OITE & ABOS Orthopedic Board MCQs: Fracture & Shoulder

About This Board Review Set

This is Part 158 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

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

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

Topics Covered in Part 158

This module focuses heavily on: Fracture, Shoulder.

Sample Questions from This Set

Sample Question 1: Examination of a 10-year-old girl with a hypoplastic breast and atrophic pectoralis major may also reveal which of the following findings?...

Sample Question 2: -A patient has a noncomminuted displaced fracture of the radial head with a distal radioulnar dissociation. What is the most appropriate treatment for the radial head?...

Sample Question 3: A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his sho...

Sample Question 4: Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?...

Sample Question 5: An investigation studying whether physical therapy or subacromial injection can be successfully used to treat shoulder pain is conducted. Two groups are identified. One group is prescribed physical therapy, while the other receives a subacr...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

00:00

Start Quiz

Question 1

Examination of a 10-year-old girl with a hypoplastic breast and atrophic pectoralis major may also reveal which of the following findings?

Explanation

DISCUSSION: Poland’s syndrome has four main features: 1) short digits as the result of absence or shortening of the middle phalanx; 2) syndactyly of the short digits usually consisting of a simple, complete type; 3) hypoplasia of the hand and forearm; and 4) absence of the sternocostal head of the pectoralis major on the same side.
REFERENCES: Wilson MR, Louis DS, Stevenson TR: Poland’s syndrome: Variable expression and associated anomalies. J Hand Surg 1988;13:880-882.
Poland A: Deficiency of the pectoralis muscle. Guys Hosp Rep 1841;6:191.

Question 2

A patient has a noncomminuted displaced fracture of the radial head with a distal radioulnar dissociation. What is the most appropriate treatment for the radial head?

Explanation

This is a rare injury, and it is important to recognize both the proximal and distal concurrent injuries. In the past, the radial head excision has been the primary form of treatment, but this has shown poor long-term results; silicone replacement has been fraught with reactive synovitis. Radial ulnar synostosis is a complication, not a planned course of treatment.

Question 3

A 30-year-old man underwent an open Bankart repair with capsulorrhaphy for recurrent anterior instability 6 months ago. In a recent fall, he described a hyperabduction and external rotation mechanism of injury. He denies dislocating his shoulder. He now has anterior shoulder pain, weakness, and the sensation of instability. Examination reveals tenderness just lateral to the coracoid and bicipital groove. An MRI scan is shown in Figure 31. Management should now consist of

Explanation

DISCUSSION: Subscapularis tendon tears are being recognized with increasing frequency, and the mechanism of injury involves hyperabduction and external rotation. The patient will have anterior shoulder pain and may report a sensation of instability. Examination will reveal anterior shoulder tenderness over the lesser tuberosity and bicipital groove, and the Gerber lift-off test usually is positive. The MRI scan shown here reveals an intact anterior labrum. The subscapularis tendon is avulsed and retracted, with no evidence of the biceps tendon within the groove; this implies dislocation of the biceps, a common accompanying feature of a subscapularis tear. This injury is also recognized as a complication after open anterior shoulder stabilizations where the subscapularis has been incised as part of the approach. Therefore, the appropriate management involves repair of the subscapularis. The injury does not represent a recurrence so immobilization or revision stabilization, which may be reasonable treatment for recurrent instability, is not indicated. The findings are not consistent with a superior labral tear.
REFERENCES: Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 1997;25:13-22.
Gerber C, et al: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 1996;78:1015-1023.

Question 4

Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?

Explanation

DISCUSSION: The sagittal image reveals increased signal and decreased size of the supraspinatus and infraspinatus muscles, indicating muscle atrophy. The rotator cuff tendon signal is normal. The subscapularis and teres minor muscles are unaffected. Muscular dystrophy and thoracic outlet syndrome would be expected to have a more global effect. Although muscular atrophy can occur in the setting of a rotator cuff tear, the coronal image shows an intact supraspinatus. The suprascapular nerve supplies the supraspinatus and infraspinatus muscles. Therefore, suprascapular nerve entrapment would result in atrophy of these muscles with sparing of the surrounding musculature. Any lesion within the suprascapular notch, including neoplastic disease, a venous varix, or neuroma, can place pressure on the suprascapular nerve. Suprascapular nerve entrapment most commonly results from extension of a paralabral cyst or ganglion, often with associated labral pathology. Spinal accessory nerve disruption would show trapezius muscle atrophy.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangement of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 308-317.
El-Khoury G: MRI of the Musculoskeletal System. Philadelphia, PA, JB Lippincott, 1998, p 123.

Question 5

An investigation studying whether physical therapy or subacromial injection can be successfully used to treat shoulder pain is conducted. Two groups are identified. One group is prescribed physical therapy, while the other receives a subacromial injection. The groups have similar baseline demographics and shoulder pathologies. Ten patients are randomized in each group and findings show that there is no significant difference in any patient-reported outcome measure. An increase in sample size would reduce the risk of what parameter?

Explanation

A football player injures his knee when he is tackled and falls awkwardly. He does not note any discreet “pop,” but pain prevents him from returning to the game. An effusion is noted the following day and an MRI scan is ordered. Selected images are shown in Figures 1 through 3. Based on these images, physical examination findings likely include

Question 6

CLINICAL SITUATION Figures 1 and 2 are the radiographs of a 35-year-old man who is brought into the emergency department after a motor vehicle collision. He is complaining of isolated knee pain. Examination reveals swelling, blood filled blisters, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. Figures 3 through 8 are the axial and sagittal CT scan sections of the injury. Intra-operative patient positioning for definitive fixation should be

Explanation

Discussion: Posterior partial articular tibial plateau fractures are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the lateral radiograph include maintenance of continuity between the anterior articular surface and tibial shaft along with subluxation of the knee joint with excessively anterior tibial station (the
femoral condyles remain with the fractured posterior articular pieces while the remainder of the tibia subluxes anteriorly).
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Attempting to visualize, reduce, and stabilize a posterior partial articular pattern in the supine position from an anterior approach is fraught with difficulties. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

Question 7

A 23-year-old woman has had a 14-month history of ankle pain after surgical treatment of multiple injuries resulting from a motor vehicle accident. Weight bearing began 4 months after surgery. The pain occurs with weight bearing and motion, but there is very little pain at rest. She has no pertinent medical history and does not smoke. Figures 23a and 23b show current radiographs. What is the most appropriate surgical option?

Explanation

The radiographs reveal nonunion of a talar neck fracture. There is no radiographic evidence of osteonecrosis or significant degenerative arthritis. The results of talectomy are suboptimal. Arthrodesis would be indicated for degenerative arthritis. Revision ORIF is feasible and preserves motion. A vascularized graft should be considered whenever osteonecrosis is present, but the talar body appears viable in this case.

Question 8

If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be

Explanation

DISCUSSION
The treatment of thoracolumbar burst fractures has evolved over the years. In the absence of a neurologic deficit or a posterior ligamentous complex injury, nonsurgical treatment is as effective as surgery. The degree of spinal canal compromise is not a risk factor for neurologic symptoms. Similarly, although kyphosis may be a marker of more significant injury, the degree of kyphosis does not correlate with chronic pain. In the setting of a burst fracture, MRI can be used to evaluate the integrity of the posterior ligamentous complex. Polytrauma may be considered a relative indication for surgical intervention in the setting of a stable burst fracture.
RECOMMENDED READINGS
Rechtine GR 2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S22-7; discussion S36. Review. PubMed PMID: 16685232. View Abstract at PubMed
Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine (Phila Pa 1976). 1999 Feb 15;24(4):412-5. PubMed PMID: 10065527. View Abstract at PubMed
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024. View Abstract at PubMed
Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. doi: 10.1016/j.spinee.2012.10.041. Review. PubMed PMID: 24332321.View Abstract at PubMed

Question 9

The patient experiences little improvement with activity modification and more physical therapy. An intra-articular corticosteroid injection provides excellent relief, but relief only lasts for 1 month. The player requests further treatment for his hip and is counseled regarding surgical intervention. Hip arthroscopy is performed. Intrasurgically, a capsulolabral separation is observed with an underlying pincer lesion. No articular cartilage injury is seen. Which treatment is most appropriate considering these findings?

Explanation

DISCUSSION

Video 67 for reference
This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown.
The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. An ultrasound may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasound is not commonly used to diagnose labral pathology.
Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 10

A 25-year-old man is unresponsive at the scene of a high-speed motor vehicle accident and remains obtunded. Initial evaluation in the emergency department reveals a left-sided femoral shaft fracture and a right-sided humeral shaft fracture. The cervical spine remains immobilized in a semi-rigid cervical collar, and the initial AP and lateral radiographs obtained in the emergency department are unremarkable. What is the most appropriate management at this time?

Explanation

DISCUSSION: Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity.
REFERENCES: Chiu WC, Haan JM, Cushing BM, et al: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome. J Trauma 2001;50:457-463.
Sanchez B, Waxman K, Jones T, et al: Cervical spine clearance in blunt trauma: Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179-183.
Nunez D Jr: Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries:

A prospective study. J Trauma 2000;48:988-989.

Question 11

A 36-year-old softball player sustains a shoulder dislocation making a diving catch. The shoulder is successfully reduced in the emergency department. A postreduction MRI is shown in Figure 35. What anatomic lesion is a result of the dislocation? Review Topic

Explanation

The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.

Question 12

A collegiate football player who sustained a blow to the head during the first quarter of a game is confused for several minutes after the hit but does not lose consciousness. He had two similar episodes in games earlier in the season. When should he be allowed to return to play?

Explanation

DISCUSSION: Using the traditional concussion grading scale, the patient sustained a grade I concussion because he did not lose consciousness and his abnormal cognitive level lasted less than 1 hour. If this was the player’s first concussion, theoretically he could return to play later in the game provided that he had no confusion, headache, or associated symptoms. However, because it was the third concussion for the year, participation in contact sports should be terminated for the season.
REFERENCES: Guskiewwicz KM, Barth JT: Head injuries, in Schenk RC Jr (ed): Athletic Training and Sports Medicine. Rosemont, IL, American Academy of Orthopedic Surgeons, 1999, pp 143-167.
Kelly JP, Rosenberg JH: Diagnosis and management of concussion in sports. Neurology 1997;48:575-580.

Question 13

A 35-year-old man reports the development of a painful 2-cm nodule on his dorsal wrist over the past 3 years. A surgeon excised the lesion with a presumptive diagnosis of a ganglion cyst. Histology sections from the excision are shown in Figures 11a and 11b. What is the most likely diagnosis?

Explanation

DISCUSSION: The histologic appearance of the soft-tissue lesion reveals compact nests of cells with a clear cytoplasm surrounded by a delicate border of fibrocollagenous tissue. There can be scattered multinucleated giant cells. This is consistent with a clear cell sarcoma, also called malignant melanoma of soft parts. This tumor is usually positive for S-100 and HMB45 (a melanoma-associated antigen). These tumors are frequently found around the foot and ankle. Similar to epithelioid sarcoma, it is usually intimately bound to tendons or tendon sheaths. Often the tumors are present for many years. The classic histologic appearance of this lesion differentiates it from the other choices.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 913.
Lucas DR, Nascimento AG, Sim FH: Clear cell sarcoma of soft tissues: Mayo Clinic experience with 35 cases. Am J Surg Pathol 1992;16:1197-1204.

Question 14

A 53-year-old man with insulin-dependent diabetes has the ulcer on his heel shown in Figure 9. Radiographs and an MRI scan are consistent with osteomyelitis of the calcaeus, contiguous with the ulcer itself. Arterial flow to the foot is adequate. Management should consist of

Explanation

Smith looked at 12 pts (7 pts with DM) with a large ulcer and osteomyelitis of the calcaneus all treated with a partial calcanectomy. All pts had an ABI >.45, Transcutaneous P02 > 28mmHg, Albumin level > 3.0 and WBC > 1500. 10 of 12 healed and retained mobility. A total contact cast could be used in a pt with adequate blood flow, and no osteomyelitis A syme's amputation(through ankle) requires the use of a healthy plantar soft tissue flap for coverage . A transtibial (BKA) amputation would be the choice for a failed partial calcanectomy or in a patient who had an ABI < .45 and who wasn't a candidate for a revasculization procedure. Nonweightbearing and IV antibiotics would not be adequate in a diabetic pt with osteo of this extent.

Question 15

-A 45-year-old woman sustained a fall from height and has the injury shown in Figures 135a and 135b.A 3-dimensional reconstruction CT scan is shown in Figure 135c. Joint-spanning external fixation is applied on the day of injury. Ten days later, her skin is acceptable for definitive fixation. What is the most appropriate type of fixation for her fracture?

Explanation

Question 16

A 24-year-old avid volleyball player has noted gradual onset of shoulder fatigue and weakness limiting his game. Radiographs done by his primary care physician were normal and he has failed to improve with 6 weeks of physical therapy. Given the MRI image shown in Figure A, this patients physical exam may reveal weakness with which of the following actions? Review Topic

Explanation

The MRI demonstrates of a ganglion cyst within the suprascapular notch, leading to atrophy of both the supraspinatus and infraspinatus. Thus, the patient would have weakness with both abduction and external rotation.
Extrinsic compression or traction on the suprascapular nerve can result in suprascapular neuropathy. Compression of the nerve may occur at two distinct locations: the suprascapular notch and the spinoglenoid notch. Extrinsic compression of the suprascapular nerve by ganglion cysts can occur at the spinoglenoid notch or, less commonly, at the suprascapular notch. These cysts may originate from the transverse scapular ligament, the fibrous tissue of the scapula, or the glenohumeral joint.
Mittal et al. reviewed the literature and found that the formation of ganglionic cysts in the spinoglenoid fossa occurs with cumulative trauma and leads to entrapment neuropathy of the suprascapular nerve and denervation of the infraspinatus muscle.
Romeo et al. reported on various etiologies of suprascapular neuropathy including traction injury at the level of the transverse scapular ligament or the spinoglenoid ligament and direct trauma to the nerve. They noted that sports involving overhead motion, such as tennis, swimming, and weight lifting, may result in traction injury to the suprascapular nerve, leading to dysfunction. They also reported that the onset of weakness can be subtle and must be differentiated from cervical radiculopathy and degenerative disease of the shoulder.
Figure A depicts a T2 coronal MRI of the shoulder with a cyst easily visualized occupying the suprascapular notch. Illustration A is an algorithm for the management of suprascapular neuropathy. Illustration B is a sagittal MRI from the same patient depicting the ganglion cyst within the suprascapular notch once again leading to atrophy of both the supraspinatus and infraspinatus (asterisks).
Incorrect Answers:

Question 17

Figure below shows the standing AP radiograph obtained from a 55-year-old man who has a 5-year history of daily left knee medial joint line pain with weight-bearing activities. He denies night pain or symptoms of instability. On examination, his range of motion is 0° to 140°. He has a mild, fully correctable varus deformity and a negative Lachman test result. Nonsurgical treatment has failed. What is the UKA survivorship for a 55-year-old patient, compared with the survivorship for total knee arthroplasty?

Explanation

DISCUSSION:
A patient with medial compartment arthritis and a correctable varus deformity with no clinical or examination findings of knee instability most likely has an intact anterior cruciate ligament (ACL). The pattern of medial compartment osteoarthritis most commonly associated with an intact ACL is that of anteromedial osteoarthritis. An incompetent ACL is commonly associated with a fixed varus deformity and radiographic signs of posteromedial wear. An incompetent ACL is a relative contraindication to a mobile-bearing UKA. When evaluating patients for a mobile-bearing UKA, a stress radiograph aids the orthopaedic surgeon in determining the correction of the varus deformity and assessing the lateral compartment. An inability to fully correct the deformity or narrowing of the lateral compartment with valgus stress should influence the surgeon against UKA. Joint registries across the world have shown decreased survivorship associated with TKA and UKA in men compared with other age groups, but survivorship is lower for UKA than for TKA. No studies to date have shown any differences in survivorship between fixed-bearing and mobile-bearing UKAs. The complication that is unique to mobile-bearing UKA is bearing spinout, which occurs in less than 1% of mobile-bearing UKA procedures. In vivo and in vitro polyethylene wear in mobile-bearing UKA are low. Arthritis may progress faster in patients with mobile-bearing UKAs than in those with fixed-bearing UKAs.

Question 18

Figure 1 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain?

Explanation

This patient has a mechanism of injury and MRI scan consistent with a posterior labral tear and posterior instability. Flexion, adduction, and internal rotation produce a net posterior vector on the glenohumeral joint and should reproduce this patient's symptoms. Pain or instability with the arm elevated in the scapular plane describes an impingement sign. Pain or instability with the arm in external rotation and abduction describes the apprehension sign. Pain or instability with the arm in flexion and abduction is a nonspecific finding.

Question 19

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Explanation

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,

as indicated by the arrow. This technique suppresses the signal of the surrounding fat

and causes the stationary surrounding tissues to become intermediate in signal intensity.

The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 20

A 10-year-old soccer player has bilateral heel pain and reports that the pain is worse during and immediately after sports. Examination reveals that the calcaneal tuberosities are painful to palpation bilaterally. What is the most likely diagnosis?

Explanation

DISCUSSION: Calcaneal apophysitis (Sever’s disease) is a common cause of heel pain in children who are active in sports. The symptoms are most commonly bilateral and will often respond to a gastrocnemius-soleus complex stretching program. In addition, rest, anti-inflammatory drugs, and heel pads for the shoe may be prescribed. There is no effect on the long-term growth of the calcaneus.
REFERENCES: Micheli LJ, Ireland ML: Prevention and management of calcaneal apophysitis in children: An overuse syndrome. J Pediatr Orthop 1987;7:34-38. 500.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 21

Following a vertebroplasty of L2, cement is noted to protrude directly anterior to the L2 vertebral body. The cement is closest to which of the following structures?

Explanation

DISCUSSION: At the level of L2, the liver and the vena cava lie to the right. The pancreas

and duodenum are anterior to the aorta. The aorta lies in the midline just in front of the

vertebral body.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.

Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 331.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 328.

Question 22

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Explanation

DISCUSSION: The radiograph shows a volarly dislocated lunate. Initial emergent treatment of perilunate dislocations should consist of closed reduction and splinting, especially if the patient exhibits median nerve compression. Open reduction and pinning or ligament repair are necessary but are not emergent. A dorsal approach is sometimes required for ligament repair or bony visualization; however, this can be done in a more semi-elective manner.
REFERENCES: Isenberg J, Prokop A, Schellhammer F, et al: Palmar lunate dislocation. Unfallchirurg 2002;105:1133-1138.
Ruby LK: Fractures and dislocations of the carpus, in Browner BD, Jupiter JB (eds): Skeletal Trauma, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 1367-1372.

Question 23

Venous thrombolembolism is a common complication following total hip and total knee arthroplasty; therefore, prophylaxis is deemed efficacious. Several studies on low-molecular-weight heparin (LMWH) have shown which of the following findings?

Explanation

DISCUSSION: Prophylactic LMWH is associated with a risk of bleeding complications, especially if administered too soon after surgery. The risk of major bleeding is 0.3% for control, 0.4% for aspirin, 1.3% for warfarin, 1.8% for LMWH, and 2.6% for unfractionated heparin. Colwell and associates conducted a prospective, randomized trial on over 1,500 total hip arthroplasty patients. Overall, the risk of clinically apparent venous thrombolembolism was 3.6% for LMWH and 3.7% for warfarin. LMWH acts in several sites of the coagulation cascade, with its principal action being inhibition of factor 10a. Thrombocytopenia is less common with LMWH than with unfractionated heparin. The use of LMWH is a relative contraindication with indwelling epidural anesthesia.
REFERENCES: Colwell CW Jr, Collis DK, Paulson R, et al: Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty:. Evaluation during hospitalization and three months after discharge. J Bone Joint Surg Am 1999;81:932-940.
Salvati EA, Pelligrini VD Jr, Sharrock NE, et al: Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg Am 2000;82:252-270.

Question 24

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Explanation

DISCUSSION: Robinson et al have shown that lack of cortical apposition, comminution, female gender, and advancing age are the 4 factors that contribute to nonunion.
The Canadian Orthopaedic Trauma Society in a randomized, prospective study showed that for midshaft fracture in adults with 100% displacement, ORIF results in improved DASH and Constant scores (p = 0.001 and p < 0.01, respectively), lower nonunion (2 vs. 7, p=0.042) & lower malunion (0 vs. 9, p=0.001). Surgery resulted in quicker radiographic union (16.4 weeks vs. 28.4 weeks, p=0.001). However, 15% had hardware and wound complications. At one year, the operative group was more likely to be satisfied with the shoulder in general (p=0.002) and the appearance of the shoulder in particular (p=0.001) in comparison to the nonoperative group.
Prior studies have shown that greater than 2cm of shortening treated non-operatively results in increased fatigueability and poor outcome, but not necessarily nonunion. The Lazarides article concluded that “Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result.”
Studies have shown no difference in outcome when treated with a Figure-of-8 harness compared to a simple sling

Question 25

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Explanation

A provocative test for medial epicondylitis can be elicited by applying resistance to a patient with their fist clenched, wrist flexed and pronated.
Medial epicondylitis is an overuse syndrome of the flexor-pronator mass. The pronator teres (PT) and flexor carpi radialis (FCR) are thought to be most affected with this condition. It is most common in the dominant arm and occurs with activities that require repetitive wrist flexion/forearm pronation. Patients are most tender over the origin of PT and FCR at the medial epicondyle. Resisting a patient with their fist clenched, wrist flexed and pronated can cause worsening of their pain. This maneuver can be used as a provocative test for this condition.
Cain et al. reviewed elbow injuries in throwing athletes. They comment that the common flexor-pronator muscle origin provides dynamic support to valgus stress in the throwing elbow, especially during early arm acceleration and help produce wrist flexion during ball release.
Amin et al. reviewed the evaluation and management of medial epicondylitis. They report that medial epicondylitis typically occurs in the fourth through sixth decades of life, the peak working years, and equally affects men and women. Physical therapy and rehabilitation is the main aspect of recovery from medial epicondylitis, once acute symptoms have been alleviated.
Illustration A shows a video of this provocative test for medial epicondylitis. Incorrect Answers:

Question 26

What is the most appropriate treatment at this time?

Explanation

DISCUSSION
Prompt diagnosis and treatment of patients with spinal epidural abscess is crucial to maintain and/or improve neurologic function. This clinical scenario stresses the importance of advanced imaging studies. It is also important to recognize the imaging features of spinal epidural abscess. T1-weighted gadolinium-enhanced images show ring enhancement with a central nonenhancing, low-signal area. In such a case, urgent decompression is indicated. Because of the location of the abscess, which is anterior to the spinal cord, an anterior decompression and reconstruction (ie, fusion) is probably the best treatment plan. Steroids are contraindicated in the presence of an epidural abscess. IV antibiotics alone will not adequately treat a patient with a neurological deficit. A posterior laminectomy and fusion will not safely allow access to the abscess.
RECOMMENDED READINGS
Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. 2004 May-Jun;12(3):155-63. Review. PubMed PMID: 15161168. View Abstract at PubMed Ghobrial GM, Beygi S, Viereck MJ, Maulucci CM, Sharan A, Heller J, Jallo J, Prasad S, Harrop JS. Timing in the surgical evacuation of spinal epidural abscesses. Neurosurg Focus. 2014 Aug;37(2):E1. doi: 10.3171/2014.6.FOCUS14120. PubMed PMID: 25081958. View Abstract
at PubMed
This is the last question of the exam.

Question 27

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

Explanation

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

Question 28

An 18-year-old boy has had pain in the right knee for the past 6 months. Examination reveals some fullness behind the knee but no significant palpable soft-tissue mass. There is no effusion, and he has full knee range of motion. The remainder of the examination is unremarkable. A radiograph and MRI scans are shown in Figures 33a through 33c, and biopsy specimens are shown in Figures 33d and 33e. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has parosteal osteosarcoma. The posterior aspect of the distal femur is the typical location for this variant of osteogenic sarcoma. The imaging studies indicate a surface lesion with no involvement of the adjacent intramedullary canal. The histologic appearance is that of a low-grade fibroblastic osteosarcoma, consisting of relatively mature bone and a bland fibroblastic stroma lacking cytologic atypia and mitotic activity. A cartilaginous component is also frequently seen. Classic osteosarcoma typically has a more aggressive radiologic and histologic appearance. Sessile osteochondromas, while common behind the knee, have a presence of hematopoietic marrow and fat. The cartilage found in the associated cartilaginous cap is oriented. Chondrosarcomas are more typical in an older age group and have a histologic pattern consisting of malignant chondroid.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 20-21.
Unni KK, Dahlin DC, Beabout JW, Ivins JC: Parosteal osteogenic sarcoma. Cancer 1976;37:2466-2475.

Question 29

The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Explanation

Figure 50A: AP pelvis with a 1 cm lucency in the calcar region of the femoral neck and diffuse osteopenia of the proximal femur. Figure 50B: CT scan of the same patient showing a well demarcated lcm lesion in the femoral neck with an obvious nidus. Careful evaluation of the radiographs is critical in this question. First the obvious osteoid osteoma must be recognized. From there answers 2 and 3 can be eliminated. Neither radiograph reveals any sign that treatment has occurred, and the CT scan shows no signs of extensive involvement, thus answer 5 should also be eliminated. The real key is believing that such diffuse osteoporosis could occur in such a young child, as Jones described in his article from 1969.

Question 30

A right-handed 20-year-old college baseball pitcher has had a 6-month history of vague right elbow pain while pitching. Examination reveals full flexion of the elbow and a loss of only a few degrees of full extension. The elbow is stable, but palpation reveals tenderness over the olecranon. Plain radiographs are inconclusive. MRI and CT scans are shown in Figures 20a and 20b. Management should consist of

Explanation

DISCUSSION: The patient has a stress fracture of the olecranon that occurs with repetitive throwing motions. If the fracture is not displaced, the initial treatment of choice is rest and rehabilitation to maintain elbow motion, followed by aggressive strengthening at 6 to 8 weeks. A light throwing program generally can begin at 8 to 12 weeks. Complete recovery may require 3 to 6 months. If the fracture is displaced or if nonsurgical management fails, surgery is indicated for internal fixation of the stress fracture.
REFERENCES: Azar FM, Wilk KE: Nonoperative treatment of the elbow in throwers. Oper Tech Sports Med 1996;4:91-99.
Griffin LY (ed): Orthopaedic Knowledge Uupdate: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 191-203.

Question 31

When comparing mobile-bearing total knee arthroplasty (TKA) to fixed-bearing total condylar arthroplasty, the mobile-bearing procedure provides

Explanation

DISCUSSION: Survivorship is similar in the two groups. In a recent study, mobile-bearing TKAs showed a slightly higher maximum flexion than the total condylar fixed-bearing-type designs (112 degrees versus 108 degrees with no difference in recovery rate). Using a fixed-bearing or a mobile-bearing design did not seem to influence the recovery rate in early results after knee arthroplasty. Mobile-bearing arthroplasties are suggested, in theory, to offer a reduction in polyethylene wear; however, clinical studies have not yet proven this. Recovery rates have yet to be statistically seen as improved with either method. Differences in strength have not been shown.
REFERENCES: Aglietti P, Baldini A, Buzzi R, et al: Comparison of mobile-bearing and fixed-bearing total knee arthroplasty: A prospective randomized study. J Arthroplasty 2005;20:145-153.
Sorrells RB: The rotating platform mobile bearing TKA. Orthopedics 1996;19:793-796.
Dennis DA, Komistek RD: Kinematics of mobile-bearing total knee arthroplasty. Instr Course Lect 2005;54:207-220.

Question 32

A 17-year-old presents with persistent left knee pain after a twisting injury during a soccer match 24 hours ago. On physical exam he has a mild effusion. He has tenderness to palpation on the medial joint line. Lachman test, anterior drawer test and posterior drawer test are attempted but limited secondary to pain. Dial test reveals a side-to-side external rotation difference of roughly 5 degrees. His MRI images are seen in Figures A-D. These findings would be most consistent with: Review Topic

Explanation

The patient has sustained a complex tear involving the posterior horn of the medial meniscus. Localizing joint line tenderness is the most sensitive physical examination finding for this injury.
Many provocative tests have been described to aid in the diagnosis of meniscus tears.
The Apley test is performed with the patient prone, by axially loading the tibiofemoral joint at 90° of knee flexion. Pain with compression and external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Ege's test is performed by having the patient squat with their knees maximally externally rotated or internally rotated. The test is positive when pain and/or a click is felt by the patient.
The McMurray test is performed by passively moving the knee from flexion to extension while externally or internally rotating the leg. A palpable click at the joint line with external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Thessaly test is performed by supporting the patient as they internally or externally rotate their knee and body while keeping the foot planted, with the knee in 5° of flexion and then 20° of flexion. The test is positive when joint line pain and/or sense of locking/catching is experienced by the patient.
Ryzewicz et al. performed a systematic review of prospective cohort studies comparing magnetic resonance imaging (MRI) and clinical examination to arthroscopy in the diagnosis of meniscus tears. The Apley test, Ege's test, McMurray test and Thessaly test at 5° were shown have high specificity but low sensitivity. Joint line tenderness has a higher sensitivity, but lower specificity. The Thessaly test at 20° demonstrated the highest sensitivity and specificity, although there was only one available study evaluating this test.
Abdon et al. performed a prospective study looking at 68 clinical parameters to
determine which combinations of symptoms and signs indicated the presence of a meniscus tear. They found that joint-line tenderness and mechanical locking were predictive of a meniscus tear, while the McMurray sign did not prove valuable. Pain at rest, sick leave and medial patellar tenderness all negated the presence of a meniscus tear. The clinical accuracy in diagnosing meniscal tears was 61% in this study.
Figures A and B are T1 sagittal MR images demonstrating an intact anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), respectively. Figures C and D are T2 coronal and sagittal MR images showing a complex tear of the posterior horn of the medial meniscus. Illustration A demonstrates the Ege's test. Illustration B shows the Thessaly test at 5° of flexion.
Incorrect

Question 33

A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Explanation

DISCUSSION: The athlete has a corneal abrasion. Fluorescein staining identifies the break in the epithelium when examined with ultraviolet light. Topical antibiotics are used as prophylaxis against secondary bacterial infection, and the patch, applied with the lid closed, is used for comfort and to promote epithelial healing. The accompanying symptoms, including pain, tearing, and photophobia, are usually too intense to allow a return to play. Surgery is reserved for a corneal laceration with associated loss of the anterior chamber. While a proper fundoscopic examination may be a consideration, increased intraocular pressure is not typically associated with this injury. Traumatic hemorrhage in the anterior chamber (hyphema) necessitates strict bed rest during the early phases of healing; examination will most likely reveal the red fluid level of blood settling inferiorly in the anterior chamber. It is often associated with increased intraocular pressure.
REFERENCES: Brucker AJ, Kozart DM, Nichols CW, et al: Diagnosis and management of injuries to the eye and orbit, in Torg JS (ed): Athletic Injuries to the Head, Neck, and Face. St Louis, MO, Mosby-Year Book, 1991, pp 650-670.
Zagelbaum BM: Treating corneal abrasions and lacerations. Phys Sports Med 1997;25:38-44.

Question 34

What is the treatment of choice for the injury shown in Figures 20a through 20c?

Explanation

DISCUSSION: The radiographs show multiple carpometacarpal dislocations. Reduction is often obtainable but difficult to maintain. Internal fixation is required to maintain the reduction, preferably with Kirschner wires. Closed reduction and percutaneous pinning is preferred by some surgeons. Others recommend open reduction to remove irreconstructable osteochondral fragments from the individual joints and to ensure correct reduction of the carpometacarpal joints. Kirschner wires are removed at 6 to 8 weeks.
REFERENCES: Prokuski LJ, Eglseder WA Jr: Concurrent dorsal dislocations and fracture-dislocations of the index, long, ring, and small (second to fifth) carpometacarpal joints. J Orthop Trauma 2001;15:549-554.
Lawlis JF III, Gunther SF: Carpometacarpal dislocations: Long-term follow-up. J Bone Joint Surg Am 1991;73:52-59.

Question 35

Figure 1 is the MR image of a 14-year-old football player who injured his right knee during a game. He describes feeling a "pop" and then needing help walking off the field. His knee is visibly swollen. The patient undergoes surgery to repair/reconstruct the damaged structure and has no postsurgical complications and begins physical therapy rehabilitation. The boy and his parents stress they want to “get the therapy over with as fast as possible" to expedite his return to sports, and the surgeon and rehabilitation team consider their request. Compared with nonaccelerated rehabilitation, patients who follow an early accelerated rehabilitation protocol experience

Explanation

The MR image shows bone bruises (“kissing contusions”) consistent with an ACL tear. During the ACL subluxation event, the posterolateral tibial plateau subluxes anteriorly, making contact with the mid portion of the lateral femoral condyle and resulting in this characteristic bone bruise pattern on MRI. Randomized clinical trials comparing early accelerated versus nonaccelerated rehabilitation programs have demonstrated no significant differences in long-term results with regard to function, reinjury, and successful return to play. These studies did not address timing of return to play with an early accelerated rehabilitation program. At 2 and 3 years postsurgically, there are no differences in laxity, number of graft failures, or KOOS scores.

Question 36

Which of the following types of ultra-high molecular weight polyethylene has been associated with the poorest clinical performance?

Explanation

DISCUSSION: Numerous studies have documented the poor performance of heat-pressed ultra-high molecular weight polyethylene used in the porous-coated anatomic tibial inserts of both total knee and unicompartmental arthroplasty. The other processing and sterilization methods have not been associated with significantly high failure rates.
REFERENCES: Wright TM, Rimnac CM, Stulberg SD, et al: Wear of polyethylene in total joint replacements: Observations from retrieved PCA knee implants. Clin Orthop 1992;276:126-134.
Landy MM, Walker PS: Wear of ultra-high molecular-weight polyethylene components of 90 retrieved knee prostheses. J Arthroplasty 1988;3:S73-S85.
Skyrme AD, Mencia MM, Skinner PW: Early failure of the porous-coated anatomic cemented unicompartmental knee arthroplasty: . A 5- to 9-year follow-up study. J Arthroplasty 2002;17:201-205.

Question 37

A 15-year-old boy who participates in track reports acute pain along the left iliac crest during a sprint. Examination reveals that the anterior superior iliac spine is nontender. The most likely diagnosis is an injury to the

Explanation

DISCUSSION: The patient has iliac apophysitis. The radiographic findings are easily overlooked but usually reveal slight asymmetric widening of the iliac crest apophysis. The apophysis is the most vulnerable structure, as it is three to five times weaker than the tendon. This is not an epiphyseal site, and injury to the muscle or the tendinous insertion to bone (enthesis) is unlikely.
REFERENCES: Clancy WG Jr, Foltz AS: Iliac apophysitis and stress fractures in adolescent runners. Am J Sports Med 1976;4:214-218.
Waters PM, Millis MB: Hip and pelvic injuries in the young athlete, in Stanitski CL, DeLee JC, Drez D Jr (eds): Pediatric and Adolescent Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 279-293.
Lombardo SJ, Retting AC, Kerlan RK: Radiographic abnormalities of the iliac apophysis in adolescent athletes. J Bone Joint Surg Am 1983;65:444-446.
Paletta GA Jr, Andrish JT: Injuries about the hip and pelvis in the young athlete. Clin Sports Med 1995;14:591-628.

Question 38

03 Figure 9 shows the radiograph of a patient who has anterior knee pain and range of motion from 0-of the tibial tubercle. Treatment should consist of

Explanation

r the medial 1/3
The picture shows a laterally subluxed and a relatively-externally rotated patella on a femoral component. The question tells us that the femoral component is internally rotated and the tibial component is perfectly placed. If we know that the femoral component should be externally
rotated about 3 degrees, we know that in this patient, that’s where the problem is. So, we don’t have to do anything to the quads, tubercle or tibial component. We need to revise the femur. Besides, a lateral retinacular release may damage the lateral geniculates; since this patient most likely had a medial arthrotomy, this may devascularize the patella and lead to patellar AVN. A lateral retinacular release will not address the malpositioned components )
back to this question next question

Question 39

The acceleration of an object under the influence of a force depends directly on the mass of the object. The angular acceleration of an object under the influence of a moment depends directly on the

Explanation

DISCUSSION: Similar to the action of a force, a moment tends to angularly accelerate an object in a manner proportional to a quantity related to the mass of the object. The concept of a more massive object requiring a larger force to cause the same straight line acceleration is straightforward. The concept for changing angular velocity is similar but not identical. The proportional constant between the moment and the resulting angular acceleration is the mass moment of inertia, which depends not only on the mass of the object, but also its distribution. The unit of mass moment of inertia is obtained by multiplying the mass of the object by the square of the distance between an equivalent location of the center of rotation of the object and an equivalent location of the center of mass. Orthopaedic surgeons can change both the amount of mass carried by a limb and the way that the mass is distributed. For example, in applying a cast to the leg, the physician can affect the mass of the cast by the choice of casting material and by the size of the cast. As the mass moment of inertia of the limb increases (eg, by applying the cast farther down on the leg or using a heavier casting material), the patient will need to exert larger moments to angularly accelerate the leg during gait.
REFERENCES: Andriacchi T, Natarajan RN, Hurwitz DE: Musculoskeletal dynamics, locomotion, and clinical applications, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 43-47.
Burstein AH, Wright TM: Fundamentals of Orthopaedic Biomechanics. Baltimore, MD, Williams and Wilkins, 1994, pp 3-7.

Question 40

A 25-year-old woman returns for her first postoperative visit after arthroscopic thermal capsulorrhaphy for recurrent multidirectional instability. Examination reveals that the portals are healed, there is no swelling; and passive range of motion is within the normal range. However, she is unable to actively raise her arm. Shoulder radiographs are normal. What is the most likely cause of these findings? Review Topic

Explanation

Treatment of shoulder instability with thermal devices has lead to numerous complications including recurrent instability, chondrolysis, stiffness, and capsular necrosis. This patient’s findings are consistent with a heat-induced axillary nerve injury. Normal radiographs exclude extensive chondrolysis.

Question 41

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 42

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

Explanation

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

Question 43

A 4-year-old boy who was struck by a motor vehicle has a right pneumothorax requiring placement of a chest tube, an open (Gustilo) grade IIIA midshaft fracture of the left femur, and a closed displaced subtrochanteric fracture of the right femur. He also sustained a subdural hematoma that requires neurosurgical intervention. In addition to irrigation and debridement of the left femur, treatment should include

Explanation

In children ages 3 to 5, who have sustained multiple trauma, the treatment priority is initially their more serious life threatening injuries. Once other injuries are stabilized, then femoral fractures can be treated. External fixation is rarely needed in this age group, except in the multi-trauma patient with ipsilateral fractures or contralateral fractures. It is also useful in patients with head injuries, in open fractures, and when traction has not prevented significant shortening and angulation of the fracture.

Question 44

A B Figures 90a and 90b are MR images of a 34-year-old man who is referred to your office by his primary care physician after failing 4 months of nonsurgical treatment that included epidural steroids for severe right arm pain occurring in a C6 distribution. He also has associated paresthesias in this region. The patient is weak in elbow flexion and wrist extension. What are his likely outcomes if he is treated with a posterior foraminotomy instead of anterior cervical diskectomy and fusion (ACDF)?

Explanation

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617. View Abstract at PubMed Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 45

A 45-year-old woman with grade II adult-acquired flatfoot deformity has pain on the lateral side of her foot just distal to the tip of the fibula. Which component of a comprehensive flatfoot reconstruction most likely will address the deformity responsible for this pain?

Explanation

DISCUSSION
Patients develop lateral ankle pain with progression of adult-acquired flatfoot deformity. This is associated with increased hindfoot valgus deformity. Calcaneal fibular impingement has been considered the primary cause of this pain. Studies demonstrate that arthrosis of the posterior facet of the subtalar joint strongly correlates with lateral pain in adult-acquired flatfoot deformity. Both conditions are related to hindfoot valgus deformity. Although lateral column lengthening is a powerful tool for correction of flatfoot deformity, its effect on hindfoot deformity is less defined. Lateral column lengthening provides better correction of the longitudinal arch of the midfoot and realignment of the medial column than other osteotomies. A medializing calcaneal osteotomy has a significant linear effect on hindfoot valgus alignment. Spring ligament reconstruction and medial cuneiform opening-wedge osteotomies have less effect on hindfoot alignment than the medial calcaneal slide.
RECOMMENDED READINGS
Ellis SJ, Deyer T, Williams BR, Yu JC, Lehto S, Maderazo A, Pavlov H, Deland JT. Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging. Foot Ankle Int. 2010 May;31(5):361-71. doi: 10.3113/FAI.2010.0361. PubMed PMID:

Question 46

Which of the following factors will adversely affect bone ingrowth in a revision porous-coated stem?

Explanation

DISCUSSION: The optimal conditions for bony ingrowth include a pore size of 100 to 400 mm, interface micromotion of 50 mm or less, intimate contact between the bone and the implant, circumferential porous coating of the implant, and use of a biocompatible material. Stem designs with patch coatings have a poor record of bony ingrowth, especially in the revision setting. Failure of ingrowth in the previous stem would be the result of its own mechanical milieu and would not necessarily predict results for the new stem.
REFERENCES: Berry DJ, Harmsen WS, Ilstrup D, Lewallen DG, Cabanela ME: Survivorship of uncemented proximally porous-coated femoral components. Clin Orthop 1995;319:168-177.
Cook SD, Thomas KA, Haddad RJ Jr: Histologic analysis of retrieved human porous-coated total joint components. Clin Orthop 1988;234:90-101.
Spector M: Historical review of porous-coated implants. J Arthroplasty 1987;2:163-177.

Question 47

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?

Explanation

DISCUSSION: Proximal tibial osteotomy is appropriate for the younger and/or athletic patient who has mild to moderate medial compartment osteoarthritis. Relative contraindications include limited range of motion (eg, flexion contracture of 15°), anatomic varus of greater than 10°, advanced patellofemoral arthritis, and tibial subluxation. Inflammatory arthritides involve all the compartments and are a contraindication to osteotomies around the knee.
REFERENCE: Kelly MA: Nonprosthetic management of the arthritic knee, in Callaghan JJ, Dennis DA, Paprosky WG, Rosenberg AG (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1995, pp 245-249.

Question 48

-Figures 14a through 14d are the radiographs and sagittal T1- and T2-weighted MRI scans of an otherwise healthy 10-year-old girl who has experienced 3 weeks of worsening pain with weight bearing and is now refusing to bear weight to either of her lower extremities. She denies any history of injury or trauma.She has not had any fevers or recent illnesses. She denies any numbness or parasthesias. She has had no bowel or bladder incontinence. In the emergency department she is afebrile and tender to palpation over the midlumbar spine. She has pain with hyperextension and flexion of her back. Her white blood cell count is 11.4 (reference range, 4.5-11.0 x109/L), erythrocyte sedimentation rate is 40 mm/h (reference range, 0-20 mm/h), and C-reactive protein is 2.6 mg/L (reference range, 0.08-3.1 mg/L). What is the most appropriate course of action at this time?

Explanation

Question 49

Figure 35 is the sagittal MR image of a 56-year-old woman who has a 3-year history of severe back pain. Her pain is worse with flexion at the lumbosacral junction and is relieved with extension. She denies any pain in her lower extremities and has no symptoms of neurogenic claudication. Which mediators play roles in the pathogenesis of this condition?

Explanation

DISCUSSION
The patient has degenerative disk disease with diskogenic back pain. Several studies in both humans and animals have implicated TNF-a, IL-1, and MMP in extracellular matrix degeneration and disk degradation. TGF-ß, BMP-2, latent membrane protein 1, and growth and development factor-5 are all postulated to play anabolic roles in the intervertebral disk. Biglycan is a small leucine-rich proteoglycan that regulates extracellular matrix assembly within the disk. Noggin and gremlin are biochemical factors not involved in disk degradation.
RECOMMENDED READINGS
Kim HT, Yoon ST, Jarrett C. Articular cartilage and intervertebral disk. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:23-33.
Hoyland JA, Le Maitre C, Freemont AJ. Investigation of the role of IL-1 and TNF in matrix degradation in the intervertebral disc. Rheumatology (Oxford). 2008 Jun;47(6):809-14. doi: 10.1093/rheumatology/ken056. Epub 2008 Apr 8. PubMed PMID: 18397957. View Abstract at PubMed
Gruber HE, Ingram JA, Hanley EN Jr. Immunolocalization of MMP-19 in the human intervertebral disc: implications for disc aging and degeneration. Biotech Histochem. 2005 May-Aug;80(3-4):157-62. PubMed PMID: 16298901. View Abstract at PubMed

Question 50

An otherwise healthy 30-year-old man undergoes right shoulder arthroscopic Bankart repair under regional anesthesia using an interscalene brachial plexus block. In the recovery room, he reports mild difficulty breathing and his chest radiograph shows a high riding diaphragm on the right side. His peripheral oxygenation is 97% on 2 liters of oxygen by nasal cannula. What is the most appropriate management?

Explanation

Because the phrenic nerve lies in close proximity to the site of anesthetic injection, temporary hemidiaphragmatic paresis is a very common side effect of interscalene brachial plexus block. Pulmonary function and chest wall mechanics may be slightly compromised, but can easily be compensated in a healthy patient. Therefore, with sufficient oxygenation, aggressive assessments or treatments such as arterial blood gas measurements, emergent spiral CT scans, chest tube insertions, or endotracheal intubation are not warranted. For this stable patient, continued monitoring with gradual withdrawal of oxygen is the most appropriate treatment.

Question 51

Figure 3 shows the radiograph of an asymptomatic 10-year-old boy. Management should consist of

Explanation

DISCUSSION: Asymptomatic spondylolysis in a child or adolescent should be observed for the possible development of spondylolisthesis, but no other active intervention is needed. The initial treatment of choice for symptomatic spondylolysis includes rest and activity modifications, nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and casting. Immobilization with a TLSO or pantaloon spica cast may permit healing of an acute pars fracture. Rarely, surgical treatment may be necessary. Surgical options include posterolateral L5-S1 fusion or direct repair of the pars defect.
REFERENCES: Pizzutillo PD, Hummer CD III: Nonoperative treatment for painful adolescent spondylolysis or spondylolisthesis. J Pediatr Orthop 1989;9:538-540.
Richards BS (ed): Orthopaedic Knowledge Update: Pediatrics. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 129-137.

Question 52

While performing long fusion with osteotomies for a patient with adult scoliosis and sagittal plane deformity, the neurophysiologist reports a change in motor-evoked potentials in the lower extremities. What is the most appropriate next step?

Explanation

DISCUSSION
The use of intraoperative neuromonitoring is expanding, especially in the setting of deformity surgery. Changes in monitoring are concerning for the possibility of a neurologic injury; however, several other factors can alter signals. These include hypotension, changes in anesthesia depth and medications, the use of paralytic agents, and technical issues such as leads falling out or becoming disconnected. If a change in neuromonitoring signals is noted, these factors should be checked first to rule out false-positive findings. If this does not correct the problem, the wound should be explored to ensure there is no compression on the neural elements. Finally, if the deformity has been corrected, some of the correction can be released in an attempt to improve the signals. A wake-up test is difficult to perform and does not provide specific information regarding the location of the problem or how to correct it. Steroids may be used depending on surgeon preference, but should not be used until neurologic injury is ruled out. Any neuromonitoring changes always necessitate immediate investigation.
RECOMMENDED READINGS
Ziewacz JE, Berven SH, Mummaneni VP, Tu TH, Akinbo OC, Lyon R, Mummaneni PV. The design, development, and implementation of a checklist for intraoperative neuromonitoring changes. Neurosurg Focus. 2012 Nov;33(5):E11. doi: 10.3171/2012.9.FOCUS12263. PubMed PMID: 23116091. View Abstract at PubMed
Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2167-79. doi: 10.1097/BRS.0b013e3181f6f0d0.
Review. PubMed PMID: 21102290. View Abstract at PubMed

Question 53

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Explanation

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 54

Figure 62 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks? Review Topic

Explanation

The structure shown is the posterolateral bundle of the anterior cruciate ligament (ACL). This bundle is optimally positioned in the knee to resist rotatory forces during terminal knee extension. "Resist anterior translation during knee flexion" best describes the anteromedial bundle. "Resist rotatory loads during knee flexion" is unlikely because the posterolateral bundle is tightest during knee extension. The posterior cruciate ligament, not the ACL, functions to resist posterior translation.

Question 55

An awake and alert patient with neck pain arrives at the emergency department after an automobile crash. Upon examination he is weak in the left deltoid and biceps muscles (3/5 strength). CT scans performed 2 hours after admission are shown in Figures 70a and 70b. His weakness deteriorates to 1/5 strength in the upper and lower extremities. What is the most appropriate treatment? A B

Explanation

DISCUSSION
Facet subluxation reduction may be performed in awake patients. Posterior spinal laminectomy and fusion can result in worsening neurologic status and is not recommended in this setting. Generally, corpectomy in the setting of facet subluxation is not recommended because it does not facilitate reduction or fully alleviate spinal cord compression. High-dose steroid use is not supported by current literature.
RECOMMENDED READINGS
Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S28-35; discussion S36. Review. PubMed PMID: 16685233. View Abstract at PubMed
Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6. PubMed PMID: 8175833.View Abstract at PubMed

Question 56

A 32-year-old male hockey player who is right-hand dominant was checked from behind and landed with full force into the boards. In the emergency department he reports shortness of breath. Figure 113 shows a 2-D CT scan. What is the best initial treatment for this injury?

Explanation

The CT scan shows a posterior sternoclavicular joint dislocation. Initial management involves attempted closed reduction in the operating room. This can be performed with a towel clip and anterior translation of the displaced clavicle. However, the orthopaedic surgeon should be prepared to open this injury and reconstruct the joint if necessary. Furthermore, it is recommended that a thoracic surgeon be available prior to beginning these procedures. Open reduction should be done only if closed reduction is unsuccessful.

Question 57

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 58

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

Explanation

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

Question 59

Figures 21a and 21b show a transverse MRI scan at L4/5 and a lateral radiograph of a 75-year-old man with a 2-year history of worsening low back and bilateral leg pain that occurs with ambulation beyond approximately a half a block. Management consisting of physical therapy, anti-inflammatory medications, and muscle relaxants has failed to successfully resolve his symptoms. He has minimal medical comorbidities. What is the best treatment approach for this patient? Review Topic

Explanation

The patient has spinal stenosis and degenerative spondylolisthesis. Laminectomy and posterior spinal fusion have been demonstrated to be superior to both nonsurgical management and laminectomy without fusion in prospective randomized studies. The effect of instrumentation on improvement of clinical outcomes remains a matter of debate. This patient has exhausted physical therapy approaches per the history. Epidural steroid injections have not been shown to significantly alter the natural history of patients with degenerative lumbar spinal stenosis and spondylolisthesis. While minimal access decompression has been described, percutaneous endoscopic diskectomy would be more appropriate for a disk herniation.

Question 60

Figures 26a and 26b show the radiograph and MRI scan of an 18-year-old man who fell from a trampoline. Examination reveals exquisite local tenderness at the thoracolumbar junction, but he is neurologically intact. Management should consist of

Explanation

DISCUSSION: Based on the radiographic findings of marked disruption of the posterior ligamentous complex with a relatively small anterior bony fracture, the patient has a classic Chance-type ligamentous flexion-distraction injury. The pathology is mostly in soft tissues with limited healing potential. The treatment of choice is posterior reconstruction of the tension band with a short segment fusion with instrumentation. Casting or bracing may result in a painful kyphosis with ligamentous insufficiency. The anterior bony column is mostly intact, so anterior reconstruction is not necessary.
REFERENCES: Carl AL: Adult spine trauma, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 406-423.
Lewandrowski KU, McLain RF: Thoracolumbar fractures: Evaluation, classification, and treatment, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 817-843.

Question 61

-An athletic 30-year-old sustained multiple injuries in a high-speed motor vehicle collision that resulted in a loss of approximately 30% of blood volume. On arrival to the emergency department, the heart rate is100 and blood pressure is 104/62. The best means with which to evaluate true hemodynamic status is

Explanation

Question 62

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Explanation

Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 63

A 78-year-old man with ankylosing spondylitis sustains a minor fall. Shortly afterward he experiences sudden worsening of his chronic back pain and is brought to the emergency department by his caregiver. Radiographs and a CT scan of the spine do not show a clear fracture. What is the most appropriate next step?

Explanation

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514. View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682. View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 64

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Explanation

Arthroscopic anterior labral repair spares the subscapularis, and does not require significant mobilization or incision of the anterior capsule. Therefore, it is less likely to result in significant impairment in external rotation of the glenohumeral joint when compared with traditional open stabilization procedures. Recurrent instability rates are either slightly higher or equivalent to open procedures. Both procedures can be performed on an outpatient basis and require generally identical recovery times.

Question 65

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up 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?

Explanation

DISCUSSION: 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.
REFERENCES: Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome.

J Hand Surg Br 1992;17:510-512.
Seror P: Anterior interosseous nerve lesions: Clinical and electrophysiological features. J Bone Joint Surg Br 1996;78:238-241.

Question 66

What is the most common cause for poor outcomes in patients who undergo total shoulder arthroplasty?

Explanation

DISCUSSION: In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.
REFERENCES: Chin PY, Sperling JW, Cofield RH, et al: Complications of total shoulder arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 2006;15:19-22.
Hasan SS, Leith JM, Campbell B, et al: Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg 2002;11:431-441.

Question 67

A 24-year-old male presents following a motorcycle crash with an isolated injury to his right lower extremity. He has a 3x2cm wound over the fracture site, and he immediately receives Gram positive and Gram negative coverage along with a tetanus booster. The patient is splinted, optimized, and brought to the operating room where the wound is debrided and classified as a Type IIIB fracture. Deemed stable, the plastic surgery team arrives and acutely performs a free flap for coverage, following definitive fixation with an intramedullary nail. All of the following are factors that have been shown to increase infection risk EXCEPT: Review Topic

Explanation

Time to definitive fixation is not a modifiable risk factor concerning open fractures. The other factors are risk factors that have been studied in regards to infection, and all are more important than definitive fixation. Definitive fixation can wait until complete closure and/or coverage.
When concerning management of open fractures, the most important factor is a thorough debridement. However, the quality of debridement is often not able to be quantified and thus, often not mentioned in studies. While early clinical and animal studies have shown that initial debridement should occur within 6 hours of injury, more recent clinical trials have not found a significant correlation within that urgent time frame, but rather recommend initial debridement as soon as possible within 24 hours. Time to antibiotic administration has been found to have a significant impact in lowering infection risk. Immediate administration in the emergency room is recommended. The ability to cover and/or close an open wound also has a significant impact on infection. Recent studies have recommended placing hardware after fasciotomy closure and have also demonstrated lower infection rates when flaps are placed within 72 hours of injury.
Pape and Webb concisely review the evolution of open fractures and wound management. The authors describe the early days where amputation was favored, to wet-to-dry dressings, to the advent of negative pressure wound therapy. Throughout, however, the authors emphasize the importance of soft tissue coverage. They also stress the importance of a technically thorough debridement, the most important factor of any wound management.
Scheneker et al. performed a systematic review and meta-analysis of 16 studies to determine if time to the operating room for debridement was an independent, modifiable risk factor in regards to subsequent infection following open tibia fracture. At the time of the study, the gold standard (based on a previous rat model), had recommended initial debridement within 6 hours of injury. The results of this meta-analysis, however, could not find conclusive evidence to suggest that late debridement alone placed the patient at a significantly higher risk for infection. The authors provided a moderate recommendation that initial debridement should occur as soon as possible within 24 hours, although more data is required in order to find a definitive time.
The SPRINT investigators report a landmark study that randomized over 1200 patients to either reamed or unreamed tibial IMN with the primary outcome analyzed as return to the operating room for either non-union treatment or deep infection. A notable difference between the two cohorts was a significantly higher primary event rate in the unreamed group.
Figure A exhibits a distal third open tibia fracture.
Incorrect answers:

Question 68

03 Fig 51c. What laboratory finding is most likely associated with this disease entity?

Explanation

The first question is what is it? The xray shows a mass in the leg with periosteal reaction in the fibula. The MRI shows a soft tissue mass arising from the fibula that looks aggressive. The path shows a bunch of small blue cells. The combination of small blue cells with a soft tissue mass and and onion skin appearance on xray in a patient in the 2nd decade of life has to scream Ewing’s sarcoma. 85% of Ewing’s sarcomas have the 11:22 translocation. None of the other answers are associated with Ewing’s.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Inst Course Lect 2002;51:413-428
back to this question next question

Question 69

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty? Review Topic

Explanation

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 70

The bending stiffness of a slotted stainless steel intramedullary nail will be increased most by

Explanation

To increase stiffness (bending) of an IM nail the diameter must be increased. The moment of inertia is increased by the 4th power of the diameter. The modulus of elasticity of titanium alloy is half of stainless steel. Cross sectional shape influences fixation. Interlocking screws influence rotation.

Question 71

Fixed hyperextension of the metatarsophalangeal joint is associated with

Explanation

DISCUSSION: Claw toe and hammer toe deformities are associated with dorsal subluxation of the interossei, which can no longer serve to flex the metatarsophalangeal joint. The extensor digitorum longus then loses its tenodesing effect on the proximal interphalangeal and distal interphalangeal joints and works unopposed to extend the metatarsophalangeal joint and the proximal phalanx. Without the antagonistic action of the extensor digitorum longus, the extrinsic flexors become unopposed flexors of the proximal and distal interphalangeal joints.
REFERENCES: Marks RM: Anatomy and pathophysiology of lesser toe deformities. Foot Ankle Clin 1998;3:199-213.
Myerson MS, Shereff MJ: The pathological anatomy of claw and hammer toes. J Bone Joint Surg Am 1989;71:45-49.

Question 72

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

Explanation

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

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

Question 73

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Explanation

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?

A. Inability to flex the distal interphalangeal joint of the index finger

B. Positive Froment’s sign

C. Weakness with wrist extension

D. Decreased capillary refill

Question 74

A patient is treated with volar plating for a distal radius fracture. The CT scan shown in Figure 15 is obtained after union of the fracture because the patient reports ongoing symptoms. The prominent hardware is most likely injuring what tendon?

Explanation

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 75

When performing a long fusion to the sacrum in an osteopenic patient in whom optimal sagittal balance is restored, which of the following is a benefit of extending the distal fixation to the pelvis, rather than the sacrum alone? Review Topic

Explanation

In osteopenic individuals, even those with excellent obtained or maintained balance, long instrumented fusions to the sacrum impart a high degree of strain, and the sacrum may fail in a transverse fracture or fracture-dislocation pattern. The risk of proximal functional kyphosis is unrelated to distal fixation as are coronal plane correction and rod contouring. Pubic ramus fractures have been shown to be associated with both fixation to the sacrum alone as well as to the ilium.

Question 76

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable. If the component is loose, revision to a longer device is recommended with appropriate stabilization of the fracture using the aforementioned methods. If bone loss has occurred, allograft supplementation or a tumor prosthesis may be indicated. Fractures located well below the stem tip can be treated without regard for the prosthesis. Closed reduction and bracing is not associated with good results for periprosthetic femoral fractures. Retrograde intramedullary nailing is not appropriate for this fracture.
REFERENCES: Duncan CP, Masri BA: Fractures of the femur after hip replacement. Instr Course Lect 1995;44:293-304.
Bono JV, McCarthy JC, Thornhill TS, Bierbaum BE, Turner RH (eds): Revision Total Hip Arthroplasty. New York, NY, Springer Verlag, 1999, pp 530-592.

Question 77

They found statistically significant decreases in need for secondary intervention, hardware failure, and infection as well as faster wound healing and faster time to fracture union.

Explanation

OrthoCash 2020
A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern?

Testicular torsion
Posterior urethral tear
Bladder denervation
Testicular rupture
Renal hematoma
The figure shows an anteroposterior pelvic ring injury. The most common urological injury with pelvic ring injuries remains the posterior urethral tear, followed by bladder rupture.
Watnik et al notes lower urinary tract (bladder to end of urethra) injuries in up to 25% of patients with this injury. He reports that when contaminated urine communicates with the anterior arch, the possibility of infection exists, and early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk.
Routt et al notes that even with simultaneous treatment of these injuries, complications are common (late stricture in 44%, impotence in 16%, delayed incontinence in 20% of females, anterior deep pelvic infection in 4%). Despite this, they report that early urological repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.
OrthoCash 2020
A 26-year-old women, 31-weeks pregnant, presents to the emergency department with the injury shown in Figure A. She states the injury occurred while lifting a heavy vacuum five days ago. She suffers from chronic headaches and sleep disturbances. On inspection, there are multiple dorsal and volar bruising over her wrist and upper arm. She is neurologically intact. After closed reduction and immobilizing the arm, what would be the next best step in management of this patient?

Diagnostic wrist arthroscopy
Urgent MRI wrist
Skeletal survey radiographs
Request a consultation with social worker in the hospital
Urgent open reduction internal fixation Corrent answer: 4
This patient presents with classic features of domestic violence. The most appropriate next step would be consultation with a social worker at the hospital, assess for child and patient safety, and encouraging the patient to seek self-protection.
Factors suggestive of domestic violence in the patient include pregnancy, delayed presentation after injury, inconsistent history, multiple bruises and complaints of chronic headache/sleep disturbances. Victims frequently miss days of work and as a result are at risk for losing their jobs. Victims are also more likely to engage in high-risk behavior with sex, drugs, alcohol, smoking, and eating.
The AAOS published a document outlining the Orthopaedic Surgeon’s responsibilities in domestic and family violence. Musculoskeletal injuries that should raise a suspicion of a problem include (1) Multiple injuries/fractures; (2) Unusual patterns of injury/fracture; (3) Injuries/fractures of varying ages; (4)
Injuries/fractures inconsistent with or disproportional to the history; (5) Multiple injuries treated in different hospital emergency departments or by different providers.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man undergoes open reduction and internal fixation for a comminuted intra-articular humerus fracture . An olecranon osteotomy is performed and subsequently fixed with an intramedullary cancellous screw. Which of the following options in the table shown in Figure A best describes the characteristics of this osteotomy?

Question 78

An active 65-year-old man has pain in the left shoulder 5 years after undergoing a hemiarthroplasty. He has a remote history of two previous instability operations. Examination reveals that forward elevation is 140 degrees and external rotation is 40 degrees. Serologic studies for infection are negative. AP and axillary radiographs are shown in Figures 7a and 7b. What surgical procedure will provide the most predictable pain relief and function? Review Topic

Explanation

The radiographs show glenoid arthrosis, which is common after a hemiarthroplasty. Conversion to a conventional total shoulder arthroplasty with placement of a glenoid component predictably decreases pain and improves function. There is no indication for a reverse total shoulder arthroplasty because the patient has 140 degrees of elevation with an intact rotator cuff. Biologic resurfacing has more unpredictable results and is usually reserved for younger patients in whom a prosthetic glenoid component might not be desired. Both resection arthroplasty and arthrodesis are associated with poor function.

Question 79

A 19-year-old collegiate offensive lineman injures his left elbow in a scrimmage. He reports reaching out with his left arm to prevent the defensive player from getting around him, and, as he grabbed the player, his elbow was forced into extension. He had immediate pain and weakness and heard a “pop.” He has mild swelling in the antecubital fossa and a prominent-appearing biceps muscle belly. His hook test result is abnormal at the elbow. Which type of contraction of the involved muscle most likely resulted in this lineman's injury?

Explanation

This patient had an eccentric muscle contraction (muscle lengthening while contracting) of his biceps muscle while trying to stop a defender from getting around him. This in turn caused failure of the distal biceps tendon, as evidenced by pain in the antecubital fossa, lack of elbow supination strength, and his positive biceps active test finding (supination/pronation of the forearm showing no motion of the biceps muscle belly). Eccentric contractors have the highest potential for building strength but also are at highest risk for injury. Concentric (muscle shortening with contraction), isometric (no change in muscle length with contracture), and isokinetic (constant velocity of muscle contraction with a variable force) do not describe the mechanism detailed. The loss of distal biceps attachment will result in loss of elbow supination strength in flexion (the biceps is the only supinator to cross the elbow) while still retaining elbow flexion (albeit weakened) because of the other elbow flexors (brachioradialis and brachialis). Consequently, treatment should be anatomic repair of the distal biceps insertion, which can be performed with a 2-incision or 1-incision technique. Although all of the listed complications have been reported with these techniques, LABC neuropraxia is by far the most common. Radiographs show that this athlete’s injury was repaired using a 1-incision technique with a cortical fixation device and a radial bone tunnel. This technique has gained favor because of its decreased incidence of heterotopic ossification and radioulnar synostosis compared with the 2-incision technique. The most troubling complication for most surgeons is the development of a posterior interosseous nerve (PIN) palsy, which this patient clearly demonstrates in addition to the more common LABCN upon postsurgical examination. Because the LABCN injury is typically a neuropraxia from retraction, a period of observation is indicated. PIN injury can result from excessive traction during surgical exposure or from entrapment by the fixation button. Considering the anatomy of the PIN, successful recovery of the nerve typically progresses based on the distance from the origin of the nerve to the muscle indicated. The extensor indicis proprius (EIP) muscle is the most distal muscle innervated and can be expected to recover last. First to return would be the EDC
followed by the ECU, EDQ, and, finally, the EIP.

Question 80

Figure 83 is the CT scan of a 36-year-old man who fell from a roof. Eight hours later at the emergency department he describes low-back pain with numbness and weakness in his bilateral lower extremity. A neurologic examination reveals 2/5 strength in his quadriceps and iliopsoas bilaterally, 2/5 strength in his right anterior tibialis and gastrocsoleus, and 1/5 strength in his left anterior tibialis and gastrocsoleus. Two hours later, strength in his lower extremities has diminished markedly. What is the best next step?

Explanation

DISCUSSION
Any progressive neurologic deficit requires emergent surgical intervention. Lumbar injuries cannot be reliably reduced with traction. Although IV steroids and management of mean arterial blood pressure are appropriate interventions for injuries in the region of the conus medullaris, steroids are only indicated when given within 8 hours of injury and are not appropriate as a sole means of management for progressive neurologic deficit.
RECOMMENDED READINGS
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.
Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508. View Abstract at PubMed

Question 81

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Explanation

The images demonstrate a L5 selective root block as it exits the L5-S1 foramen. This root block best helps relieve pain or paresthesias in the L5 distribution, which is the dorsal first web space and the great toe. The lateral foot is an S1 distribution and would need to be blocked through the posterior first sacral foramen. The anterior shin and thigh represent the L4 root which exits a level above this at the L4-5 foramen. A stocking distribution is nonanatomic and not indicative of a specific root.

Question 82

A 54-year-old man with metastatic renal cell carcinoma has had increasing pain in the left hip for the past 6 weeks. A radiograph is shown in Figure 36. Prophylactic stabilization will most likely result in

Explanation

DISCUSSION: Prophylactic stabilization of impending fractures does not directly affect the overall survival rate, but it does improve factors related to intraoperative and postoperative complications and decreased recovery time.
REFERENCES: Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.
Harrington KD: Impending pathologic fractures from metastatic malignancy: Evaluation and management. Instr Course Lect 1986;35:357-381.

Question 83

An anatomic reduction is obtained at the femoral neck. The most likely reason for development of avascular necrosis (AVN) in this scenario would be

Explanation

DISCUSSION
A damage-control approach is indicated for this patient. Debridement of the open fracture wound and rapid stabilization without an extensive surgical
approach are indicated. Rapid percutaneous fixation of the femoral neck would compromise long-term outcomes for this displaced fracture because obtaining a quality reduction and fixation construct is critical for the long-term outcome. This patient likely would not tolerate cephalomedullary nailing or open approaches very well at this time.
A vertically oriented (Pauwels 3) femoral neck fracture is more common in younger patients who sustain high-energy injuries. Because of the mechanism of injury, many of these patients have associated injuries. This is a biomechanically challenging fracture because the fracture is subject to shear forces rather than compression, making it inherently unstable. This type of fracture often necessitates different fixation strategies to counter shearing forces, such as use of a transversely oriented (Pauwels) screw to compress the fracture or a fixed-angle device.
The femoral neck fracture should be prioritized in this scenario. This does not necessarily mean that the femoral neck should be repaired first, but the strategy should emphasize optimal fixation of the femoral neck. It has been demonstrated that this is less successful when using a single implant to repair both fractures. It is possible to place femoral neck fixation around an antegrade femoral nail; however, it is much more likely that optimal fixation will be achieved with shaft fixation that does not obstruct placement of fixation for the femoral neck.
AVN is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.
RECOMMENDED READINGS
Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-
3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS.G.01353. PubMed PMID: 18676894. View Abstract at PubMed
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies. J Orthop Trauma. 2009 Apr;23(4):249-53. doi: 10.1097/BOT.0b013e3181a03675. PubMed PMID: 19318867. View Abstract at PubMed
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PubMed PMID: 15292419. View Abstract at PubMed Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PubMed PMID: 9682073. View Abstract at PubMed
Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40. PubMed PMID: 15446534. View Abstract at PubMed
RESPONSES FOR QUESTIONS 96 THROUGH 99
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
Match the appropriate oral anticoagulant listed with the description.
This medication is a vitamin K antagonist and can be reversed.
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Question 84

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

Explanation

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

Question 85

Figure 1 shows the radiograph of a 71-year-old man who has had increasing pain and weakness in his shoulder for the past 3 years. Nonsurgical management has failed to provide relief. Examination shows 130 degrees of active forward flexion and intact external rotation strength. During surgery, a 1- x 1-cm rotator cuff tear involving the supraspinatus is encountered. Treatment should include

Explanation

DISCUSSION: Given the size of the rotator cuff tear, it is likely to be repaired; therefore, the treatment of choice is a total shoulder replacement with rotator cuff repair. Severe rotator cuff insufficiency can lead to early glenoid failure because of superior instability, and glenoid resurfacing should be avoided in those instances.
REFERENCES: Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS: Total shoulder arthroplasty versus hemiarthroplasty: Indications for glenoid resurfacing. J Arthroplasty 1990;5:329-336.
Arntz CT, Jackins S, Matsen FA III: Prosthetic replacement of the shoulder for treatment of defects in the rotator cuff and surface of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485-491.

Question 86

A 29-year-old woman was injured in a high-speed motor vehicle accident 3 hours ago. Radiographs are shown in Figures 7a through 7e. Her right foot injury is open and contaminated. Her associated injuries include a closed head injury and a ruptured spleen requiring resection. She has had 6 units of packed red blood cells and the trauma surgeon has turned her care over to you. Her current base deficit is 10 and her urinary output has averaged 0.4 mL/kg for the last 2 hours. What is the best treatment at this time?

Explanation

DISCUSSION: The patient appears to be a borderline or unstable surgical patient following her initial trauma and spleenectomy (high base excess and low urine output). She needs continued resuscitation and minimal additional blood loss. This is best accomplished with irrigation and debridement of the ankle, external fixation of the ankle, foot, and femur, and splinting of the forearm. A traction pin for the femoral fracture will not control bleeding as well as an external fixator. Intramedullary nailing of the femur and open reduction and internal fixation of the forearm would be appropriate in patients that are euvolemic and stable.
REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.
Taeger G, Ruchholtz S, Waydhas C, et al: Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005;59:409-416.
Harwood PJ, Giannoudis PV, van Griensven M, et al: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446-452.
Renaldo N, Egol K: Damage-control orthopaedics: Evolution and practical applications.

Am J Orthop 2006;35:285-291.

Question 87

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

Explanation

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

Question 88

What is the greatest benefit of external fixation for treatment of displaced and unstable pelvic ring injuries with hemodynamic instability? Review Topic

Explanation

External fixation has been shown not to provide rigid fixation of the pelvis because a long moment arm from the fixator clamps to the posterior pelvis. Even with elaborate constructs, the fixator alone is inferior to internal fixation of the posterior ring. The main purpose of acute external fixation is to stabilize the initial clot forming about the injured pelvic plexus. This initial clot contains innate clotting factors, making it more stable, if not dislodged. If this clot is dislodged after hemorrhage and factor poor resuscitation, the ensuing hemorrhage will not have the same ability to form a stable clot around the injured vessels. The fixator does not stabilize any visceral structures. It interferes with the ability to sit depending on its application and is no more or less comfortable than skeletal traction.

Question 89

A 38-year-old man sustains a complete avulsion with retraction of the ischial attachment of the hamstring muscles in a fall while water skiing. He indicates that he is an aggressive athlete who participates regularly in multiple running and cutting-type sports, and he strongly desires to continue his athletic competition. Management should consist of

Explanation

DISCUSSION: Several studies have identified a complete proximal avulsion of the hamstring muscles as an injury that leads to significant long-term disability, with a high percentage of athletes who must permanently restrict their activities following nonsurgical management. Early surgical repair and prolonged rehabilitation have yielded consistently better results than nonsurgical management.
REFERENCES: Orava S, Kujala UM: Rupture of the ischial origin of the hamstring muscles. Am J Sports Med 1995;23:702-705.
Clanton TO, Coupe KJ: Hamstring strains in the athlete: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:237-248.

Question 90

Passive glycation of articular cartilage results in

Explanation

DISCUSSION: Passive glycation of articular cartilage occurs over decades. One of the consequences of this glycation appears to be the stiffening of collagen. This phenomenon appears to be associated with an increased collagen degradation and development of osteoarthrosis. Passive glycation also results in a relatively yellow appearance. Passive glycation does not directly influence chondrocyte proliferation.
REFERENCES: DeGroot J, Verzijl N, Wenting-van Wijk MJ, et al: Accumulation of advanced glycation end products as a molecular mechanism for aging as a risk factor in osteoarthritis. Arthritis Rheum 2004;50:1207-1215.
Chen AC, Temple MM, Ng DM, et al: Induction of advanced glycation end products and alterations of the tensile properties of articular cartilage. Arthritis Rheum 2002;46:3212-3217.

Question 91

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

Explanation

DISCUSSION: In the study done by Pevny and associates, 35% of patients older than age 40 years sustained rotator cuff tears and 8% had axillary nerve palsies. All of the patients with axillary nerve palsy also had rotator cuff tears. Imaging of the rotator cuff is indicated in this age group. The incidence of recurrent instability in patients older than age 40 years is 10% to 15%.
REFERENCES: Pevny T, Hunter RE, Freeman JR: Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy 1998;14:289-294.
Sonnabend DH: Treatment of primary anterior shoulder dislocation in patients older than 40 years of age: Conservative versus operative. Clin Orthop 1994;304:74-77.
Hawkins RJ, Mohtadi NG: Controversy in anterior shoulder instability. Clin Orthop 1991;272:152-161.

Question 92

The mother of an otherwise healthy 1-month-old infant reports that he is not moving his left leg after falling from his high chair 2 days ago. He has a temperature of 99.5°F (37.5°C). Examination reveals that the left thigh is moderately tender to palpation. Because the infant is apprehensive, range of motion is difficult to quantify, but appears to be normal at the hips and ankles. Range of motion of the left knee is approximately 25° to 90°. A radiograph of the leg is shown in Figure 27. Management should consist of

Explanation

DISCUSSION: The patient has a bucket-handle fracture of the distal femur with bilateral corner fractures of the distal femur and a transverse fracture of the proximal tibia. These fractures are virtually pathognomonic of child abuse. The infant should be admitted to the hospital, and child protection services should be notified for investigation of possible abuse. A skeletal survey should be obtained, along with laboratory studies that include a CBC, a platelet count, a prothrombin time, a partial thromboplastin time, and a bleeding time.
REFERENCES: Akbarnia BA: The role of the orthopaedic surgeon in child abuse, in Morrissy RT, Weinstein SL (eds): Lovell & Winter’s Pediatric Orthopaedics, ed 4. Philadelphia, Pa, Lippincott-Raven, 1996, pp 1315-1334.
Black GB: Child abuse fractures, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 931-944.

Question 93

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Explanation

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

Question 94

In a patient who has rheumatoid arthritis with acetabular protrusion, what is the best biomechanical position for the cup with respect to the preoperative center of rotation?

Explanation

DISCUSSION: Acetabular protrusion in patients with rheumatoid arthritis moves the center of hip rotation medially and posteriorly. Positioning of the acetabular component in a patient with protrusion is best accomplished in the normal (anterior and inferior) position and not in a protruded position. This has been shown both clinically and in a finite-element analysis. Any medial positioning will produce impingement of the prosthesis neck on the rim, and superior placement produces improper hip mechanics.
REFERENCES: Crowninshield RD, Brand RA, Pedersen DR: A stress analysis of acetabular reconstruction in protrusio acetabuli. J Bone Joint Surg Am 1983;65:495-499.
Ranawat CS, Dorr LD, Inglis AE: Total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis. J Bone Joint Surg Am 1980;62:1059-1065.

Question 95

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Explanation

DISCUSSION: The patient has a comminuted fracture of the proximal femur and joint space narrowing of the acetabulum. Therefore, the prosthesis should be converted to a total hip arthroplasty. Because there is extensive comminution, the revision stem should bypass the area of bone loss by two bone diameters. A hemiarthroplasty is not indicated because the patient has no acetabular cartilage. Open reduction and internal fixation may not stabilize the prosthesis. A resection arthroplasty or treatment in traction will not leave the patient with adequate function.
REFERENCES: Garbuz DS, Masri BA, Duncan CP: Periprosthetic fractures of the femur: Principles of prevention and management, in Cannon WD Jr (ed): Instructional Course Lectures 47. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 237-242.
Montijo H, Ebert FR, Lennox DA: Treatment of proximal femur fractures associated with total hip arthroplasty. J Arthroplasty 1989;4:115-123.

Question 96

Results of a study demonstrating no difference between treatments when a difference truly exists is an example of which of the following?

Explanation

A type II error (also known as a beta error) occurs when results demonstrate that two groups are similar when, in reality, they are different (with regard to the statistic being measured). Type I errors show that a difference exists when, in reality, no difference exists. A statistically insignificant result may lead an investigator to conclude that no difference exists between two groups; this may be correct (and therefore not a type II error). The concept of fragile p-values is that small sample sizes may result in wide variability of p-values with only one change in a data point for a given group. This singular change could be a chance occurrence, but it still can affect the statistical
significance of the outcomes analysis. Fragility of p-values is limited by increasing sample sizes. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

Question 97

A 69-year-old woman has just undergone an uncomplicated total shoulder arthroplasty for glenohumeral osteoarthritis. A press-fit humeral stem and a cemented all-polyethylene glenoid component were placed. At this point, what is the postoperative rehabilitation plan?

Explanation

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program

at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 98

At what age does the lateral epicondyle normally ossify in males?

Explanation

The lateral epicondylar epiphysis is the last to ossify in the elbow at age 12 to 14 years in males. The first secondary ossification center to ossify is the capitellum, which ossifies during the first 6 months of life. Next is the radial head, ossifying between age 3 and 6 years. The medial epicondyle appears between 5 and 7 years; the trochlea and olecranon at 8 and 10 years, respectively. In females, the appearance of ossification centers is about a year earlier than males.

Question 99

Which modality has the broadest application for reduction of postsurgical transfusion?

Explanation

DISCUSSION
TXA is easy to administer, inexpensive, and safe for virtually all patients. Multiple studies have demonstrated transfusion rates lower than 3% for total knee arthroplasty and lower than 10% for total hip arthroplasty. Regional and hypotensive anesthesia effectively reduce transfusion; however, they cannot be used in as wide a range of patients as TXA. A reduced transfusion trigger must be considered along with patient symptoms when determining the need for transfusion.

Question 100

Changes to the properties of ultra-high molecular weight polyethylene with increasing irradiation dose include improved

Explanation

DISCUSSION: Increased irradiation doses cause a decrease in the mechanical properties of the polyethylene, resulting in a decrease in ultimate tensile strength, fracture toughness, and resistance to crack propagation.
Irradiation leads to the production of free radicals, requiring a step in the manufacturing process (melting, annealing, vitamin E doping) to stabilize the free radicals and reduce the potential for oxidation. Wear resistance is improved with irradiation; however, there is minimal benefit with doses of greater than 10 Mrads.
REFERENCES: Collier JP, Currier BH, Kennedy FE, et al: Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop Relat Res 2003;414:289-304.
Gordan AC, D’Lima DD, Colwell CW Jr: Highly cross-linked polyethylene in total hip arthroplasty. J Am Acad
Orthop Surg 2006;14:511-523.
Jacobs CA, Christian CP, Greenwald AS, et al: Clinical performance of highly cross-linked polyethylenes in total hip arthroplasty. J Bone Joint Surg Am 2007;89:2779-2786.

Full Question & Answer Text (for Search Engines)

Question 1:

Examination of a 10-year-old girl with a hypoplastic breast and atrophic pectoralis major may also reveal which of the following findings?

Options:

Absent middle phalanx
Absent deltoid muscle
Absent radius
Contralateral hypoplastic thumb
Clubfoot deformity

Correct Answer: Absent middle phalanx

Explanation:

Question 2:

- A patient has a noncomminuted displaced fracture of the radial head with a distal radioulnar dissociation. What is the most appropriate treatment for the radial head?

Options:

Allograft Replacement
Radioulnar synostosis
Excision of the radial head
Open reduction and internal fixation
Silicone radial head replacement

Correct Answer: Open reduction and internal fixation

Explanation:

Question 3:

Options:

immobilization for 3 weeks, followed by rehabilitation.
open biceps tenodesis.
arthroscopy with revision stabilization.
arthroscopy with repair of the superior labrum.
subscapularis repair.

Correct Answer: subscapularis repair.

Explanation:

Question 4:

Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?

Options:

Suprascapular nerve entrapment
Supraspinatus and infraspinatus tendon tear
Muscular dystrophy
Thoracic outlet syndrome
Spinal accessory nerve disruption

Correct Answer: Suprascapular nerve entrapment

Explanation:

Question 5:

Options:

Type I error
Type II error
Selection bias
Recall bias This study represents a randomized clinical trial with two groups. However, the sample size is small, increasing the risk for type II error, or false-negative findings. Increasing the number of patients in each group would lead to increased power, thereby reducing the risk of a type II error. A type I error is the rejection of a true null hypothesis (false-positive). A randomized trial reduces the risk of selection bias as patients are assigned to groups in a random fashion. Recall bias occurs when participants do not accurately remember previous events or experiences from the past.

Correct Answer: Type II error

Explanation:

Question 6:

Options:

prone.
lateral.
supine.
sloppy lateral .

Correct Answer: prone.

Explanation:

Question 7:

Options:

Talectomy
Revision open reduction and internal fixation (ORIF) with bone grafting
Ankle arthrodesis
Tibiotalocalcaneal arthrodesis
Triple arthrodesis

Correct Answer: Revision open reduction and internal fixation (ORIF) with bone grafting

Explanation:

Question 8:

If the patient had an isolated spine injury without neurologic deficit, the most appropriate next step would be

Options:

anterior corpectomy with percutaneous pedicle screw stabilization.
percutaneous pedicle screw stabilization.
posterior pedicle screw stabilization with fusion.
MRI.

Correct Answer: MRI.

Explanation:

DISCUSSION
The treatment of thoracolumbar burst fractures has evolved over the years. In the absence of a neurologic deficit or a posterior ligamentous complex injury, nonsurgical treatment is as effective as surgery. The degree of spinal canal compromise is not a risk factor for neurologic symptoms. Similarly, although kyphosis may be a marker of more significant injury, the degree of kyphosis does not correlate with chronic pain. In the setting of a burst fracture, MRI can be used to evaluate the integrity of the posterior ligamentous complex. Polytrauma may be considered a relative indication for surgical intervention in the setting of a stable burst fracture.
RECOMMENDED READINGS
Rechtine GR 2nd. Nonoperative management and treatment of spinal injuries. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S22-7; discussion S36. Review. PubMed PMID: 16685232.
View Abstract at PubMed
Shen WJ, Shen YS. Nonsurgical treatment of three-column thoracolumbar junction burst fractures without neurologic deficit. Spine (Phila Pa 1976). 1999 Feb 15;24(4):412-5. PubMed PMID: 10065527.
View Abstract at PubMed
Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V. Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am. 2003 May;85-A(5):773-81. Erratum in: J Bone Joint Surg Am. 2004 Jun;86-A(6):1283. Butterman, G [corrected to Buttermann, G]. PubMed PMID: 12728024.
View Abstract at
PubMed
Wood KB, Li W, Lebl DS, Ploumis A. Management of thoracolumbar spine fractures. Spine J. 2014 Jan;14(1):145-64. doi: 10.1016/j.spinee.2012.10.041. Review. PubMed PMID: 24332321.
View Abstract at PubMed

Question 9:

Options:

Debridement of the labral tear plus bony resection of the pincer lesion
Debridement of the labral tear and no bony resection of the pincer lesion
Femoral neck osteoplasty plus labral repair using suture anchor
Resection of the bony pincer lesion plus labral repair using suture anchor

Correct Answer: Resection of the bony pincer lesion plus labral repair using suture anchor

Explanation:

DISCUSSION
Video 67 for reference
This clinical scenario describes a patient with FAI attributable to pincer (acetabular) deformity. This form of FAI, which involves prominence of the anterosuperior acetabular lip, may be more common among women. Decreased range of motion and pain occur secondary to the abutment of the femoral head against the acetabular labrum and rim. Hip flexion, combined with adduction and internal rotation, recreates this contact and causes pain, but CAM or pincer etiology remains unknown.
The differential diagnosis of hip pain in a young athlete includes femoral neck stress reaction/fracture, sacroiliac arthritis, intra-articular loose body, trochanteric bursitis, osteitis pubis, and hernia. No information presented in this scenario suggests any of these causes. Diagnosis of FAI is best performed via MR imaging, with an arthrogram increasing the sensitivity and specificity for labral pathology. An ultrasound may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasound is not commonly used to diagnose labral pathology.
Although concomitant chondral lesions of the femoral head are uncommon, the forced leverage of the anterosuperior femoral neck upon the anterior acetabulum may result a “contra-coup” chondral injury on the posteroinferior acetabulum. This is the most common location of chondral lesions in this scenario. Without bony resection to prevent further impingement, this patient will continue to experience symptoms. Because there is no evidence of femoral neck prominence (CAM lesion), there is no indication for osteoplasty of the femoral neck; resection of the pincer lesion is necessary. This will often require take-down of the labrum in this location. If possible, iatrogenic or traumatic labral tears should subsequently be repaired after pincer debridement because the labrum has important functions for hip stability and maintenance of the suction seal of the joint.

Question 10:

Options:

Lateral radiographs with passive flexion/extension views
Helical CT scan of the cervical-thoracic region
Careful manual palpation of the cervical spine for subtle defects or step-offs
MRI of the cervical spine
Continued use of the cervical collar until the patient becomes responsive for examination

Correct Answer: Helical CT scan of the cervical-thoracic region

Explanation:

DISCUSSION: Clearance of the cervical spine can be difficult in the obtunded or unresponsive patient. Various trauma series have been reported to detect up to 95% of cervical fractures but only when ideal imaging views have been obtained, which is not often possible in the unresponsive or uncooperative patient. Passively performed cervical flexion-extension under live fluoroscopy has been suggested but is not without inherent risk in the potentially unstable cervical spine. CT of the cervical spine has gained acceptance for the evaluation of these patients given the excellent evaluation of the osseous anatomy and for the common availability in most emergency departments. Sanchez and associates, using a protocol to evaluate for cervical spine injuries after blunt trauma, were able to detect 99% of cervical fractures with 100% specificity.
REFERENCES: Chiu WC, Haan JM, Cushing BM, et al: Ligamentous injuries of the cervical spine in unreliable blunt trauma patients: Incidence, evaluation, and outcome. J Trauma 2001;50:457-463.
Sanchez B, Waxman K, Jones T, et al: Cervical spine clearance in blunt trauma: Evaluation of a computed tomography-based protocol. J Trauma 2005;59:179-183.
Nunez D Jr: Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries:
A prospective study. J Trauma 2000;48:988-989.

Question 11:

Options:

Bankart lesion
Humeral avulsion of the glenohumeral ligament (HAGL) lesion
Superior labrum anterior-posterior (SLAP) lesion
Hill-Sach deformity
Glenoid fracture (bony Bankart)

Correct Answer: Humeral avulsion of the glenohumeral ligament (HAGL) lesion

Explanation:

The MRI scan reveals a HAGL lesion. It more commonly affects older patients and is associated with more violent trauma.

Question 12:

Options:

Immediately
In the second half
In 1 week
In 4 weeks
Next season

Correct Answer: Next season

Explanation:

Question 13:

Options:

Ganglion cyst
Clear cell sarcoma
Epithelioid sarcoma
Epidermal inclusion cyst
Synovial sarcoma

Correct Answer: Clear cell sarcoma

Explanation:

DISCUSSION: The histologic appearance of the soft-tissue lesion reveals compact nests of cells with a clear cytoplasm surrounded by a delicate border of fibrocollagenous tissue. There can be scattered multinucleated giant cells. This is consistent with a clear cell sarcoma, also called malignant melanoma of soft parts. This tumor is usually positive for S-100 and HMB45 (a melanoma-associated antigen). These tumors are frequently found around the foot and ankle. Similar to epithelioid sarcoma, it is usually intimately bound to tendons or tendon sheaths. Often the tumors are present for many years. The classic histologic appearance of this lesion differentiates it from the other choices.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 913.
Lucas DR, Nascimento AG, Sim FH: Clear cell sarcoma of soft tissues: Mayo Clinic experience with 35 cases. Am J Surg Pathol 1992;16:1197-1204.

Question 14:

Options:

a total contact cast.
partial calcanectomy
Syme’s amputation
transtibial amputation.
nonweightbearing and IV antibiotics.

Correct Answer: partial calcanectomy

Explanation:

Question 15:

Options:

Percutaneous screws and cast
Conversion to a circular fixator
Medial and anterolateral locked plates
Medial and anterolateral nonlocked plates
Lateral locked plate and medial malleolus screws

Correct Answer: Medial and anterolateral nonlocked plates

Question 16:

Options:

Adduction
Internal rotation
Abduction and external rotation
Abduction
External rotation

Correct Answer: Adduction

Explanation:

Question 17:

Options:

Equal at 10 years
Lower at 10 years
Higher at 10 years
Not known when using a mobile-bearing UKA

Correct Answer: Lower at 10 years

Explanation:

Question 18:

Options:

Forward elevation in the scapular plane
External rotation and abduction
Flexion, adduction, and internal rotation
Flexion and abduction

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 19:

A 70-year-old former baseball catcher reports long-standing pain in the ring and little fingers. A gradient-echo MRI scan is shown in Figure 26. What is the most likely diagnosis?

Options:

Giant cell tumor of the tendon sheath
Ulnar artery aneurysm
Lipoma
Hematoma
Neurolemmoma

Correct Answer: Ulnar artery aneurysm

Explanation:

DISCUSSION: The gradient-echo MRI scan highlights the ulnar and radial arteries,
as indicated by the arrow. This technique suppresses the signal of the surrounding fat
and causes the stationary surrounding tissues to become intermediate in signal intensity.
The flowing blood is then easily identified with a bright signal because it does not absorb the radiofrequency pulse. Based on the findings, the diagnosis is an ulnar artery aneurysm, most likely caused by years of repetitive trauma as the result of catching baseballs. Neurolemmoma and giant cell tumor of the tendon sheath would be intermediately enhanced on this image sequence, and the continuity with the ulnar artery, demonstrated here, would not be expected. Lipomas are not enhanced using the gradient-echo technique. The chronic nature of the patient’s symptoms is not indicative of a hematoma, and the hematoma would be dark on this imaging sequence since it is stationary tissue.
REFERENCES: Koman LA, Ruch DS, Patterson Smith B, et al: Vascular disorders, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, vol 2, pp 2254-2302.
Holder LE, Merine DS, Yang A: Nuclear medicine, contrast angiography, and magnetic resonance imaging for evaluating vascular problems in the Hand: Vasospastic disorders. Hand Clin 1993;9:95-113.

Question 20:

Options:

Plantar fasciitis
Calcaneal apophysitis
Achilles tendinitis
Calcaneal bursitis
Stress fractures of the calcanei

Correct Answer: Calcaneal apophysitis

Explanation:

Question 21:

Following a vertebroplasty of L2, cement is noted to protrude directly anterior to the L2 vertebral body. The cement is closest to which of the following structures?

Options:

Inferior vena cava
Pancreas
Duodenum
Left lobe of the liver
Descending aorta

Correct Answer: Descending aorta

Explanation:

DISCUSSION: At the level of L2, the liver and the vena cava lie to the right. The pancreas
and duodenum are anterior to the aorta. The aorta lies in the midline just in front of the
vertebral body.
REFERENCES: Clement CD: Anatomy: A Regional Atlas of Human Anatomy, ed 3.
Baltimore, MD, Munich, Germany, Urban and Schwarzberg, 1987, Figure 331.
Netter FH: Atlas of Human Anatomy. Summit, NJ, Ciba-Geigy, 1989, plate 328.

Question 22:

Based on the findings seen in the radiograph in Figure 26, emergent management should consist of

Options:

volar open reduction and pinning.
open reduction, ligament repair, and pinning.
closed reduction and splinting.
closed reduction and pinning.
dorsal open reduction and pinning.

Correct Answer: closed reduction and splinting.

Explanation:

Question 23:

Options:

LMWH is associated with bleeding complications of less than 1% and may be administered immediately after surgery.
LMWH is superior to adjusted-dose warfarin.
LMWH acts on several sites of the coagulation cascade, with its principal action inhibition of factor 10a.
LMWH and unfractionated heparin are equally likely to cause thrombocytopenia.
LMWH may be used in conjunction with regional anesthesia and is not contraindicated in patients with indwelling epidural catheters.

Correct Answer: LMWH acts on several sites of the coagulation cascade, with its principal action inhibition of factor 10a.

Explanation:

Question 24:

Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively?

Options:

Sling immobilization
Displacement and comminution
Age less than 40 years old
Immediate motion exercises
Male

Correct Answer: Sling immobilization

Explanation:

Question 25:

Which of the following provocative tests would most likely be positive in a patient with medial epicondylitis? Review Topic

Options:

Resisted forearm pronation and wrist flexion with a clenched fist
Resisted forearm supination and wrist extension with a clenched fist
Dynamic valgus stress test
Milking maneuver
Pinch grip test

Correct Answer: Milking maneuver

Explanation:

Question 26:

What is the most appropriate treatment at this time?

Options:

IV steroids and antibiotics
IV antibiotics
Anterior decompression and fusion
Posterior laminectomy and instrumented fusion

Correct Answer: Anterior decompression and fusion

Explanation:

DISCUSSION
Prompt diagnosis and treatment of patients with spinal epidural abscess is crucial to maintain and/or improve neurologic function. This clinical scenario stresses the importance of advanced imaging studies. It is also important to recognize the imaging features of spinal epidural abscess. T1-weighted gadolinium-enhanced images show ring enhancement with a central nonenhancing, low-signal area. In such a case, urgent decompression is indicated. Because of the location of the abscess, which is anterior to the spinal cord, an anterior decompression and reconstruction (ie, fusion) is probably the best treatment plan. Steroids are contraindicated in the presence of an epidural abscess. IV antibiotics alone will not adequately treat a patient with a neurological deficit. A posterior laminectomy and fusion will not safely allow access to the abscess.
RECOMMENDED READINGS
Bluman EM, Palumbo MA, Lucas PR. Spinal epidural abscess in adults. J Am Acad Orthop Surg. 2004 May-Jun;12(3):155-63. Review. PubMed PMID: 15161168.
View Abstract at PubMed
Ghobrial GM, Beygi S, Viereck MJ, Maulucci CM, Sharan A, Heller J, Jallo J, Prasad S, Harrop JS. Timing in the surgical evacuation of spinal epidural abscesses. Neurosurg Focus. 2014 Aug;37(2):E1. doi: 10.3171/2014.6.FOCUS14120. PubMed PMID: 25081958.
View
Abstract
at PubMed
This is the last question of the exam.

Question 27:

Options:

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

Correct Answer: Periacetabular osteotomy

Explanation:

Question 28:

Options:

Parosteal osteosarcoma
Classic osteogenic sarcoma
Ewing’s sarcoma
Osteochondroma
Chondrosarcoma

Correct Answer: Parosteal osteosarcoma

Explanation:

Question 29:

- The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Options:

disuse osteopenia
paraendocrine effect of the tumor
abnormally increased density on the right side
side effect of the treatment of the lesion
extensive tumor involvement of the left hip

Correct Answer: disuse osteopenia

Explanation:

Question 30:

Options:

repair of a triceps tendon avulsion.
arthroscopy of the elbow for removal of loose bodies.
arthroscopic removal of a posteromedial olecranon osteophyte.
internal fixation of an olecranon stress fracture.
rest, rehabilitation, and resumption of pitching when the fracture is healed.

Correct Answer: rest, rehabilitation, and resumption of pitching when the fracture is healed.

Explanation:

Question 31:

When comparing mobile-bearing total knee arthroplasty (TKA) to fixed-bearing total condylar arthroplasty, the mobile-bearing procedure provides

Options:

no improvement in survivorship.
approximately 15 degrees greater flexion.
appreciable reduction in wear rates.
a faster recovery profile.
better quadriceps strength.

Correct Answer: no improvement in survivorship.

Explanation:

DISCUSSION: Survivorship is similar in the two groups. In a recent study, mobile-bearing TKAs showed a slightly higher maximum flexion than the total condylar fixed-bearing-type designs (112 degrees versus 108 degrees with no difference in recovery rate). Using a fixed-bearing or a mobile-bearing design did not seem to influence the recovery rate in early results after knee arthroplasty. Mobile-bearing arthroplasties are suggested, in theory, to offer a reduction in polyethylene wear; however, clinical studies have not yet proven this. Recovery rates have yet to be statistically seen as improved with either method. Differences in strength have not been shown.
REFERENCES: Aglietti P, Baldini A, Buzzi R, et al: Comparison of mobile-bearing and fixed-bearing total knee arthroplasty: A prospective randomized study. J Arthroplasty 2005;20:145-153.
Sorrells RB: The rotating platform mobile bearing TKA. Orthopedics 1996;19:793-796.
Dennis DA, Komistek RD: Kinematics of mobile-bearing total knee arthroplasty. Instr Course Lect 2005;54:207-220.

Question 32:

Options:

ACL tear and medial meniscal tear
Medial mensical tear only
PCL tear and medial meniscal tear
PLC tear and meniscal tear
PCL tear only

Correct Answer: ACL tear and medial meniscal tear

Explanation:

Question 33:

A college basketball player is struck in the eye by a player’s hand while driving to the basket. Fluorescein evaluation reveals the injury shown in Figure 18. Management should consist of

Options:

administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.
evaluation of intact visual fields and pupillary responses prior to a return to play.
consultation with an ophthalmologist prior to emergent repair of the damaged structure.
measurement of ocular pressure and fundoscopic examination in a properly lit examination room.
strict bed rest with the head elevated, minimizing head motion during the healing process.

Correct Answer: administration of ophthalmic corticosteroids and antibiotics with application of an eye patch.

Explanation:

Question 34:

What is the treatment of choice for the injury shown in Figures 20a through 20c?

Options:

Closed reduction and a short arm cast
Splinting in a functional position and early motion
Closed or open reduction and internal fixation with Kirschner wires
Open reduction and internal fixation with mini-fragment screws
Primary arthrodeses of the carpometacarpal joints

Correct Answer: Closed or open reduction and internal fixation with Kirschner wires

Explanation:

Question 35:

Options:

increased laxity.
increased risk for graft failure.
no differences in long-term results.
lower Knee Injury and Osteoarthritis Outcome Score (KOOS).

Correct Answer: no differences in long-term results.

Explanation:

Question 36:

Which of the following types of ultra-high molecular weight polyethylene has been associated with the poorest clinical performance?

Options:

Compression molded
Heat pressed
Ram extruded
Gamma irradiated
Ethylene oxide sterilized

Correct Answer: Heat pressed

Explanation:

Question 37:

Options:

epiphysis.
apophysis.
enthesis.
tendon.
muscle.

Correct Answer: apophysis.

Explanation:

Question 38:

03 Figure 9 shows the radiograph of a patient who has anterior knee pain and range of motion from 0-of the tibial tubercle. Treatment should consist of

Options:

lateral retinacular release
tibial tubercle transfer
revision of femoral component
revision of tibial component
proximal quadriceps realignment back answer Question 44.03

Correct Answer: revision of femoral component

Explanation:

Question 39:

The acceleration of an object under the influence of a force depends directly on the mass of the object. The angular acceleration of an object under the influence of a moment depends directly on the

Options:

area moment of inertia.
weight squared.
length of the lever arm.
mass moment of inertia.
initial velocity.

Correct Answer: mass moment of inertia.

Explanation:

Question 40:

Options:

Adhesive capsulitis
Sling immobilization
Thermal chondrolysis
Subacromial impingement
Axillary nerve injury

Correct Answer: Axillary nerve injury

Explanation:

Question 41:

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 42:

Options:

Renal osteodystrophy
Diastrophic dysplasia
Metaphyseal dysplasia
Osteogenesis imperfecta
Fibrous dysplasia

Correct Answer: Renal osteodystrophy

Explanation:

Question 43:

Options:

Closed reduction of both fractures and immediate spica casting
Bilateral skin traction for 3 weeks, followed by spica casting
External fixation of both femora
External fixation of the left femur and a long leg cast brace for the right femur
External fixation of the left femur and use of a reamed intramedullary nail in the right femur

Correct Answer: External fixation of both femora

Explanation:

Question 44:

Options:

Similar incidence of postsurgical neck pain with higher risk for radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level
Higher incidence of postsurgical neck pain and adjacent-level radiculopathy
Lower incidence of adjacent segment degeneration and postsurgical neck pain

Correct Answer: Higher incidence of postsurgical neck pain and radiculopathy recurrence at the same level

Explanation:

DISCUSSION
This patient has a right-sided C5-C6 disk herniation causing C6 radicular symptoms in the right upper extremity. Studies have shown that both ACDF and posterior foraminotomy confer similar results in terms of pain relief and functional outcome. Patients treated with posterior foraminotomy are at higher risk for neck pain and recurrence of radiculopathy at the same level. Those who receive ACDF are at higher risk for occurrence of radiculopathy at an adjacent level.
RECOMMENDED READINGS
Rao RD, Currier BL, Albert TJ, Bono CM, Marawar SV, Poelstra KA, Eck JC. Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78. Review. PubMed PMID: 17575617.
View Abstract at PubMed
Bolesta MJ, Gill K. Acute neck pain and cervical disk herniation. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:227-234.

Question 45:

Options:

Spring ligament reconstruction
Lateral column lengthening
Medial-displacing calcaneal osteotomy
Medial cuneiform opening-wedge osteotomy

Correct Answer: Medial-displacing calcaneal osteotomy

Explanation:

Question 46:

Which of the following factors will adversely affect bone ingrowth in a revision porous-coated stem?

Options:

Pore size of 400 m m
Interface instability of 25 m m of micromotion
Use of a nonmodular implant
Noncircumferential metaphyseal patch coating
Failure of ingrowth in the previous stem

Correct Answer: Noncircumferential metaphyseal patch coating

Explanation:

DISCUSSION: The optimal conditions for bony ingrowth include a pore size of 100 to 400
m
m, interface micromotion of 50
m
m or less, intimate contact between the bone and the implant, circumferential porous coating of the implant, and use of a biocompatible material. Stem designs with patch coatings have a poor record of bony ingrowth, especially in the revision setting. Failure of ingrowth in the previous stem would be the result of its own mechanical milieu and would not necessarily predict results for the new stem.
REFERENCES: Berry DJ, Harmsen WS, Ilstrup D, Lewallen DG, Cabanela ME: Survivorship of uncemented proximally porous-coated femoral components. Clin Orthop 1995;319:168-177.
Cook SD, Thomas KA, Haddad RJ Jr: Histologic analysis of retrieved human porous-coated total joint components. Clin Orthop 1988;234:90-101.
Spector M: Historical review of porous-coated implants. J Arthroplasty 1987;2:163-177.

Question 47:

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?

Options:

Flexion contracture of 5°
Subchondral cyst in the medial tibial condyle
Lateral meniscal degeneration seen in an MRI scan
Rheumatoid arthropathy
Previous medial meniscectomy

Correct Answer: Rheumatoid arthropathy

Explanation:

Question 48:

Options:

Admission and traction
Open surgical debridement of the lesion
Perform an open biopsy of the lesion
Nonsurgical treatment with antibiotics and immobilization DISCUSSION -Childhood diskitis represents one end of a continuum of spinal infections, from diskitis to vertebral osteomyelitis with soft-tissue abscess. Diskitis is now generally accepted as a bacterial infection involving the disk space and adjacent vertebral end plates. Optimal treatment includes the use of antibiotics. Empiric coverage is directed against Staphylococcus aureus because it has been the most common organism isolated from culture-positive biopsy specimens. Open biopsy is not necessary for patients who exhibit all of these clinical characteristics, but it is indicated for those whose symptoms do not resolve rapidly with treatment or who have atypical presentation.

Correct Answer: Nonsurgical treatment with antibiotics and immobilization DISCUSSION -Childhood diskitis represents one end of a continuum of spinal infections, from diskitis to vertebral osteomyelitis with soft-tissue abscess. Diskitis is now generally accepted as a bacterial infection involving the disk space and adjacent vertebral end plates. Optimal treatment includes the use of antibiotics. Empiric coverage is directed against Staphylococcus aureus because it has been the most common organism isolated from culture-positive biopsy specimens. Open biopsy is not necessary for patients who exhibit all of these clinical characteristics, but it is indicated for those whose symptoms do not resolve rapidly with treatment or who have atypical presentation.

Question 49:

Options:

Transforming growth factor-beta (TGF-ß), bone morphogenetic protein-2 (BMP-2), latent membrane protein 1
Tissue inhibitor of matrix metallo-proteinase-1 (MMP-1), growth and development factor-5, noggin
Gremlin, MMP, biglycan
Tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), MMP

Correct Answer: Tumor necrosis factor-alpha (TNF-a), Interleukin-1 (IL-1), MMP

Explanation:

DISCUSSION
The patient has degenerative disk disease with diskogenic back pain. Several studies in both humans and animals have implicated TNF-a, IL-1, and MMP in extracellular matrix degeneration and disk degradation. TGF-ß, BMP-2, latent membrane protein 1, and growth and development factor-5 are all postulated to play anabolic roles in the intervertebral disk. Biglycan is a small leucine-rich proteoglycan that regulates extracellular matrix assembly within the disk. Noggin and gremlin are biochemical factors not involved in disk degradation.
RECOMMENDED READINGS
Kim HT, Yoon ST, Jarrett C. Articular cartilage and intervertebral disk. In: Fischgrund JS, ed. Orthopaedic Knowledge Update 9. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:23-33.
Hoyland JA, Le Maitre C, Freemont AJ. Investigation of the role of IL-1 and TNF in matrix degradation in the intervertebral disc. Rheumatology (Oxford). 2008 Jun;47(6):809-14. doi: 10.1093/rheumatology/ken056. Epub 2008 Apr 8. PubMed PMID: 18397957.
View Abstract
at PubMed
Gruber HE, Ingram JA, Hanley EN Jr. Immunolocalization of MMP-19 in the human intervertebral disc: implications for disc aging and degeneration. Biotech Histochem. 2005 May-Aug;80(3-4):157-62. PubMed PMID: 16298901.
View Abstract at PubMed

Question 50:

Options:

Continued observation and monitoring
Obtain arterial blood gas measurements
Obtain emergent spiral CT scan to assess for pulmonary embolism
Insertion of a chest tube
Airway control and, if necessary, endotracheal intubation

Correct Answer: Continued observation and monitoring

Explanation:

Question 51:

Figure 3 shows the radiograph of an asymptomatic 10-year-old boy. Management should consist of

Options:

physical therapy.
restriction from contact sports.
periodic observation, but no activity restriction.
immobilization with a thoracolumbosacral orthosis (TLSO).
direct surgical repair.

Correct Answer: periodic observation, but no activity restriction.

Explanation:

Question 52:

Options:

Perform an immediate wake-up test
Continue with the surgery and reassess in 5 minutes
Administer intravenous methylprednisolone
Ensure that mean arterial blood pressure is 80 or higher

Correct Answer: Ensure that mean arterial blood pressure is 80 or higher

Explanation:

DISCUSSION
The use of intraoperative neuromonitoring is expanding, especially in the setting of deformity surgery. Changes in monitoring are concerning for the possibility of a neurologic injury; however, several other factors can alter signals. These include hypotension, changes in anesthesia depth and medications, the use of paralytic agents, and technical issues such as leads falling out or becoming disconnected. If a change in neuromonitoring signals is noted, these factors should be checked first to rule out false-positive findings. If this does not correct the problem, the wound should be explored to ensure there is no compression on the neural elements. Finally, if the deformity has been corrected, some of the correction can be released in an attempt to improve the signals. A wake-up test is difficult to perform and does not provide specific information regarding the location of the problem or how to correct it. Steroids may be used depending on surgeon preference, but should not be used until neurologic injury is ruled out. Any neuromonitoring changes always necessitate immediate investigation.
RECOMMENDED READINGS
Ziewacz JE, Berven SH, Mummaneni VP, Tu TH, Akinbo OC, Lyon R, Mummaneni PV. The design, development, and implementation of a checklist for intraoperative neuromonitoring changes. Neurosurg Focus. 2012 Nov;33(5):E11. doi: 10.3171/2012.9.FOCUS12263. PubMed PMID: 23116091.
View
Abstract at PubMed
Malhotra NR, Shaffrey CI. Intraoperative electrophysiological monitoring in spine surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2167-79. doi: 10.1097/BRS.0b013e3181f6f0d0.
Review. PubMed PMID: 21102290.
View Abstract at PubMed

Question 53:

There is increasing concern about the ethical relationship of orthopaedists to the orthopaedic equipment industry. Which of the following describes the most appropriate relationship?

Options:

Industry-paid travel, hotel (for the surgeon and spouse), and registration at a university-sponsored CME course
Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved
Consultation agreement ($50,000/annum) between the surgeon and the company for evaluation of the implant system with required oral reporting of impressions
A restricted grant from a company to an orthopaedic residency program with the stipulation that the third year residents be sent to an industry-sponsored course
Industry-paid dinner at a premium restaurant ($200/person) for surgeon and office staff at which a new set of surgical instrumentation is presented

Correct Answer: Industry-paid travel and hotel for a faculty member at an industry-sponsored meeting that is not CME approved

Explanation:

DISCUSSION: It is appropriate for orthopaedic surgeons to have relationships with industry as long as the relationship is for the good of the patient and no “quid pro quo” intent exists. A grant to cover registration at a CME event is appropriate but travel and hotel for a spouse is not. For orthopaedists who are faculty at a meeting sponsored by industry, it is appropriate for travel and expenses to be covered for that faculty member. Care must be exercised that the faculty member contributes in an amount appropriate for the expenses paid. The faculty member must ensure that information presented is unbiased and based on reasonable data and opinion. Consulting agreements should spell out specifically the duties of the agreement and payment should be appropriate for the time spent. There should be a defined work product for the consulting. Agreements that are thinly veiled payments for use of a company’s products must be avoided. In all cases, the agreements must stand up to public scrutiny. Restricted grants for specific industry-sponsored programs aimed at residents are not appropriate. Unrestricted grants intended for attendance at approved CME courses are appropriate. Dinners at which information is presented about topics that can aid in patient care are appropriate as long as the expense is reasonable ($100 or less/person) and the guest list includes individuals who can use the information in a patient case. Clearly a “premium” dinner for office staff to review new surgical instrumentation would not pass this test.
REFERENCE: Opinions on ethics and professionalism, in Guide to The Ethical Practice of Orthopaedic Surgery, ed 6. American Academy of Orthopaedic Surgeons, Rosemont, IL, 2006, pp 38-42.

Question 54:

Figure 62 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. What is the main function of the structure delineated by the black asterisks? Review Topic

Options:

Resist anterior translation during knee flexion
Resist posterior translation during knee flexion
Resist rotatory loads during knee flexion
Resist rotatory loads during knee extension

Correct Answer: Resist rotatory loads during knee extension

Explanation:

Question 55:

Options:

Immediate closed reduction in the intensive care unit while the patient is awake
Posterior spinal laminectomy and fusion with instrumentation
Anterior cervical diskectomy, corpectomy, and plating
High-dose methylprednisolone

Correct Answer: Immediate closed reduction in the intensive care unit while the patient is awake

Explanation:

DISCUSSION
Facet subluxation reduction may be performed in awake patients. Posterior spinal laminectomy and fusion can result in worsening neurologic status and is not recommended in this setting. Generally, corpectomy in the setting of facet subluxation is not recommended because it does not facilitate reduction or fully alleviate spinal cord compression. High-dose steroid use is not supported by current literature.
RECOMMENDED READINGS
Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006 May 15;31(11 Suppl):S28-35; discussion S36. Review. PubMed PMID: 16685233.
View Abstract
at PubMed
Lee AS, MacLean JC, Newton DA. Rapid traction for reduction of cervical spine dislocations. J Bone Joint Surg Br. 1994 May;76(3):352-6. PubMed PMID: 8175833.
View Abstract at
PubMed

Question 56:

Options:

Observation
Closed reduction with a towel clip
Open reduction
Open reduction and internal fixation
Open reduction and sternoclavicular ligament allograft reconstruction

Correct Answer: Closed reduction with a towel clip

Explanation:

Question 57:

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 58:

Options:

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

Correct Answer: Intramedullary nailing of both femurs

Explanation:

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

Question 59:

Options:

Initiation of lumbar flexion and core strengthening exercises
Laminectomy and posterior spinal fusion of L4/5
Laminectomy of L4 without fusion
Percutaneous endoscopic diskectomy
A course of three epidural steroid injections

Correct Answer: Laminectomy and posterior spinal fusion of L4/5

Explanation:

Question 60:

Options:

posterior fusion with instrumentation.
posterior instrumentation without fusion.
anterior fusion with instrumentation.
an orthosis.
bed rest with gradual mobilization.

Correct Answer: posterior fusion with instrumentation.

Explanation:

Question 61:

Options:

hematocrit.
serial heart rate.
serial blood pressure with a manual cuff.
serial blood pressure with an arterial line.
lactate and base deficit levels.

Correct Answer: lactate and base deficit levels.

Question 62:

During placement of an external fixator for a distal radius fracture, the most commonly injured nerve is a branch of which of the following nerves? Review Topic

Options:

Ulnar
Median
Superficial radial
Lateral antebrachial cutaneous
Medial antebrachial cutaneous

Correct Answer: Superficial radial

Explanation:

Pin track infections and sensory injuries are among the most common complications of external fixation for distal radius fractures. The proximal pins of most distal radius external fixators are placed in the “bare area” of the distal radius, about four finger-breadths above the radial styloid. This corresponds to the area where the dorsal sensory branch of the radial nerve penetrates the fascia dorsal to the brachioradialis tendon to become a subcutaneous structure. Injury to the superficial radial nerve may produce painful dysesthesias and neuromas.
(SBQ12TR.106) A 67-year-old female sustains the injury shown in Figure A after a trip and fall. When discussing the outcomes of surgery with the patient, which of the following statements is true?
Post-surgical mortality rates are significantly lower after total hip arthroplasty compared to hemiarthroplasty
Internal fixation shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to arthroplasty
Bipolar hemiarthroplasty shows better outcomes (reoperation rate, functional status, and/or complication rates) compared to unipolar hemiarthroplasty
A delay in surgery greater than 48 hours is recommended if the patient has multiple medical comorbiditiesm which are not fully optimized
Dislocation rates are equivalent between total hip arthroplasty and hemiarthroplasty
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes. However, patients with significant medical comorbidity should be fully optimized before surgery.
Although several studies have shown a benefit to surgery within 48 hours, no definitive time frame has been elucidated. The majority of literature has shown improved outcomes in regards to pain, complications, and length of stay with early surgery. Patients with significant medical comorbidities have been shown to have the highest mortality rates.
Moran et al. aimed to determine whether a delay in surgery for hip fractures had an affect on postoperative mortality among elderly patients. In an observational study of 2660 patients, they showed that mortality following hip fracture surgery was 9% at 30-days, 19% at 90-days, and 30% at 12-months. Patients with medical comorbidities had 2.5 times the risk of death within 30-days of surgery. In addition, individuals who had surgery delayed beyond 4 days had increased mortality at 90-days and 12-months.
Papakostidis et al. examined the timing of internal fixation of intracapsular fractures of the neck of femur on the development of late complications, particularly osteonecrosis of femoral head (ONFH) and non-union. They showed no benefit of
early surgery on incidence of AVN. However, delay of internal fixation of more than
24 hours showed increased rates of non-union.
Figure A shows a displaced right femoral neck fracture. Incorrect Answers:

Question 63:

Options:

Nonsteroidal anti-inflammatory drugs
MRI of the spine
CT myelography
Flexion-extension plain films

Correct Answer: MRI of the spine

Explanation:

DISCUSSION
Patients with ankylosing spondylitis are at high risk for occult fractures after low-energy injuries. Although radiographs and a CT scan do not demonstrate a spinal fracture in this patient, high risk for an unstable occult fracture necessitates further imaging with MRI to ensure that no fractures are missed. Although a CT scan is typically the primary imaging modality for workup of spine injuries in similar patients, CT and MRI complement each other and each detects fractures that are missed using the other modality. A CT myelogram might detect cord or root compression but would not aid in the diagnosis of an occult fracture. Nonsteroidal anti-inflammatory drugs are first-line treatment for idiopathic low-back pain. In a patient with ankylosing spondylitis at high risk for fracture, further workup is needed to rule out an occult fracture. Flexion and extension radiographs of the spine are inferior to MRI for evaluating occult fractures and ligamentous injuries. The primary concern for this patient remains an unstable spinal fracture, which necessitates an MRI of the spine before initiating a workup for other possible causes of his back pain.
RECOMMENDED READINGS
Duane TM, Cross J, Scarcella N, Wolfe LG, Mayglothling J, Aboutanos MB, Whelan JF, Malhotra AK, Ivatury RR. Flexion-extension cervical spine plain films compared with MRI in the diagnosis of ligamentous injury. Am Surg. 2010 Jun;76(6):595-8. PubMed PMID: 20583514.
View Abstract at PubMed
Hitchon PW, From AM, Brenton MD, Glaser JA, Torner JC. Fractures of the thoracolumbar spine complicating ankylosing spondylitis. J Neurosurg. 2002 Sep;97(2 Suppl):218-22. PubMed PMID: 12296682.
View Abstract at PubMed
Koivikko MP, Koskinen SK. MRI of cervical spine injuries complicating ankylosing spondylitis. Skeletal Radiol. 2008 Sep;37(9):813-9. doi: 10.1007/s00256-008-0484-x. Epub 2008 Apr

Question 64:

Which of the following is considered a potential advantage of arthroscopic repair for anterior instability of the shoulder? Review Topic

Options:

Decreased healing time at the glenoid-labral junction
Completion of the procedure on an outpatient basis
Faster return to play than with open procedures
Preservation of external rotation
Decreased risk of recurrent instability in comparison to open repair

Correct Answer: Preservation of external rotation

Explanation:

Question 65:

Options:

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

Correct Answer: Anterior interosseous nerve palsy

Explanation:

DISCUSSION: 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.
REFERENCES: Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome.
J Hand Surg Br 1992;17:510-512.
Seror P: Anterior interosseous nerve lesions: Clinical and electrophysiological features. J Bone Joint Surg Br 1996;78:238-241.

Question 66:

What is the most common cause for poor outcomes in patients who undergo total shoulder arthroplasty?

Options:

Loosening of the humeral component
Loosening of the glenoid component
Infection
Brachial plexus injury
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: In an article in the Journal of Shoulder and Elbow, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component between 1990 and 2000. Follow-up averaged 4.2 years. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only one shoulder. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Complications involving the brachial plexus have been reported following total shoulder arthroplasty but are not as common of a cause for failure.
REFERENCES: Chin PY, Sperling JW, Cofield RH, et al: Complications of total shoulder arthroplasty: Are they fewer or different? J Shoulder Elbow Surg 2006;15:19-22.
Hasan SS, Leith JM, Campbell B, et al: Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg 2002;11:431-441.

Question 67:

Options:

Time to antibiotic administration
Thoroughness of debridement
Time to initial debridement
Ability to close/cover an open wound
Time to definitive fixation

Correct Answer: Time to antibiotic administration

Explanation:

Question 68:

03 Fig 51c. What laboratory finding is most likely associated with this disease entity?

Options:

acid fast bacilli
gram-positive cocci
translocation (9:22)
translocation (11:22)
mutation of the Rb gene back answer

Correct Answer: translocation (11:22)

Explanation:

The first question is what is it? The xray shows a mass in the leg with periosteal reaction in the fibula. The MRI shows a soft tissue mass arising from the fibula that looks aggressive. The path shows a bunch of small blue cells. The combination of small blue cells with a soft tissue mass and and onion skin appearance on xray in a patient in the 2
nd
decade of life has to scream Ewing’s sarcoma. 85% of Ewing’s sarcomas have the 11:22 translocation. None of the other answers are associated with Ewing’s.
Gibbs CP, Weber K, Scarborough MT: Malignant bone tumors. Inst Course Lect 2002;51:413-428
back to this question next question

Question 69:

What are the proposed biomechanical advantages of the Grammont reverse total shoulder arthroplasty when compared to a standard shoulder arthroplasty? Review Topic

Options:

Lateralization of the center of rotation, lengthening the deltoid, and decreasing the deltoid moment arm
Lateralization of the center of rotation, shortening the deltoid, and decreasing acromial stress
Lateralization of the center of rotation, lengthening the deltoid, and increasing the transverse force couple
Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm
Medialization of the center of rotation, shortening the deltoid, and decreasing acromial stress

Correct Answer: Medialization of the center of rotation, lengthening the deltoid, and increasing the deltoid moment arm

Explanation:

The Grammont reverse total shoulder arthroplasty is designed to medialize the center of rotation, thereby increasing the deltoid moment arm and lengthening the deltoid.

Question 70:

The bending stiffness of a slotted stainless steel intramedullary nail will be increased most by

Options:

Changing to a titanium nail
Changing to a nonslotted nail
Changing the cross-sectional shape of the nail
Increasing the diameter of the nail by 3 mm
Increasing the diameter of the interlocking screws

Correct Answer: Increasing the diameter of the nail by 3 mm

Explanation:

Question 71:

Fixed hyperextension of the metatarsophalangeal joint is associated with

Options:

dorsal subluxation of the interossei.
dorsal subluxation of the lumbricals.
fibrosis of the plantar plate.
attenuation of the extensor longus tendon.
extrinsic flexor paralysis.

Correct Answer: dorsal subluxation of the interossei.

Explanation:

Question 72:

Options:

Hematoma
Edema
Soft-tissue sarcoma
Antecubital lipoma
Brachial artery aneurysm

Correct Answer: Edema

Explanation:

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

Question 73:

Figures 1 and 2 are the CT and MRI scans of a patient with shoulder instability. Contrasting these two imaging techniques for decision making in shoulder instability would suggest

Options:

Both CT and MRI have equivalent cost for the patient.
Both CT and MRI have equivalent safety for the patient.
Associated soft-tissue damage can be more reliably shown on CT scans.
Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Correct Answer: Two-dimensional CT scans represent better definition of bone loss than two-dimensional MRI scans. Two-dimensional CT scan is generally accepted as a superior imaging modality for evaluating bone loss in shoulder instability than two-dimensional MRI scan. This advantage is offset by the relatively high radiation dose. Although CT in most situations is less costly, MRI can provide more data regarding associated soft-tissue damage that can be associated with recurrent instability. It should be noted that three-dimensional MRI has recently been shown as equivalent to three-dimensional CT in its ability to identify glenoid bone loss.

Explanation:

A 43-year-old woman is involved in a motor vehicle collision. She sustains the isolated injury shown in the radiograph in Figure 1. Her neurovascular examination is compromised. What is the most likely deficit?
A. Inability to flex the distal interphalangeal joint of the index finger
B. Positive Froment’s sign
C. Weakness with wrist extension
D. Decreased capillary refill

Question 74:

Options:

Extensor pollicis brevis (EPB)
Extensor carpi radialis brevis (ECRB)
Extensor digitorum communis (EDC)
Extensor carpi ulnaris (ECU)
Extensor carpi radialis longus (ECRL)

Correct Answer: Extensor digitorum communis (EDC)

Explanation:

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 75:

Options:

Decreased risk of sacral fractures
Decreased risk of proximal functional kyphosis
Easier contouring of the instrumentation
Reduced risk of late pubic ramus fractures
Improved coronal plane correction

Correct Answer: Decreased risk of sacral fractures

Explanation:

Question 76:

A 42-year-old man sustained the periprosthetic fracture shown in Figures 19a and 19b. The femoral component is well fixed. What is the next most appropriate step in management?

Options:

Closed reduction and bracing
Retrograde femoral intramedullary nailing
Open reduction and internal fixation of the fracture, leaving the femoral stem in place
Open reduction and internal fixation of the fracture and insertion of a proximally porous-coated stem
Open reduction and internal fixation of fracture fragments and insertion of a fully porous-coated femoral stem with diaphyseal fixation distal to the fracture

Correct Answer: Open reduction and internal fixation of the fracture, leaving the femoral stem in place

Explanation:

Question 77:

They found statistically significant decreases in need for secondary intervention, hardware failure, and infection as well as faster wound healing and faster time to fracture union.

Options:

Wei et al. provide a meta analysis regarding use of rhBMP-2 in open tibia fractures. Due to decreased rates of secondary interventions they estimated a net savings of $6,000 per case when rh-BMP2 was used. They found no significant difference in rates of infection, postoperative pain, hardware failure, or fracture healing at 20 weeks.
Incorrect answers:

Correct Answer: Wei et al. provide a meta analysis regarding use of rhBMP-2 in open tibia fractures. Due to decreased rates of secondary interventions they estimated a net savings of $6,000 per case when rh-BMP2 was used. They found no significant difference in rates of infection, postoperative pain, hardware failure, or fracture healing at 20 weeks.

Explanation:

OrthoCash 2020
A 76-year old patient underwent partial foot amputation through the talonavicular and calcaneocuboid joints. Besides Achilles tendon lengthening, what additional procedure(s) may be required to prevent the most common post-operative deformity?
Posterior capsule release
Anterior tibialis transfer to the talar neck
Anterior tibialis transfer to cuboid
Flexor hallucis longus transfer to calcaneus
Peroneus brevis transfer to calcaneus
Corrent answer: 2
Achilles tendon lengthening AND anterior tibialis transfer to the talar neck would be required to prevent equinovarus deformity.
Partial foot amputation through the talonavicular and calcaneocuboid joints is also known as the Chopart amputation. Chopart amputation alone is known to result in significant equinovarus deformity. This deformity results in excessive pressure on the anterior wound during gait, causing pain and wound complications. Transfer of the tibialis anterior tendon to talar neck will provide force, and muscle tone, that promotes ankle dorsiflexion. Lengthening of the Achilles tendon will also reduce the equinus moment force across the ankle joint.
Dillion et al. examined the gait patterns of partial foot amputees. They found that amputations proximal to the metatarsal heads compromised the normal propulsive function of the foot and ankle. The ideal level of amputation to maintain normal propulsive function was distal to the metatarsal heads (i.e., disarticulating the metatarsophalangeal (MTP) joint).
Illustration A is a lateral radiograph showing a Chopart amputation. Incorrect Answers:
prevent the equinovarus deformity.
OrthoCash 2020
A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What is the most common urological injury associated with this injury pattern?
Testicular torsion
Posterior urethral tear
Bladder denervation
Testicular rupture
Renal hematoma
The figure shows an anteroposterior pelvic ring injury. The most common urological injury with pelvic ring injuries remains the posterior urethral tear, followed by bladder rupture.
Watnik et al notes lower urinary tract (bladder to end of urethra) injuries in up to 25% of patients with this injury. He reports that when contaminated urine communicates with the anterior arch, the possibility of infection exists, and early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk.
Routt et al notes that even with simultaneous treatment of these injuries, complications are common (late stricture in 44%, impotence in 16%, delayed incontinence in 20% of females, anterior deep pelvic infection in 4%). Despite this, they report that early urological repairs are easily performed at the time of anterior pelvic open reduction and internal fixation.
OrthoCash 2020
A 26-year-old women, 31-weeks pregnant, presents to the emergency department with the injury shown in Figure A. She states the injury occurred while lifting a heavy vacuum five days ago. She suffers from chronic headaches and sleep disturbances. On inspection, there are multiple dorsal and volar bruising over her wrist and upper arm. She is neurologically intact. After closed reduction and immobilizing the arm, what would be the next best step in management of this patient?
Diagnostic wrist arthroscopy
Urgent MRI wrist
Skeletal survey radiographs
Request a consultation with social worker in the hospital
Urgent open reduction internal fixation
Corrent answer: 4
This patient presents with classic features of domestic violence. The most appropriate next step would be consultation with a social worker at the hospital, assess for child and patient safety, and encouraging the patient to seek self-protection.
Factors suggestive of domestic violence in the patient include pregnancy, delayed presentation after injury, inconsistent history, multiple bruises and complaints of chronic headache/sleep disturbances. Victims frequently miss days of work and as a result are at risk for losing their jobs. Victims are also more likely to engage in high-risk behavior with sex, drugs, alcohol, smoking, and eating.
The AAOS published a document outlining the Orthopaedic Surgeon’s responsibilities in domestic and family violence. Musculoskeletal injuries that should raise a suspicion of a problem include (1) Multiple injuries/fractures; (2) Unusual patterns of injury/fracture; (3) Injuries/fractures of varying ages; (4)
Injuries/fractures inconsistent with or disproportional to the history; (5) Multiple injuries treated in different hospital emergency departments or by different providers.
Incorrect Answers:
OrthoCash 2020
A 45-year-old man undergoes open reduction and internal fixation for a comminuted intra-articular humerus fracture . An olecranon osteotomy is performed and subsequently fixed with an intramedullary cancellous screw. Which of the following options in the table shown in Figure A best describes the characteristics of this osteotomy?

Question 78:

Options:

Conversion to a reverse total shoulder arthroplasty
Conversion to a standard total shoulder arthroplasty
Conversion to a glenohumeral fusion
Resection arthroplasty
Biologic resurfacing of the glenoid

Correct Answer: Conversion to a standard total shoulder arthroplasty

Explanation:

Question 79:

Options:

Eccentric
Concentric
Isometric
Isokinetic

Correct Answer: Eccentric

Explanation:

Question 80:

Options:

Intravenous (IV) methylprednisolone with a 30-mg/kg loading dose followed by continuous infusion of 5.4 mg/kg/hour for 24 hours
Immediate awake traction reduction
Emergent open reduction/decompression
Admission to the intensive care unit for fluid resuscitation followed by reduction/decompression when stable

Correct Answer: Emergent open reduction/decompression

Explanation:

Question 81:

The injection shown in Figures 1a and 1b would most benefit a patient who reports which of the following symptoms? Review Topic

Options:

Dorsal foot pain extending into the great toe
Foot pain extending along the lateral border of the foot
Pain extending into the foot in a stocking distribution
Anterior thigh and shin pain ending at the ankle
Lateral foot paresthesias

Correct Answer: Dorsal foot pain extending into the great toe

Explanation:

Question 82:

Options:

a more technically difficult operation.
increased intraoperative blood loss.
increased overall survival rate.
increased pain compared to an actual pathologic hip fracture.
faster postoperative recovery and decreased hospitalization time.

Correct Answer: faster postoperative recovery and decreased hospitalization time.

Explanation:

Question 83:

An anatomic reduction is obtained at the femoral neck. The most likely reason for development of avascular necrosis (AVN) in this scenario would be

Options:

- an ORIF delay exceeding 24 hours because of hemodynamic ?instability.
- an associated femur fracture.
- patient age and mechanism of injury.
- treatment with a closed reduction.

Correct Answer: - an ORIF delay exceeding 24 hours because of hemodynamic ?instability.

Explanation:

DISCUSSION
A damage-control approach is indicated for this patient. Debridement of the open fracture wound and rapid stabilization without an extensive surgical
approach are indicated. Rapid percutaneous fixation of the femoral neck would compromise long-term outcomes for this displaced fracture because obtaining a quality reduction and fixation construct is critical for the long-term outcome. This patient likely would not tolerate cephalomedullary nailing or open approaches very well at this time.
A vertically oriented (Pauwels 3) femoral neck fracture is more common in younger patients who sustain high-energy injuries. Because of the mechanism of injury, many of these patients have associated injuries. This is a biomechanically challenging fracture because the fracture is subject to shear forces rather than compression, making it inherently unstable. This type of fracture often necessitates different fixation strategies to counter shearing forces, such as use of a transversely oriented (Pauwels) screw to compress the fracture or a fixed-angle device.
The femoral neck fracture should be prioritized in this scenario. This does not necessarily mean that the femoral neck should be repaired first, but the strategy should emphasize optimal fixation of the femoral neck. It has been demonstrated that this is less successful when using a single implant to repair both fractures. It is possible to place femoral neck fixation around an antegrade femoral nail; however, it is much more likely that optimal fixation will be achieved with shaft fixation that does not obstruct placement of fixation for the femoral neck.
AVN is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.
RECOMMENDED READINGS
Liporace F, Gaines R, Collinge C, Haidukewych GJ. Results of internal fixation of Pauwels type-
3 vertical femoral neck fractures. J Bone Joint Surg Am. 2008 Aug;90(8):1654-9. doi: 10.2106/JBJS.G.01353. PubMed PMID: 18676894.
View Abstract at PubMed
Bedi A, Karunakar MA, Caron T, Sanders RW, Haidukewych GJ. Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies. J Orthop Trauma. 2009 Apr;23(4):249-53. doi: 10.1097/BOT.0b013e3181a03675. PubMed PMID: 19318867.
View
Abstract at PubMed
Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative treatment of femoral neck fractures in patients between the ages of fifteen and fifty years. J Bone Joint Surg Am. 2004 Aug;86-A(8):1711-6. PubMed PMID: 15292419.
View Abstract at PubMed
Peljovich AE, Patterson BM. Ipsilateral femoral neck and shaft fractures. J Am Acad Orthop Surg. 1998 Mar-Apr;6(2):106-13. PubMed PMID: 9682073.
View
Abstract at PubMed
Upadhyay A, Jain P, Mishra P, Maini L, Gautum VK, Dhaon BK. Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. J Bone Joint Surg Br. 2004 Sep;86(7):1035-40. PubMed PMID: 15446534.
View Abstract at PubMed
RESPONSES FOR QUESTIONS 96 THROUGH 99
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
Match the appropriate oral anticoagulant listed with the description.
This medication is a vitamin K antagonist and can be reversed.
- Warfarin (Coumadin)
- Dabigatran (Pradaxa)
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)

Question 84:

Options:

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

Correct Answer: Excise the spacer

Explanation:

Question 85:

Options:

humeral head replacement with rotator cuff repair.
humeral head replacement without rotator cuff repair.
arthrodesis of the shoulder.
total shoulder replacement with rotator cuff repair.
total shoulder replacement without rotator cuff repair.

Correct Answer: total shoulder replacement with rotator cuff repair.

Explanation:

Question 86:

Options:

Irrigation and debridement, external fixation of the ankle and foot, traction and pinning of the femur, open reduction and internal fixation of the forearm
Irrigation and debridement, external fixation of the ankle, foot, and femur, splinting of the forearm
Irrigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, open reduction and internal fixation of the forearm
Irrigation and debridement and open reduction and internal fixation of the ankle and foot, intramedullary nailing of the femur, splinting of the forearm
Irrigation and debridement, external fixation of the foot and ankle, intramedullary nailing of the femur, open reduction and internal fixation of the forearm

Correct Answer: Irrigation and debridement, external fixation of the ankle, foot, and femur, splinting of the forearm

Explanation:

DISCUSSION: The patient appears to be a borderline or unstable surgical patient following her initial trauma and spleenectomy (high base excess and low urine output). She needs continued resuscitation and minimal additional blood loss. This is best accomplished with irrigation and debridement of the ankle, external fixation of the ankle, foot, and femur, and splinting of the forearm. A traction pin for the femoral fracture will not control bleeding as well as an external fixator. Intramedullary nailing of the femur and open reduction and internal fixation of the forearm would be appropriate in patients that are euvolemic and stable.
REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.
Taeger G, Ruchholtz S, Waydhas C, et al: Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe. J Trauma 2005;59:409-416.
Harwood PJ, Giannoudis PV, van Griensven M, et al: Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 2005;58:446-452.
Renaldo N, Egol K: Damage-control orthopaedics: Evolution and practical applications.
Am J Orthop 2006;35:285-291.

Question 87:

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

Options:

Hypertrophic cardiomyopathy
Atrial fibrillation
Pulmonary embolism
Ruptured aorta
Mitral valve prolapse

Correct Answer: Hypertrophic cardiomyopathy

Explanation:

Question 88:

What is the greatest benefit of external fixation for treatment of displaced and unstable pelvic ring injuries with hemodynamic instability? Review Topic

Options:

It provides rigid fixation of the pelvis.
It helps maintain a stable clot over injured vessels.
It stabilizes the visceral injuries.
It allows the patient to sit and eat without pain.
It is more comfortable than skeletal traction.

Correct Answer: It helps maintain a stable clot over injured vessels.

Explanation:

Question 89:

Options:

ultrasound, iontophoresis, and stretching, with an early return to sports.
a local corticosteroid injection and strengthening, with a delayed return to sports.
immobilization and rehabilitation, with a delayed return to sports.
early surgical repair, prolonged rehabilitation, and a return to sports.
rehabilitation, with delayed surgical repair if the patient is unable to return to sports.

Correct Answer: early surgical repair, prolonged rehabilitation, and a return to sports.

Explanation:

Question 90:

Passive glycation of articular cartilage results in

Options:

protection of collagen from degradation.
increased collagen stiffness and degradation.
increased chondrocyte proliferation.
increased proteoglycan association with type II collagen.
decreased synthesis of new collagen.

Correct Answer: increased collagen stiffness and degradation.

Explanation:

Question 91:

In patients older than age 40 years who sustain a first-time anterior dislocation of the shoulder, prolonged morbidity is most commonly associated with

Options:

recurrent dislocation.
posttraumatic arthritis.
a rotator cuff tear.
stiffness secondary to immobilization.
nerve injury.

Correct Answer: a rotator cuff tear.

Explanation:

Question 92:

Options:

application of a long leg splint and admission to the hospital for further evaluation and consultation.
application of a long leg cast, with follow-up radiographs in 3 days.
immediate application of a spica cast under general anesthesia.
a CBC, an erythrocyte sedimentation rate, blood cultures, aspiration of the distal femur for culture, and hospital admission with administration of IV antibiotics if required.
a CBC, an erythrocyte sedimentation rate, a technetium bone scan, and consultation for bone marrow aspiration.

Correct Answer: application of a long leg splint and admission to the hospital for further evaluation and consultation.

Explanation:

Question 93:

Tension band wire fixation is best indicated for which of the following types of olecranon fractures?

Options:

Comminuted fractures
Fractures that involve the coronoid process
Fractures associated with Monteggia fracture-dislocations
Oblique fractures distal to the midpoint of the trochlear notch
Transverse fractures through the midpoint of the trochlear notch

Correct Answer: Transverse fractures through the midpoint of the trochlear notch

Explanation:

Question 94:

In a patient who has rheumatoid arthritis with acetabular protrusion, what is the best biomechanical position for the cup with respect to the preoperative center of rotation?

Options:

Medial and superior
Medial
Lateral and superior
Anterior and inferior
Posterior and lateral

Correct Answer: Anterior and inferior

Explanation:

Question 95:

Figure 10 shows the radiograph of an active 75-year-old woman who reports severe leg pain after a fall. Management should consist of

Options:

a total hip arthroplasty with a long-stem prosthesis.
a resection arthroplasty with skeletal traction.
hemiarthroplasty with a long-stem prosthesis.
retention of the prosthesis and open reduction and internal fixation.
closed treatment with skeletal traction.

Correct Answer: a total hip arthroplasty with a long-stem prosthesis.

Explanation:

Question 96:

Results of a study demonstrating no difference between treatments when a difference truly exists is an example of which of the following?

Options:

Statistical insignificance
Type I error
Type II error
Fragile p-values
Negative predictive value

Correct Answer: Type II error

Explanation:

A type II error (also known as a beta error) occurs when results demonstrate that two groups are similar when, in reality, they are different (with regard to the statistic being measured). Type I errors show that a difference exists when, in reality, no difference exists. A statistically insignificant result may lead an investigator to conclude that no difference exists between two groups; this may be correct (and therefore not a type II error). The concept of `fragile` p-values is that small sample sizes may result in wide variability of p-values with only one change in a data point for a given group. This singular change could be a chance occurrence, but it still can affect the statistical
significance of the outcomes analysis. Fragility of p-values is limited by increasing sample sizes. Negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

Question 97:

Options:

Maintain sling immobilization for 6 weeks, and then begin a global range-of-motion program.
Maintain sling immobilization for 3 weeks, and then begin a global range-of-motion program.
Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.
Immediately begin a passive range-of-motion program for forward elevation only; no external rotation is allowed for 6 weeks.
Immediately begin active range of motion in forward elevation and external rotation to the side with a progression to full rotator cuff strengthening in 3 weeks.

Correct Answer: Immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side.

Explanation:

DISCUSSION: The patient needs to immediately begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side. Sling immobilization without stretching for either 3 or 6 weeks will result in severe stiffness that will compromise her ultimate range of motion. Since she has a good quality subscapularis tendon, there is no need to avoid beginning external rotation to the side. However, starting a strengthening program
at 3 weeks risks tearing the subscapularis tendon repair. Active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal.
REFERENCES: Boardman ND III, Cofield RH, Bengston KA, et al: Rehabilitation after total shoulder arthroplasty. J Arthroplasty 2001;16:483-486.
Matsen FA III, Lippitt SB, Sidles JA, et al: Practical Evaluation and Management of the Shoulder. Philadelphia, PA, WB Saunders, 1994, pp 215-218.

Question 98:

At what age does the lateral epicondyle normally ossify in males?

Options:

2 to 4 years
5 to 6 years
7 to 8 years
9 to 11 years
12 to 14 years

Correct Answer: 12 to 14 years

Explanation:

Question 99:

Which modality has the broadest application for reduction of postsurgical transfusion?

Options:

Regional anesthesia
Tranexamic (TXA) acid administration
Reduced transfusion trigger
Hypotensive anesthesia

Correct Answer: Tranexamic (TXA) acid administration

Explanation:

Question 100:

Changes to the properties of ultra-high molecular weight polyethylene with increasing irradiation dose include improved

Options:

resistance to oxidation.
ultimate tensile strength.
resistance to crack propagation.
fracture toughness.
volumetric wear.

Correct Answer: volumetric wear.

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

OITE & ABOS Orthopedic Board Prep MCQs: Fracture & Shoulder | Part 158

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 158

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index