Orthopedic Board Exam MCQs: Arthroplasty & Trauma Practice | Part 156

Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of

A 51-year-old man sustained an open fracture of his tibia in Korea 42 years ago. An infection developed and it was resolved with surgical treatment. For the past 6 months, an ulcer with mild drainage has developed over the medial tibia. The ulcer is small and there is minimal erythema at the ulcer site. A radiograph and MRI scan are shown in Figures 43a and Figure 43b. Initial cultures show Staphylococcus aureus susceptible to the most appropriate antibiotics. Laboratory studies show an erythrocyte sedimentation rate of 70 mm/h. What is the most appropriate surgical treatment at this time?

Serum phosphate levels are high. Tumoral calcinosis is a heritable condition that is characterized by periarticular metastatic calcification. Most patients are black, and the inheritance is usually autosomal recessive. Metastatic calcifications occur around joints and in the skin, marrow, teeth, and blood vessels. The periarticular masses may grow quite large and are attached to the fascia, but they are extra-articular. The masses may occur at the shoulder, hip, and elbow. Radiographically: The masses are composed of heavy, amorphous calcification in nodules. Laboratory:

-Where is the physis with the highest growth rate (in mm per year) located?

If a surgeon inadvertently burrs through the midlateral wall of C5 during a anterior corpectomy, what structure is at greatest risk for injury? Review Topic

Which of the following diagnostic studies best distinguishes Ewing’s sarcoma from small cell osteosarcoma?

The photomicrograph seen in Figure 41 shows which of the following conditions?

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

A 23-year-old student complains of recurrent left shoulder instability. He first dislocated his shoulder in high school while playing lacrosse and was managed with physical therapy. A second dislocation occurred one year later while skiing. He has since sustained two more dislocations and says that his shoulder feels “loose.” Examination reveals grade II anterior load and shift, positive apprehension and relocation tests, and normal rotator cuff strength. An MRI arthrogram is ordered and surgical treatment is recommended. What factor would most strongly represent an indication for a procedure including bone augmentation (e.g. Latarjet) rather than a soft-tissue-only stabilization (isolated labral repair/capsulorrhaphy)?

A 67-year-old man with right shoulder osteoarthritis (OA) remains symptomatic despite a course of nonsurgical treatment. A CT scan of the shoulder shows eccentric posterior glenoid wear with 10° of retroversion. What is the appropriate management of this glenoid bone loss during surgery for an anatomic total shoulder arthroplasty?

A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of the bone fragment and returns to play football the following year. He has a recurrent dislocation at football practice but decides to finish the football season before considering additional treatment. He sustains nine additional dislocations, with the last dislocation occurring while sleeping.What diagnostic test is most appropriate when planning revision surgery?

Which of the following factors is associated with the worst prognosis in soft-tissue sarcomas?

A baseball player reports a dull pain in the posterior aspect of his throwing arm. Examination reveals decreased internal rotation and prominence of the inferomedial corner of the scapula. An MRI scan suggests a partial-thickness tear of the posterior supraspinatus tendon. Successful treatment would most likely include which of the following? Review Topic

Polyethylene wear of the bearing surface has been recognized as a mode of failure in total knee arthroplasty; therefore, many patients are offered polyethylene exchange. In terms of success rates, this surgical procedure has been reported to have a

A 12-year-old girl has had progressive left knee pain for the past 4 months. She reports that the pain is unrelated to activity, and she has no history of fever or recent infections. Examination reveals full range of motion of the knee but tenderness along the medial joint line. Plain radiographs and MRI scans are shown in Figures 39a through 39d. A biopsy specimen of the lesion is shown in Figure 39e. Treatment should include

-Figure 235 is the radiograph of a 75-year-old woman who is seen in the emergency department following a low-energy fall. What is the most appropriate treatment based on her radiographic findings?

-Assuming that the lesion can be covered appropriately and there is no drainage from the lesion, when should the patient be allowed to safely return to wrestling?

A 75-year-old woman undergoes hybrid total hip arthroplasty for osteoarthritis. A postoperative radiograph obtained in the recovery room is shown in Figure 18. Treatment should now consist of

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Which of the following factors is most critical to the success of a meniscal allograft transplantation?

Osteoarthritic cartilage is characterized by decreased

Figure 21 shows the radiograph of an 18-year-old man who was brought to the emergency department with shoulder pain following a rollover accident on an all-terrain vehicle. Examination reveals a fracture with massive swelling; however, the skin is intact and not tented over the fracture. Based on these findings, initial management should consist of

Figure 38 shows the radiograph of a 75-year-old woman who has had right shoulder pain, difficulty sleeping on the affected arm, and difficulties performing activities of daily living for the past 6 weeks. Initial nonsurgical management includes analgesics, a subacromial cortisone injection, and gentle range-of-motion exercises. However, these modalities have failed to provide relief, and the patient reports that she is unable to elevate her arm. Her pain is worse and she would like the most reliable treatment method for pain relief and functional improvement. What is the best surgical treatment?

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

The diagnosis of an infection after total knee arthroplasty is most reliably proven based on what single study?

A 72-year-old female presents to your office with a 24-month old painful nonunion of a 3-part fracture of the proximal humerus. She has been treated conservatively with range of motion exercises but continues to complain of debilitating pain and dysfunction. Operative management should include:

An 18-year-old football player has intense pain and is unable to bear weight on the right knee after being tackled from the front. A posterior knee dislocation is reduced on the field. Because the game took place in a remote location, the patient is not examined in the emergency department until 5 hours after the injury. Examination now shows a grossly swollen knee with moderate ischemia in the lower leg. Posterior tibial and dorsalis pedis pulses are diminished. The best course of action should be to

Which of the following is helpful on physical examination to diagnose a fixed posterior shoulder dislocation? Review Topic

0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C). What is the most appropriate management for the femoral shaft fracture at this point?

A 37-year-old man has had isolated chronic knee swelling for the past 6 months. He denies any history of specific trauma. Examination reveals a large effusion with a stable knee, but the remainder of the examination is normal. Plain radiographs are unremarkable. An MRI scan reveals a large effusion without meniscal injury. An arthroscopic image of the suprapatellar pouch is shown in Figure 23. What is the most likely diagnosis?

A 70-year-old man undergoes removal of an infected total hip arthroplasty (THA) and insertion of an articulating antibiotic-loaded spacer to treat a deep periprosthetic hip infection. While in a nursing home receiving intravenous antibiotics 3 weeks after surgery, the patient trips and falls. Examination reveals swelling in the mid and distal thigh, intact skin and neurovascular structures, and severe pain with knee or hip movement. Radiographs of the femur are shown in Figures 1 through 4. What is the most appropriate treatment for the fracture below the implant?

The most appropriate next surgical procedure is

A 35-year-old male sustains a posterior column/posterior wall acetabular fracture. Which of the following is the preferred approach for open treatment of this injury?

Figure 16 shows the radiograph of a 75-year-old man who has progressive groin pain and a limp following total hip replacement. At revision surgery, the anterior and posterior columns of the acetabulum are noted to be intact. The optimal surgical technique for acetabular component reconstruction is a

What clinical finding is associated with the least favorable prognosis in an adolescent patient who has been diagnosed with a high-grade osteosarcoma of the distal femur?

• A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include

A 75-year-old woman who sustained a fall now reports neck pain and upper extremity weakness. Examination reveals 4 of 5 strength in the upper extremities and 5 of 5 strength in the lower extremities. Radiographs show multilevel degenerative disk disease. An MRI scan is shown in Figure 96. Her clinical presentation is most compatible with which of the following? Review Topic

A teenage female is referred to you for evaluation of curvature in her back that was discovered on routine school screening. She is diagnosed with adolescent idiopathic scoliosis. In which of the following scenarios is a bracing program the most appropriate treatment? Review Topic

All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:

A researcher is working on Medication A, a drug FDA-approved for the treatment of osteoporosis in men and women. It is an anti-resorptive agent that inhibits the formation, function and survival of osteoclasts. It does not bind to calcium hydroxyapatite. At 1-year after the initial dose, tissue levels are non-detectable. It can be used in the presence of cancer metastases to bone. What is Medication A? Review Topic

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

What is the prognosis for ambulation, from best to worst, for patients with an incomplete spinal cord injury?

Clinical studies on the use of topical and intravenous (IV) forms of tranexamic acid (TXA) administration demonstrate which results?

-What is the diagnosis?

A right-handed 44-year-old construction worker reports pain and limited range of motion in his right elbow that has limited his ability to work for the past year. Examination reveals range of motion from 60 to 90 degrees, and he has pain at the extremes of flexion and extension. Pronation and supination are minimally restricted. Anti-inflammatory drugs have failed to provide relief. A radiograph is shown in Figure 8. Management should now consist of

What percent of patients initially diagnosed with classic, high-grade osteosarcoma of the extremity have visible evidence of pulmonary metastasis on CT of the chest?

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

Figure 68 shows the MRI scan of a 13-year-old boy who has had knee pain and swelling following training lessons for ski racing for the past 6 months. The only abnormal finding on physical examination is an effusion. Management should consist of

In a patient with a soft-tissue sarcoma treated by wide excision and radiation therapy, the risk of subsequent fracture is probably most influenced by

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

A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of

A 73-year-old man who underwent repair of the left rotator cuff 6 years ago reports good pain relief but notes residual weakness of the left shoulder, especially with overhead tasks. He denies having pain at night and has minimal discomfort with activities of daily living but is dissatisfied with his shoulder strength. Radiographs show an acromiohumeral interval of 2 mm. Appropriate management should consist of

What is the most important feature in choosing an outcome instrument to assess shoulder disorders?

A 45-year-old man with a painful varus knee is being considered for an upper tibial osteotomy. Which of the following factors is considered the most compelling argument against this procedure?

Figures 38a and 38b

A 2-day-old infant has the hyperextended knee deformity shown in Figure 7. No other deformities are found on examination. A radiograph shows that the ossified portion of the proximal tibia is slightly anterior to that of the distal femur. Management should consist of

During establishment of an anterior portal for hip arthroscopy, what structure is at greatest risk for injury? Review Topic

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

The postoperative neurologic prognosis of a patient who has a tumor that is compressing the spinal cord and causing a neurologic deficit depends primarily on the

A 77-year-old man with diabetes mellitus has had a nonhealing Wagner grade I ulcer under the medial sesamoid for the past 3 months. He smokes tobacco regularly. He has undergone several debridements and total contact casting. Examination reveals no palpable pulses. He has no erythema or purulence, and he is afebrile. Radiographs reveal no abnormalities. What is the best initial diagnostic test to help determine why the ulcer has failed to heal?

An 8-year-old sustains the injury shown in Figures A and B. Postoperative radiographs are shown in Figures C and D. After cast removal and in-office k-wire removal, elbow range of motion is found to be between 20-80 degrees of flexion. How soon after surgery is range of motion expected to be >90% of normal? Review Topic

An osteoconductive bone graft material has which of the following properties?

A 10-year-old girl has been unable to walk for the past 5 days because of bilateral hip pain. Administration of IV morphine has provided some pain relief. She is afebrile. History reveals that she had an upper respiratory tract infection 3 weeks ago that resolved uneventfully. Examination reveals moderate pain with internal rotation and abduction, while log rolling maneuvers do not cause significant pain. An MRI scan shows a small effusion of one hip; however, a bone scan and plain radiographs are normal. Initial laboratory studies showed a markedly elevated WBC count, which subsequently declined to normal levels with IV antibiotics. Current studies show an erythrocyte sedimentation rate (ESR) of 100 mm/h. Aspiration of the hip obtains 3 mL of fluid; Gram stain is negative for bacteria, but a cell count shows a WBC count of 16,500/mm 3 . Streptozyme titer of the peripheral blood is 200 units (normal is less than 100 units). Management should now consist of

Of the following variables, which has the strongest influence on external fixator stiffness?

Figure 17 shows the radiograph of an 11-year-old boy with Duchenne muscular dystrophy who has been nonambulatory for the past 2 years. Management of the spinal deformity should consist of

A 48-year-old woman reports bilateral thigh pain that is limiting her function as a librarian. A radiograph and a bone scan are shown in Figures 23a and 23b. What is the most likely diagnosis?

Benign Ethnic Neutropenia is more common in males.

• The Injury Severity Score (ISS), using point scores from five different body systems, is a method that aids in predicting the chances of mortality in a patient with multiple injuries by

Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury. History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture. Management should consist of

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

All of the following are characteristic of end-stage septic shock EXCEPT?

Figure 56 is the radiograph of an otherwise healthy 3-year-old boy who fell and sustained the isolated injury shown. What is the best treatment modality?

What mechanism of injury is most likely to cause a fracture of the anteromedial facet of the coronoid?

006%-3.4 %. The typical skin flora includes staph and strep as well as P. acnes, which has a propensity for the shoulder. Because it is an anaerobic organism, cultures may only become positive after 7-21 days.

Gaucher’s disease is manifested by reticuloendothelial system macrophage accumulation of

• Which of the following surgical approaches to the hip is associated with the highest incidence of heterotopic ossification?

..First-line treatment recommendations include

An 8-year-old boy reports ankle pain after striking the ground with the medial aspect of his foot while attempting to kick a soccer ball. Radiographs reveal slight distal tibial physeal widening but no other abnormalities. In treating this injury, which of the following associated conditions is most likely present but may be missed without careful evaluation?

A 40-year-old woman has a symptomatic mass on the anterior aspect of the ankle. She reports no constitutional symptoms. An MRI scan is shown in Figure 12. What is the most likely diagnosis?

A B Figures 82a and 82b are the clinical photograph and radiograph of a 60-year-old man with a 30-year history of diabetes complicated by borderline chronic renal failure, heart failure controlled by medication, and bilateral lower extremity neuropathy. He is currently wheelchair bound because of his cardiopulmonary limitations, but uses his legs for transfers. He has had a progressive left ankle deformity that has progressed to the point at which he cannot use his leg for pivot transfers. He is adamant that something should be done to improve his living situation. Which surgical option can best achieve his goal of using the leg for transfers?

A 6-year-old boy is being treated for acute hematogeneous osteomyelitis of the distal femur with intravenous antibiotics. The best method to determine the success or failure of initial treatment is by serial evaluations of which of the following studies?

A 72-year-old active man has shoulder pain after undergoing an explantation of an anatomic shoulder arthroplasty 6 months prior with an antibiotic cement spacer placed. The patient has 60° of forward flexion, 40° of external rotation, and a positive belly press with limited internal rotation. A recent work-up for continued infection is negative, and a follow-up MRI reveals grade 2 atrophy of the supraspinatus and grade 3 atrophy of the subscapularis with tendon retraction to the glenoid rim. What is the best next step in definitive management?

A 54-year-old man undergoes uneventful anterior cervical diskectomy and interbody fusion at C4-5 for focal disk herniation and C5 radiculopathy. At the 3-week follow-up examination, the patient reports a persistent cough. Pulmonary evaluation reveals a mild but persistent aspiration. Laryngoscopy reveals partial paralysis of the left vocal cord, most likely caused by

The primary function of structure “A” in Figure 29 is to limit

What is the most frequent complication following primary total hip arthroplasty?

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

Patients who sustain bilateral femoral shaft fractures when compared to unilateral femur fractures have higher rates of the following EXCEPT:

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

Delayed-onset muscle soreness (DOMS) is initially evident at the muscle tendon junction and can spread throughout the entire muscle. It is primarily associated with what type of exercise? Review Topic

What neurovascular structure is at greatest risk when creating a proximal anterolateral elbow arthroscopy portal? Review Topic

A 35-year-old man is brought to the emergency department following a motorcycle accident. He is breathing spontaneously and has a systolic blood pressure of 80 mm Hg, a pulse rate of 120/min, and a temperature of 98.6° F (37° C). Examination suggests an unstable pelvic fracture; AP radiographs confirm an open book injury with vertical displacement on the left side. Ultrasound evaluation of the abdomen is negative. Despite administration of 4 L of normal saline solution, he still has a systolic pressure of 90 mm Hg and a pulse rate of 110. Urine output has been about 20 mL since arrival 35 minutes ago. What is the next best course of action?

An otherwise healthy 78-year-old woman has low back and buttock pain. Rectal examination reveals a large sacral mass. Figures 7a and 7b show a CT scan and a sagittal MRI scan of the lumbosacral spine. A biopsy specimen is shown in Figure 7c. What is the most likely diagnosis?

-Figures a and b are the posteroanterior and lateral radiographs of a 13-year-old girl with a progressive curve despite bracing with a thoracolumbosacral orthosis. Examination reveals no pain or neurologic findings. The lumbar curve measures 59 degrees and the thoracic curve measures 52 degrees.The most appropriate treatment is