the elbow to perform a biceps curl, what type of muscle contraction is occuring?
Isometric
Isokinetic
Plyometric
Eccentric
Concentric
Concentric muscle contractions occur when a muscle shortens during contraction, as in the upward motion when performing a biceps curl. An eccentric contraction occurs when a muscle lengthens with contraction, as in the "negative" or lowering motion of a biceps curl. An example of an isometric (muscle contracts while maintaining constant length) contraction would be pushing against an immovable object. An example of an isokinetic (muscle has constant speed of contraction) occurs with specialized equipment like Cybex machines. Plyometric contractions occur when a muscle rapidly lengthens just prior to contraction - like during repetitive box jumping.
Woo and Buckwalter describe the mechanisms, barriers, and molecular processes involved in ligament and tendon injury and repair.
A 34-year-old laborer has her left foot crushed in a piece of farming equipment as shown in Figure A. All of the following are reasons for a poor outcome following a crush injury to the foot EXCEPT:
Workers compensation injury
Development of reflex sympathetic dystrophy (complex regional pain syndrome)
Delayed soft-tissue coverage in mangled extremities
Immediate skeletal stabilization
Ongoing litigation
This patient has a mangled extremity. Rigid skeletal stabilization is recommended to enhance soft-tissue healing.
Level 4 evidence from Myerson et al found that delayed soft-tissue coverage in mangled extremities correlated with poor outcome. Poor results also occurred
if treatment was not immediately initiated (immediate debridement shown in Illustration A), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. Neuroischemia following substantial soft-tissue injury likely plays a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated reflex sympathetic dystrophy (complex regional pain syndrome).
A 65-year-old man undergoes total knee replacement and is found to have deep vein thrombosis two days later. What molecule is
thought to be involved in this process when it is released during surgical dissection?
Prothrombin
RANKL
IL-1b
Thromboplastin
Factor XI
Corrent answer: 4
Thromboplastin is also known more commonly as Tissue Factor (TF), which is involved in the Extrinsic Pathology of the coagulation cascade.
During surgical dissection, insults occur to the endothelial walls of blood vessels. There are three ways in which the body reacts to form a clot so that the patient does not bleed excessively. One is via vessel contraction, another is by collagen release, and a third is by tissue thromboplastin release. Thromboplastin release is part of the extrinsic coagulation pathway (see
Illustration A). Thromboplastin release activates Factor VII which activates Factor X which converts prothrombin to thrombin. Thrombin is the catalyst for converting fibrinogen to fibrin which induces clot formation. While this is useful for decreasing bleeding, it is the same mechanism by which a deep venous thrombosis (DVT) develops.
Which of the following materials has a Young's modulus of elasticity that is most similar to cortical bone
Titanium
Zirconia
Stainless steel
Ceramic (Al2O3)
Alloy (Co-Cr-Mo)
Of the materials listed Titanium has an elastic moduli closest to cortical bone. Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant. Titanium is however very notch sensitive and has poor wear resistance.
Young Modulus of Elasticity is defined as the stiffness (ability to maintain
shape under external loading) of a material. On the stress vs. strain curve it is defined as the slope of the line in the elastic zone (see Illustration A). Young’s modulus is constant and different for each material. The relevant moduli (unit GPa) are approximated below:

Question 41:

What percentage of bone weight is collagen?

Options:

1 5% to 10%
2 20% to 25%
3 50% to 60%
4 70% to 75%
90% to 95%

Correct Answer: 2 20% to 25%

Explanation:

Question 42:

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

Options:

Spinal shock
Neurogenic shock
Hypovolemic shock
Pulmonary embolism
Fat embolus syndrome

Correct Answer: Neurogenic shock

Explanation:

Question 43:

Options:

Proximal tibial varus osteotomy
Lateral unicompartmental arthroplasty
Distal femoral varus osteotomy
Total knee arthroplasty

Correct Answer: Distal femoral varus osteotomy

Explanation:

Question 44:

Options:

Revision of the polyethylene liner, removal of the screw, and debridement of the osteolytic lesion with or without bone grafting
Revision of the acetabular component to a newer design without screws
Removal of the screw, revision of the polyethylene liner, and stem cell injection into the lytic lesion
Removal of the offending screw from the metal socket and placement of a new polyethylene liner in the existing socket

Correct Answer: Revision of the polyethylene liner, removal of the screw, and debridement of the osteolytic lesion with or without bone grafting

Explanation:

Question 45:

Which soft-tissue sarcoma is most likely to develop lymphatic metastasis?

Options:

Liposarcoma
Leiomyosarcoma
Synovial sarcoma
Myxoid liposarcoma
Pleomorphic sarcoma

Correct Answer: Synovial sarcoma

Question 46:

Figure 90 is the radiograph of this patient 5 months later when he returned for his preseason football physical. He is asymptomatic. What is the best next step?

Options:

Advise against football because of increased risk for clavicle fracture
Order a bone density test prior to return to football
Allow football as tolerated and follow up as the situation demands
Perform a clavicular osteotomy and plating

Correct Answer: Allow football as tolerated and follow up as the situation demands

Explanation:

Question 47:

Options:

plating of the radial shaft fracture and open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius and pinning of the DRUJ in pronation.

Correct Answer: plating of the radius with closed reduction and evaluation of the distal radioulnar joint (DRUJ).

Explanation:

DISCUSSION: This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
REFERENCE: Rettig ME, Raskin KB: Galeazzi fracture-dislocation: A new treatment-oriented classification. J Hand Surg Am 2001;26:228-235.

Question 48:

A 17-year-old girl has multidirectional instability of the shoulder. What is the most appropriate initial management?

Options:

Immobilization in a sling and swathe
Open capsular shift
Arthroscopic capsular plication
Thermal capsulorrhaphy
Physical therapy and home exercises

Correct Answer: Physical therapy and home exercises

Explanation:

DISCUSSION: Multidirectional instability of the shoulder is defined as symptomatic instability in two or more directions (anterior, posterior) but must include a component of inferior instability. Initial treatment should always include physical therapy and instruction in a home exercise program that emphasizes periscapular and rotator cuff strengthening to improve the dynamic stability of the glenohumeral joint. Immobilization has not been shown to be effective. Open capsular shift and arthroscopic capsular plication remain the surgical options when appropriate nonsurgical management fails (typically a minimum of 6 months of dedicated therapy and home program). Thermal capsulorrhaphy remains controversial but is not recommended by many clinicians because of reported complications including recurrent instability, axillary nerve injury, chondrolysis, and capsular injury.
REFERENCES: Neer CS II, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: A preliminary report. J Bone Joint Surg Am 1980;62:897-908.
D’Alessandro DF, Bradley JP, Fleischli JE, et al: Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two- to five-year follow-up.
Am J Sports Med 2004;32:21-33.
Levine WN, Clark AM Jr, D’Alessandro DF, et al: Chondrolysis following arthroscopic thermal capsulorrhaphy to treat shoulder instability: A report of two cases. J Bone Joint Surg Am 2005;87:616-621.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 278-279.

Question 49:

Osteoporotic vertebral compression fractures are associated with Review Topic

Options:

neurologic deterioration in 33% of patients.
osteomalacia in 50% of patients.
a further fracture risk rate of 20%.
chronic pain in 75% of patients.
a 2-year mortality rate that is less than that associated with hip fractures.

Correct Answer: a further fracture risk rate of 20%.

Explanation:

Question 50:

Exostoses in which of the following anatomic locations is the most likely to undergo malignant transformation in a patient with multiple hereditary exostosis (MHE)?

Options:

Distal humerus
Distal radius
Distal femur
Lumbar spine
Scapula

Correct Answer: Scapula

Explanation:

Question 51:

- The Magnetic resonance imaging signal characteristics of a high-grade soft-tissue sarcoma are best described as

Options:

T1-low, T2-low.
T1-low, T2-high.
T1-moderate, T2-low.
T1-high, T2-low.
T1-high, T2-high.

Correct Answer: T1-low, T2-high.

Explanation:

Question 52:

Options:

- Avascular necrosis, head collapse, and screw penetration
- Fixation failure and varus collapse
- Humeral stem loosening
- Glenoid component loosening
- Hardware failure (breakage of plate or screws)
- Shoulder dislocation

Correct Answer: - Avascular necrosis, head collapse, and screw penetration

Explanation:

Question 53:

Which of the following studies has the highest sensitivity and specificity in diagnosis of osteonecrosis of the femoral head?

Options:

Intraosseous pressures
AP and frog-lateral radiographs
Technetium Tc 99m bone scan
MRI scan
CT scan

Correct Answer: MRI scan

Explanation:

Question 54:

.What is the most common detrimental impact of an unplanned excision of a high-grade soft-tissue sarcoma?

Options:

Decreased mortality
Decreased recurrence
Increased wound complications
Increased functional outcome DISCUSSION.. This is an example of an unplanned excision. The patient has a history of trauma and a painless soft-tissue mass. The most common soft-tissue masses are benign; consequently, nononcologic surgeons may not expect a malignant sarcoma. The patient was taken to surgery with appropriate imaging and without a biopsy. If the imaging is conclusive a biopsy is not always indicated, particularly for low-grade lipomatous tumors. The surgical resection was performed through a transverse incision. It is recommended that the incision be made longitudinally in the event a wider resection is needed. The grade of the tumor is the most important aspect. Benign and low-grade tumors may be observed, whereas intermediate and high-grade tumors require a wide resection and likely perioperative radiation. The appropriate work-up for a soft-tissue mass is a careful history and examination accompanied by radiographs and cross-sectional imaging. If a biopsy is needed, it should be performed or supervised by the surgeon, who would do the final resection if it proves to be a sarcoma. The most common impact of an unplanned excision is wound complications. This is because of the need for a wider surgical resection and adjuvant radiation. Mortality and recurrence have not been shown to be increased with statistical significance. Functional outcome may be compromised; however, no studies confirm that functional outcome is poorer in patients who undergo unplanned excision.

Correct Answer: Decreased mortality

Explanation:

CLINICAL SITUATION FOR QUESTIONS 64 THROUGH 66
Figures 64a through 64c are the radiograph, MRI scan, and histology of a 53-year-old man with medial knee pain and swelling below the knee.

Question 55:

Nerve conduction velocity is slowed by

Options:

increased skin temperature.
increased perineural blood flow.
external compression.
hand dominance.

Correct Answer: external compression.

Explanation:

EXPLANATION:
A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no
association between hand dominance and nerve conduction velocity.

Question 56:

Which of the following changes is seen with age and degeneration in the intervertebral disk? Review Topic

Options:

Increased number of blood vessels in the outer annulus fibrosus
Increased number of notochordal cells in the nucleus pulposus
Increase of diffusion gradient between the annulus fibrosus and the nucleus pulposus
Decreased type 1 collagen
Decreased water content of the nucleus pulposus

Correct Answer: Decreased water content of the nucleus pulposus

Explanation:

Question 57:

An inverted radial reflex is associated with

Options:

spinal cord compression with myelopathy.
acute cervical radiculopathy.
chronic cervical radiculopathy.
Parsonage-Turner syndrome.
peripheral neuropathy.

Correct Answer: spinal cord compression with myelopathy.

Explanation:

Question 58:

Options:

Application of a compressive dressing and boot brace and monitoring of compartment pressures
Administration of IV antibiotics and strict elevation
Oral antibiotics, elevation, and close follow-up
Debridement of the bullae and application of a new cast
Urgent surgical debridement and IV antibiotics

Correct Answer: Urgent surgical debridement and IV antibiotics

Explanation:

Question 59:

- Which of the following injuries is most commonly associated with a fracture of the scapular body?

Options:

Vascular injury
Tear of the rotator cuff
Injury to the brachial plexus
Fracture of the upper thoracic rib
Fracture of the proximal humerus

Correct Answer: Fracture of the upper thoracic rib

Explanation:

Question 60:

Options:

Unipolar arthritis
>3 mm of glenohumeral joint space
Walch B2 glenoid morphology
Small inferior humeral osteophyte

Correct Answer: Walch B2 glenoid morphology

Explanation:

Question 61:

Options:

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

Correct Answer: a periacetabular osteotomy.

Explanation:

Question 62:

Options:

dorsiflexion osteotomy of the first metatarsal with peroneus longus to brevis transfer.
plantar fasciotomy with dorsiflexion osteotomy of the first metatarsal and calcaneal osteotomy.
a stretching and strengthening physical therapy program and accommodative inserts.
observation.
calcaneal osteotomy, dorsiflexion osteotomy of the first metatarsal, peroneus longus to brevis transfer, plantar fascia release, Achilles tendon lengthening, and midfoot osteotomy.

Correct Answer: a stretching and strengthening physical therapy program and accommodative inserts.

Explanation:

Question 63:

Options:

revision in situ pinning and application of a cast.
hip fusion.
curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.
non-weight-bearing on the affected side and electrical stimulation of the fracture site.
vascularized fibula grafting and application of a cast.

Correct Answer: curettage of the nonunion, intertrochanteric valgus osteotomy, and revision internal fixation.

Explanation:

Question 64:

Options:

C5 and C6 spinal roots
Superior trunk
Anterior division of the inferior trunk
Posterior cord
Lateral and posterior cords

Correct Answer: Posterior cord

Explanation:

Question 65:

Options:

transcutaneous electrical stimulation and a lumbar corset.
transforaminal interbody fusion.
posterior instrumented L2-L3 reduction and fusion.
anterior interbody fusion with a cage.
spine extension bracing.

Correct Answer: posterior instrumented L2-L3 reduction and fusion.

Explanation:

Question 66:

Which of the follow scenarios is most likely to be amenable to a complete repair of a massive rotator cuff tear? Review Topic

Options:

year-old woman with rheumatoid arthritis
year-old man with a tear associated with an anterior shoulder dislocation
year-old man who underwent repair of an ipsilateral rotator cuff 3 years ago
year-old male laborer with superior humeral migration on radiographs
year-old woman with muscular atrophy noted in the supraspinatus fossa

Correct Answer: year-old man with a tear associated with an anterior shoulder dislocation

Explanation:

Question 67:

Options:

Electromyography
MRI of the shoulder joint
MRI of the brain
Radiograph of the elbow
Aspiration of the right shoulder

Correct Answer: MRI of the shoulder joint

Explanation:

DISCUSSION: The child sustained a brachial plexus injury at birth, and internal rotation/adduction contractures frequently develop at the shoulder. Initial treatment should consist of physical therapy to increase the range of motion. If this fails, as in this patient, MRI is used to evaluate the glenohumeral joint. Commonly, there is joint deformity with increased retroversion of the glenoid and even posterior shoulder subluxation. If the deformity is mild, an anterior release, coupled with teres major and latissimus transfers, is very effective. If the deformity is severe and the shoulder is unreconstructable, then humeral derotation osteotomy is the procedure of choice. MRI of the brain, a radiograph of the elbow, and aspiration of the shoulder would not be helpful.
REFERENCES: Waters PM: Update on management of pediatric brachial plexus palsy.
J Pediatr Orthop B 2005;14:233-244.
Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birth palsy. J Bone Joint Surg Am
2005;87:320-325.
Moukoko D, Ezaki M, Wilkes D, et al: Posterior shoulder dislocation in infants with neonatal brachial plexus palsy. J Bone Joint Surg Am 2004;86:787-793.

Question 68:

Figures 6a and 6b are the radiographs of a thin 23-year-old man who sustained a closed injury to his left arm in a fall. He has no other injuries and his

Options:

Intramedullary nailing
Hanging arm cast for 6 weeks
Shoulder immobilizer for 4 to 6 weeks
Open reduction and internal fixation
Coaptation splinting with conversion to a fracture brace

Correct Answer: Coaptation splinting with conversion to a fracture brace

Explanation:

Question 69:

Which of the following best describes the relative content of the components of articular cartilage in decreasing order?

Options:

Water, collagen, proteoglycan, noncollagenous protein, chondrocytes
Water, proteoglycan, collagen, chondrocytes, noncollagenous protein
Water, noncollagenous protein, collagen, proteoglycan, chondrocytes
Collagen, noncollagenous protein, proteoglycan, chondrocytes, water
Collagen, proteoglycan, water, noncollagenous protein, chondrocytes

Correct Answer: Water, collagen, proteoglycan, noncollagenous protein, chondrocytes

Explanation:

Question 70:

Options:

Closed reduction and cast immobilization for 4 weeks, followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 2 weeks after surgery
Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon and humeral fractures, and splint immobilization for 4 weeks followed by therapy directed at regaining motion
Open reduction and internal fixation of the olecranon fracture, functional bracing of the humeral fracture, and therapy directed at regaining motion initiated at 4 weeks after surgery

Correct Answer: Open reduction and internal fixation of the olecranon and humeral fractures, followed by therapy directed at regaining motion

Explanation:

DISCUSSION: The floating elbow is best managed with early open reduction and internal fixation of the humeral and forearm fractures, followed by early range of motion. These fractures predispose the elbow to stiffness, and early range of motion is recommended.
REFERENCES: Solomon HB, Zadnik M, Eglseder WA: A review of outcomes in 18 patients with floating elbow. J Orthop Trauma 2003;17:563-570.
Yokoyama K, Itoman M, Kobayashi A, et al: Functional outcomes of “floating elbow” injuries in adult patients. J Orthop Trauma 1998;12:284-290.

Question 71:

Options:

Gradual return to play
Physical therapy program
Custom orthosis
Non-weight-bearing cast
Weight-bearing AP radiograph

Correct Answer: Weight-bearing AP radiograph

Explanation:

DISCUSSION: Differentiating between a midfoot sprain and Lisfranc diastasis is critical in the management of the athlete with an acute injury to the midfoot. Greater than 2 mm of displacement between the first and second metatarsals on a weight-bearing radiograph is an indication for anatomic reduction with internal fixation of the tarsometatarsal joints. If no subluxation is noted, treatment should consist of a non-weight-bearing cast for 6 weeks, followed by a gradual return
to activity.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.
Chiodo CP, Myerson MS: Developments and advances in the diagnosis and treatment of injuries with the transmetatarsal joint. Orthop Clin North Am 2001;32:11-20.

Question 72:

Options:

Osteosarcoma
Osteochondroma
Ewing’s sarcoma
Chondrosarcoma
Periosteal chondroma

Correct Answer: Osteosarcoma

Explanation:

Question 73:

Options:

Antibiotic coverage for pseudomonas
Tetanus booster
Radiographs of the foot
MRI to evaluate for possible abscess or osteomyelitis
Surgical debridement of the wound

Correct Answer: Radiographs of the foot

Explanation:

Question 74:

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

Options:

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

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

Explanation:

Question 75:

Options:

Wide resection
Curetting and bone grafting
Percutaneous cementation and radiotherapy
Chemotherapy and radiotherapy DISCUSSION.. The imaging (which includes a clear chest CT scan) demonstrates a lytic periacetabular lesion with internal matrix production and a cellular cartilage lesion on histology, diagnostic for a chondrosarcoma with negative staging. Wide excision with limb salvage is appropriate for a lesion without evidence of neurovascular encasement. Although used for select low-grade cartilage lesions in the extremity, curettage is not indicated for pelvic chondrosarcomas. Radiation and chemotherapy are not used in the treatment of conventional chondrosarcoma.

Correct Answer: Wide resection

Question 76:

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Axillary view

Explanation:

DISCUSSION: The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
REFERENCE: Simon JA, Puopolo SM, Capla EL, et al: Accuracy of the axillary projection to determine fracture angulation of the proximal humerus. Orthopedics 2004;27:205-207.

Question 77:

Options:

Lateral collateral ligament
Tibial spine
Medial meniscus
Anterior cruciate ligament (ACL)

Correct Answer: Anterior cruciate ligament (ACL)

Explanation:

Question 78:

Options:

a drink of water.
a sports drink with electrolytes.
placement in the reverse Trendelenburg position in a shaded area.
immersion in a warm water bath.
transportation to the emergency department.

Correct Answer: transportation to the emergency department.

Explanation:

Question 79:

Options:

Hip resurfacing arthroplasty
Hip arthroscopy with removal of the cam lesion
Internal fixation of the femoral neck with multiple screws
Trial of nonsurgical treatment with no weight bearing on the left leg
Vitamin D level assessment and supplementation with 50000 units weekly

Correct Answer: Internal fixation of the femoral neck with multiple screws

Question 80:

Options:

Inflammatory elbow arthritis
A presurgical flexion-extension elbow arc of approximately 50°
Retained distal humerus hardware on presurgical radiographs
Evidence of presurgical elbow instability

Correct Answer: Evidence of presurgical elbow instability

Explanation:

Question 81:

Which muscles are responsible for the displacement of the proximal fragment of the fracture shown in Figure 75?

Options:

Iliopsoas, hip abductors, hip external rotators
Iliopsoas, hip adductors, hip internal rotators
Rectus femoris, hip abductors, hip external rotators
Hamstrings, hip abductors, hip internal rotators

Correct Answer: Iliopsoas, hip abductors, hip external rotators

Explanation:

The radiograph shows a subtrochanteric femoral shaft fracture in a skeletally immature patient. The proximal fragment is displaced into flexion, abduction, and external rotation. Flexion is attributable to the pull of the iliopsoas at the lesser trochanter. Abduction is attributable to the pull of the abductor muscles (gluteus medius and minimus) at the greater trochanter. External rotation is attributable to the pull of the small external rotators, including the piriformis. The majority of the adductor musculature originates on the symphysis pubis and bypasses the proximal femur, inserting further distally on the adductor tubercle. The hamstrings originate on the ischial tuberosity and also bypass the proximal fragment, inserting distally on the proximal tibia and fibula.
(SBQ12TR.39) A 36-year-old male falls from a 10-ft scaffold and suffers the injuries shown in Figures A and B. The patient is placed in a spanning external fixator and brought back to the operating room once his soft tissues are amenable. Planning to use a dual-incision approach, what is the correct interval to use when approaching the medial side?
Popliteus and pes anserine
Lateral head of the gastrocnemius and pes anserine
Politeus and lateral head of the gastrocnemius
Iliotibial band and medial head of the gastrocnemius
Pes anserine and medial head of the gastrocnemius
The posteromedial approach to the tibial plateau is between the the pes anserine tendons and the medial head of the gastrocnemius.
A dual-incision approach is often utilized to optimally place definitive fixation for bicondylar tibial plateau fractures. For fractures that require posterior or posteromedial fixation, the correct interval is between the pes anserine and the medial head of the gastrocnemius.
Higgins et al. in a large cohort morphological review, noted a high incidence of a posteromedial fragment in bicondylar fractures. Occurring at a high frequency, the
authors recommended direct visualization and reduction via a dual approach rather than using indirect reduction techniques.
Falker et al. describes a step-by-step approach to utilizing the posteromedial approach for the tibial plateau and placing an anti-glide plate.
Figure A and B exhibit a bicondylar tibial plateau fracture with a posteromedial fragment noted on the lateral x-ray. Illustration A exhibits the surrounding anatomy and interval in between the medial head of the gastrocnemius and the pes anserine.
Incorrect answers:

Question 82:

Options:

Platelet-rich plasma
Physical therapy
Lateral epicondyle debridement
Lateral collateral ligament reconstruction

Correct Answer: Lateral collateral ligament reconstruction

Explanation:

Question 83:

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Options:

Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness
Increased AGES is characteristic of osteoarthritis and results in increased articular cartilage stiffness
Increased AGES is characteristic of unresurfaced patellar cartilage after total knee arthroplasty and results in articular cartilage thinning
Increased AGES is characteristic of rheumatoid arthritis and results in synovial thickening
Increased AGES is characteristic hemarthrosis and results in articular cartilage staining

Correct Answer: Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness

Explanation:

Question 84:

- Which of the following nerves supply the muscles on each side of internervous plane identified when performing the anterior (Smith-Petersen) approach to the hip?

Options:

Femoral and obturator nerves
Femoral and superior gluteal nerves
Femoral and lateral femoral cutaneous nerves
Obturator and superior gluteal nerves
Obturator and lateral femoral cutaneous nerves

Correct Answer: Femoral and superior gluteal nerves

Explanation:

Question 85:

Which of the following hip fracture patterns is at increased risk of proximal fragment flexion malreduction with dynamic hip screw fixation?

Options:

Right-sided unstable intertrochanteric fracture
Left-sided unstable intertrochanteric fracture
Left-sided stable intertrochanteric fracture
Right-sided stable intertrochanteric fracture
All unstable intertrochanteric fractures

Correct Answer: Right-sided unstable intertrochanteric fracture

Explanation:

Question 86:

Options:

serial injection of steroids into the area of discomfort.
custom orthotics with a second metatarsal pad.
physical therapy for transcutaneous electrical nerve stimulation and desensitization.
plantar condylectomy of the second and third metatarsal heads.
plantar exploration and revision neurectomy to a more proximal level.

Correct Answer: plantar exploration and revision neurectomy to a more proximal level.

Explanation:

Question 87:

What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?

Options:

Tension band plating
Antiglide plating
Bridge plating
Neutralization plating
Submuscular plating

Correct Answer: Tension band plating

Explanation:

Question 88:

Options:

Elevate leg on pillows
Administer IV morphine
Observation of the patient
Bivalve and spread the cast
Apply ice to the lower extremity

Correct Answer: Administer IV morphine

Explanation:

The patient appears to have some indications of a compartment syndrome: increasing pain and signs of nerve compression. Tibia fractures also should heighten the suspicion for a compartment syndrome. Two basic mechanisms of compartment syndrome are that an increase in volume occurs in an enclosed space or there is a decrease in size of the space. In this situation, both are likely occurring; post-fracture swelling is occurring within a closed space and if a cast is in place that may constrict the space even more. One way to increase the available space for swelling would be to bivalve and spread the cast. If the extremity has been casted, then it is vitally important that the cast is bivalved and the surrounding soft dressings under the cast be removed so that all external compression of the compartment has been eliminated. In the face of compartment syndrome, elevation of the limb, masking the pain with morphine, application of ice, or observation alone are all inappropriate.
(SBQ12TR.88) When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?
A fracture of the radial head requiring ORIF
A highly comminuted radial head fracture requiring radial head arthroplasty or resection
An MCL injury requiring repair
A type I avulsion fracture of the coronoid
An anteromedial coronoid fracture
A varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.
A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.
Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.
Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.
Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.
Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture. Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]
Incorrect answers:
(SBQ12TR.78) A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure A. What would be the most appropriate treatment for this patient at this time?
Review
Topic
Observation only
Referral to physiotherapy
MRI spine and hip
Total hip arthroplasty
Intramedullary femoral nail
This osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.
Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.
Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.
Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.
Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.
Incorrect Answers

Question 89:

Options:

Sural nerve injury
Tethering of the flexor hallucis longus by fracture fragments
Medial plantar nerve neuropathy
Weakness of the tibialis posterior
Unrecognized foot compartment syndrome

Correct Answer: Sural nerve injury

Explanation:

Question 90:

Options:

Open reduction and internal fixation (ORIF) of the fracture
Remove the current stem, femur ORIF, and insertion of a longer revision stem
Femur ORIF with cables and strut graft, leaving the current stem in situ
Femur ORIF combined reimplantation of the primary component

Correct Answer: Remove the current stem, femur ORIF, and insertion of a longer revision stem

Explanation:

Question 91:

Following resection of malignant tumors, complications related to endoprosthetic reconstruction are most common in what anatomic location?

Options:

Proximal femur
Proximal humerus
Proximal tibia
Distal femur
Distal humerus

Correct Answer: Proximal tibia

Explanation:

Question 92:

Hamstring lengthening and posterior transfer of the rectus femoris will be most successful in a patient with cerebral palsy who has which of the following gait abnormalities?

Options:

Excessive knee flexion through stance, stiff knee during swing, and rectus femoris activity in swing
Excessive knee flexion through stance and continuous quadricep activity in stance and swing
Excessive knee flexion through stance, short stride length, and continuous hamstring activity in swing
Knee hyperextension in stance, knee extension during swing, and rectus femoris activity in swing
Knee hyperextension in stance, continuous rectus femoris activity in stance and swing, and drop foot

Correct Answer: Excessive knee flexion through stance, stiff knee during swing, and rectus femoris activity in swing

Explanation:

Question 93:

Options:

Continued bracing
Direct ligamentous repair
Arthroscopic electrothermal capsular and ligamentous shrinkage
Isolated plication of the capsule and ligaments
Free tendon graft reconstruction with capsuloligamentous plication

Correct Answer: Free tendon graft reconstruction with capsuloligamentous plication

Explanation:

Question 94:

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 95:

An 83-year-old man has a painful mass of the great toe. Radiographs and a biopsy specimen are seen in Figures 22a and 22b. What is the most likely diagnosis?

Options:

Gout
Pseudogout
Infection
Epidermal inclusion cyst
Charcot joint

Correct Answer: Gout

Explanation:

Question 96:

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

Options:

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

Correct Answer: Transverse

Explanation:

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

Question 97:

A patient with a transverse femur fracture undergoes statically locked antegrade intramedullary nailing. Postoperatively, the patient appears to have a

Options:

Settle the case because the surgeon made an error that resulted in unnecessary surgery, and thus the case is indefensible.
Settle the case because they are likely to lose the case, and it would be cheaper to settle than to defend.
Defend the case alleging that there was no error, and no damages, and that the patient is malingering.
Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.
Contact the patient directly to discuss why he is suing and attempt an amicable resolution.

Correct Answer: Defend the case because despite there being an error, the error was corrected and there were little or no damages compared with expected outcomes.

Explanation:

Question 98:

Options:

custom orthotics.
a below-knee non-weight-bearing cast.
exploration and resection of the calcaneocuboid joint.
exploration and resection of the talocalcaneal joint.
triple arthrodesis.

Correct Answer: triple arthrodesis.

Explanation:

Question 99:

Options:

Debulking
Wide resection with vascular and nerve grafting
Above-elbow amputation
Chemotherapy
Radiation therapy

Correct Answer: Chemotherapy

Explanation:

Question 100:

Options:

Bed rest for 6 weeks, followed by mobilization in a thoracolumbosacral orthosis until the fracture has healed
Anterior corpectomy with strut grafting and placement of an anterior plate spanning L1 to L3
Anterior corpectomy with strut grafting, followed by posterior spinal fusion and instrumentation
Posterior spinal fusion and instrumentation from T11 to L4
L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Correct Answer: L2 laminectomy and posterior spinal fusion and instrumentation from T11 to L4

Explanation:

DISCUSSION: The patient has a burst fracture with probable unilateral entrapment of the cauda equina within the elements of the fractured lamina. A dural tear is likely in this scenario as well. It is recommended that this type of burst fracture be treated surgically with laminectomy, freeing of the entrapped nerve roots, and dural repair followed by stabilization of the fracture by either a posterior or combined approach. The degree of kyphosis and the extent of anterior canal compromise does not warrant corpectomy in this patient. Therefore, after completing the laminectomy and dural repair, posterior fusion and instrumentation should be sufficient to stabilize the fracture.
REFERENCES: Cammisa FP Jr, Eismont FJ, Green BA: Dural laceration occurring with burst fractures and associated laminar fractures. J Bone Joint Surg Am 1989;71:1044-1052.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

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

Orthopedic Board Exam MCQs: Trauma, Shoulder, Elbow, & Hip | Part 154

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 154

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index