OITE & ABOS Orthopedic Board Review MCQs: Part 160

About This Board Review Set

This is Part 160 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 160

This module focuses heavily on: Hip, Knee, Scoliosis, Shoulder.

Sample Questions from This Set

Sample Question 1: What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?...

Sample Question 2: Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of...

Sample Question 3: Figure 46 shows the AP radiograph of a patient with right shoulder pain. What is the most likely diagnosis?...

Sample Question 4: Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Fi...

Sample Question 5: A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis....

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

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Explanation

DISCUSSION: Ford and associates studied 81 high school basketball players and found that females landed with greater total valgus knee loading and a greater maximum valgus knee angle than male athletes. Hewett and associates reported in a study of 205 female athletes that those with increased dynamic valgus and high abduction loads were at increased risk of anterior cruciate ligament injury.
REFERENCES: Hewett TE, Myer GD, Ford KR, et al: Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: A prospective study. Am J Sports Med 2005;33:492-501.
Ford KR, Meyer GD, Hewett TE: Valgus knee motion during landing in high school female and male basketball players. Med Sci Sports Exer 2003;35:1745-1750.

Question 2

Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of

Explanation

DISCUSSION: Because hydrosyringomyelia, with or without an Arnold-Chiari malformation, is now being recognized as the etiology of many infantile and juvenile idiopathic scolioses, management should consist of a neurosurgical consultation. Observation with follow-up radiographs is not an option in curves of this magnitude. A technitium Tc 99m bone scan is unnecessary because the etiology of the curve has been identified. Although spinal fusion may be needed in the future, it should not be undertaken before the neurosurgical problem has been addressed.
REFERENCES: Zadeh HG, Sakka SA, Powell MP, Mehta MH: Absent superficial abdominal reflexes in children with scoliosis: An early indicator of syringomyelia. J Bone Joint Surg Br 1995;77:762-767.
Schwend RM, Hennrikus W, Hall JE, Emans JB: Childhood scoliosis: Clinical indications for magnetic resonance imaging. J Bone Joint Surg Am 1995;77:46-53.
Farley FA, Song KM, Birch JG, Browne R: Syringomyelia and scoliosis in children. J Pediatr Orthop 1995;15:187-192.

Question 3

Figure 46 shows the AP radiograph of a patient with right shoulder pain. What is the most likely diagnosis?

Explanation

DISCUSSION: Posttraumatic osteolysis of the distal portion of the clavicle is a condition that can be a complication of acute or repetitive trauma. The distal end of the clavicle is frayed and resorbed. Resorption may occur after weeks or months. The end of the clavicle may reconstitute over a period of months, or the acromioclavicular joint may remain widened. The differential diagnosis for distal clavicular erosion also includes rheumatoid arthritis, hyperparathyroidism, neoplastic destruction, cleidocranial dysplasia, and pyknodysostosis. Acutely, a type 2 acromioclavicular joint injury does not result in erosion or resorption of the clavicle. Periosteal sleeve injuries radiographically mimic acromioclavicular joint dislocation. Rickets occurs only in childhood.
REFERENCE: Cahill BR: Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am 1982;64:1053-1058.

Question 4

Figures 7a and 7b show the radiographs of a 51-year-old woman who injured her left leg after falling off a stepladder. Surgical reconstruction is performed with a compression screw and side plate; the postoperative radiograph is shown in Figure 7c. Following gradual progression of weight bearing, she reports that she slipped again and placed full weight on the extremity. She now notes a new onset of increased pain in her left thigh and hip region. Follow-up radiographs are shown in Figures 7d and 7e. Reconstruction should consist of

Explanation

DISCUSSION: The initial fracture was an unstable reverse oblique intertrochanteric fracture with subtrochanteric extension. Initial fixation with a high-angled screw and side plate construct may not provide stability as well as a 95 degree fixed-angle device or a intramedullary hip screw device. The follow-up radiographs show loss of fixation and further propagation of the fracture distally. Reconstruction would best be accomplished with hardware removal and conversion to a long intramedullary nail with femoral head fixation or a 95 degree angled plate and screw device. Conversion to a longer plate does not improve the biomechanical situation at the primary fracture site. In situ bone grafting would not provide any additional stability and would not correct the deformity. The proximal femoral fracture is not amenable to retrograde nailing. Cerclage wiring will not sufficiently enhance stability and is not indicated.
REFERENCES: Bridle SH, Patel AD, Bircher M, Calvert PT: Fixation of intertrochanteric fractures of the femur: A randomized prospective comparison of a gamma nail and dynamic hip screw. J Bone Joint Surg Br 1991;73:330-334.
DeLee JC: Fractures and dislocations of the hip, in Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD (eds): Rockwood and Green’s Fractures in Adults, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 1659-1825.
Haidukewych GJ, Israel TA, Berry DJ: Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 2001;83:643-650.
Sanders RW, Regazzoni P: Treatment of subtrochanteric femur fractures using the dynamic condylar screw. J Orthop Trauma 1989;3:206-213.

Question 5

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Explanation

DISCUSSION
Complications are numerous in adult spinal deformity surgery. Many complications are related to the patient's sagittal balance following surgery and recognition of the potential to develop sagittal imbalance or flat-back syndrome following spinal fusion. The quality of bone density is important in spinal instrumented fusions, especially among older patients. Patients with osteopenia or osteoporosis have a higher incidence of proximal-level screw cut-out through the vertebral body into the cephalad disk space.
Proximal junctional kyphosis is common in longer instrumented fusions, especially when instrumented to the sacrum/pelvis; when the spine is fixed in a "flat" or hypolordotic position; when the thoracic spine is hyperkyphotic (ie, Scheuermann kyphosis); when the end instrumented vertebrae is kyphotic; or when the sagittal plumb line (measured from C7) is more than 4 cm forward of the posterior corner of the sacrum.
Sagittal imbalance is a common complication when the spine is instrumented in a hypolordotic position. This can occur with degenerative conditions that necessitate multilevel fusions or fusions to sacrum without recognition of the degree of lordosis the patient should have. Pelvic incidence (PI) is a spinopelvic measurement that is a constant that measures an angle from the hips to the midpoint of the sacral end plate. PI correlates to the amount of lumbar lordosis that a patient would typically have in an upright position (+/-10 degrees). If a patient has significant sagittal imbalance, he or she will have a forward lean and lack the ability to extend the spine to stand upright. In an attempt to stand upright, the patient may bend his or her knees or hips in a crouched position. When extending their knees, they again lean forward.
Pseudarthrosis is common with noninstrumented fusions. Deep surgical-site infections are uncommon but can be major complications that are difficult to treat, necessitating formal irrigation and debridement and long-term antibiotics. Patients with diabetes have a higher incidence of infection.
RECOMMENDED READINGS
Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976). 2005 Sep 15;30(18):2024-

Question 6

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Explanation

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the

median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 7

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

Explanation

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

Question 8

What are the five major compartments of the foot?

Explanation

DISCUSSION: The five major compartments of the foot are medial, lateral, central, interosseous, and calcaneal. There is no dorsal compartment in the foot.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 262-264.
Shereff MJ: Compartment syndromes of the foot. Instr Course Lect 1990;39:127-132.

Question 9

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following?

Explanation

DISCUSSION: The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Kohles SS, Kohles JD, Karp AP, et al: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: Comments on meta-analysis. Spine 2004;29:1281-1287.

Question 10

Which of the following zones of articular cartilage has the highest concentration of proteoglycans?

Explanation

The fundamental structure of normal adult articular cartilage is divided into four different zones: superficial, transitional, deep, and calcified. These layers vary in chondrocyte morphology, size and orientation of collagen bundles, and water and proteoglycan content. The deep zone has the highest concentration of proteoglycans and the lowest concentration of water. The tidemark is a boundary between the calcified and uncalcified layers of articular cartilage.

Question 11

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

Explanation

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

Question 12

When comparing surgical and nonsurgical extremities in patients who underwent anterior cruciate ligament (ACL) reconstruction using patellar tendon or hamstrings autografts, isokinetic strength measurements obtained 6 months after the surgery would most likely reveal

Explanation

DISCUSSION: Follow-up examination at 6 months revealed no statistically significant differences in quadricep or hamstring strength when comparing surgical versus nonsurgical extremities isokinetically. Therefore, the selection of autogenous hamstring or patellar tendon for ACL reconstruction should not be based solely on the assumption of the graft tissue source altering the recovery of quadricep and/or hamstring strength.
REFERENCES: Carter TR, Edinger S: Isokinetic evaluation of anterior cruciate ligament reconstruction: Hamstring versus patellar tendon. Arthroscopy 1999;15:169-172
Howell SM, Taylor MA: Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am 1996;78:814-825.
Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990;18:292-299.

Question 13

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 14

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Explanation

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.

The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 15

Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?

Explanation

RESPONSES FOR QUESTIONS 3 THROUGH 6
Adhesive wear
Abrasive wear
Fatigue wear
Delamination
For each scenario below, please choose the most likely dominant mechanism of wear from the list
above.

Question 16

A 75-year-old woman has a 1-year history of right hip pain and a right total hip arthroplasty (THA) performed in 1999. Her left THA, performed in 2002, is asymptomatic. Plain radiographs show that all of the components appear well fixed and in good position. There is evidence of eccentric polyethylene wear of the right hip with focal osteolysis of the calcar and great trochanter (with none of these findings on the left hip). What is the most likely explanation for her right hip pain?

Explanation

DISCUSSION
This patient likely has 1 conventional polyethylene hip (1999) and 1 hip with highly cross-linked polyethylene (HXLPE) (2002); most centers transitioned to HXLPE around 2001 to 2002. This explains the clear difference in the clinical and radiographic performance of the 2 hips during the second decade. There is clear evidence of decreased wear and osteolysis and clinical benefits (ie, decreased revision rate) during the second decade following the introduction of HXLPE for THA. Acute infection is unlikely considering the chronicity of symptoms. The radiographs show no obvious evidence of cup loosening. A pseudotumor attributable to trunnionosis, while reported, remains an infrequent clinical issue.

Question 17

Figure 1 is the radiograph of a 21-year-old college lacrosse player who has a 2-year history of progressive left groin pain that is exacerbated by activity. Pain is preventing him from participating with his team. Examination reveals a fit man without tenderness to palpation around the hip. No clicking or popping occurs with hip range of motion. Strength of all muscles about the hip is normal, but there is some mild pain with resisted hip flexion and hip adduction. While lying supine, progressive hip flexion with internal rotation and adduction reproduces his groin pain. The patient participates in physical therapy for 8 weeks with his team's trainer but notes little improvement. What is the most appropriate next diagnostic step to determine the cause of his pain?

Explanation

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. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography 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 in 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 18

The parents of a 14-year-old female soccer player are concerned about any future injury. They have been advised that she has the potential to play for the US Olympic team. They are especially concerned about the anterior cruciate ligament (ACL). What should you advise them? Review Topic

Explanation

ACL injuries are five to eight times more common in young women. The highest incidence is associated with basketball and soccer. These sports require rapid directional and rotational changes. Use of neuromuscular training programs has not been associated with a decrease in ACL injuries. It is recommended that there be more frequent rests. ACL injuries are commonly associated with meniscal injury.

Question 19

Figures 1 and 2 are radiographs of a 25-year-old man who has had persistent right hip pain for over a year. There was an acute injury and the pain has progressively worsened and is now 9/10 in severity. The pain interferes with activities of daily living and the patient's capacity to participate in sports. The patient has failed nonsurgical treatment in the form of physical therapy and activity modification. On physical examination, forward flexion is limited to 90°, internal rotation is limited to 10°, and flexion adduction internal rotation examination is positive. The hip pain was relieved on physical examination after intra-articular administration of local anesthetic. The patient had an MRI and CT scan. What is the most appropriate surgical option?

Explanation

A 50-year-old right-hand dominant man presents after a traumatic fall on an outstretched right upper extremity. Based upon the MRI scans shown in Figures 1 and 2, what examination test would be abnormal?
A. Belly press
B. Hornblower's test
C. External rotation strength
D. Empty can test
A fall on an outstretched upper extremity can commonly result in a traumatic rotator cuff tear. The images require appropriate interpretation of an acute subscapularis tendon rupture with medial subluxation of the biceps tendon. Subscapularis tendon tears result in a positive belly press or lift-off test. Hornblower's tests for external rotation strength with the arm abducted 90° (teres minor weakness). Empty can tests supraspinatus strength. External rotation strength with the arm at the side tests for infraspinatus weakness.
38- Videos 1 and 2 are the coronal plane MRI scan and arthroscopic evaluation of a 48-year-old woman with 2 weeks of posterior knee pain after feeling a “pop” in the knee while climbing stairs. Physical examination reveals passive range of motion of +5° to 120°, with pain limiting her in terminal extension. Failure of surgical repair of the injured structure is most associated with
A. poor vascularity of the injured tissue.
B. BMI >35 kg/m^2.
C. valgus alignment >5°.
D. repair technique. 30
The MRI scan and surgical video are showing an example of a posterior medial meniscal root tear/avulsion. Many studies have shown successful treatment of these tears with repair using various techniques and minimal progression to osteoarthritis (OA). Most studies exclude patients with high BMI. Brophy and associates demonstrated in their series that high BMI was associated with higher rates of clinical OA and need for subsequent surgery.
Multiple studies in the literature demonstrate good results with a variety of techniques. A valgus alignment in this setting would be considered protective, as opposed to a varus alignment >5°, which has also been associated with worse outcomes. The vascularity of the meniscus is consistently poor throughout most of its volume, including the root, and is not considered to be significantly different from person to person and should affect all root repairs equally.
39- A 47-year-old man who is an avid tennis player and laborer has had one year of shoulder pain and weakness. His pain occurs at night and radiates to the deltoid laterally. The patient denies any anterior based pain. He reports no prior surgeries and has been managed with steroid injections and physical therapy. On examination, he has full passive motion with significant weakness with external rotation. His neurologic examination is unremarkable. MRI evaluation reveals a posterior- superior rotator cuff tear with Goutallier grade 4 fatty infiltrate in the supraspinatus and infraspinatus with retraction beyond the glenoid. He is concerned about the lack of rotation of his arm and reports that this disability creates significant disability with his occupation as a mason. What is the best next step?
A. Shoulder arthroscopy and subacromial decompression
B. Tendon transfer
C. Total shoulder arthroplasty
D. Reverse total shoulder arthroplasty
In younger active patients, tendon transfer is considered a preferable treatment option. The patient has failed a course of nonoperative management. Subacromial decompression may offer pain relief but may not be advisable in a patient with rotator cuff deficient shoulder. A total shoulder arthroplasty requires functionality of the supraspinatus and infraspinatus. A reverse total shoulder is an option to alleviate pain and perhaps improve forward flexion height and strength; however, reverse arthroplasty would not improve external rotation in this patient, and there is concern for longevity of the implant in younger patient populations.
40- A multicenter prospective study of 7,500 patients that assesses differences in rerupture rates after anterior cruciate ligament (ACL) reconstruction using hamstring autograft shows a decreased rate of rerupture when the graft diameter is >9.0 mm versus <9.0 mm (p = 0.05). A follow-up study done at a single institution of 200 patients fails to show any difference in rerupture rates based upon graft size. If the multicenter trial is assumed to be accurate, which statistical error occurred in the follow-up study?
A. Type-I error
B. Type-II error
C. Selection bias
D. Alpha error
Type-II errors, or beta errors, occur when the null hypothesis is accepted and should have been rejected. An underpowered study is at risk of this type of error. Power is defined as 1-probability of a type-II (beta error), and this is generally set at a level of 80% for most studies. The type-II error occurs when a study concludes that there is no association between the studied variables when in fact one exists. The type-I error, or alpha error, is defined as rejecting the null hypothesis when it should have been accepted. Alpha errors occur when a study suggests an association does exist when in reality it does not. Selection bias occurs when proper randomization is not achieved and therefore, the study cohort is not representative of the population intended to be analyzed.
41- A 17-year-old male soccer player sustains repeated lateral patellar dislocations refractory to physical therapy, bracing, and taping. After a workup including radiographs and MRI, the orthopaedic surgeon considers an isolated tibial tubercle osteotomy (TTO). A 60-degree anteromedialization is planned to address instability and to unload the patellofemoral joint. What is a relative contraindication to this procedure?
A. Grade III chondrosis of the proximal patella
B. Caton-Deschamps ratio of 1:1
C. Tibial tubercle-trochlear groove (TT-TG) distance of 21 mm
D. Q angle of 17°
TO is a common treatment for patellofemoral instability. The angle of correction must be customized to each patient’s anatomy. For this patient, the orthopaedic surgeon plans an osteotomy that will both anteriorize and
medialize the tubercle. This will consistently result in a change of 32
patellofemoral kinematics and contact pressures. Medialization decreases lateral and increases medial patellofemoral contact pressures, and anteriorization shifts contact pressures from distal to proximal. Significant anteriorization may not be desired in a patient with proximal patellar chondrosis unless a concomitant chondral procedure is performed as well. The patellar height (Caton-Deschamps ratio) is normal, precluding the need for distalization but not medialization. The TT-TG distance, at more than 20 mm, is a strong indication for osteotomy. The Q angle, although a less precise indicator of malalignment, is also elevated and would be considered an indication for osteotomy.
42- During preseason training camp, a 23-year-old football player comes to the sideline complaining of nausea, dizziness and headache after a 2- mile run. Vital signs include blood pressure 110/80, heart rate 115 bpm and core body temperature of 39°C (102°F). He is otherwise alert and oriented. What is the recommended initial treatment?
A. Immediate ice water bath immersion
B. Immediate return to training
C. Rehydration with a carbohydrate- electrolyte beverage
D. Emergent transportation to a local emergency department
The patient has exertional heat exhaustion (EHE). In cases of exertional heat illness with elevated core body temperature, it is critical to differentiate between EHE and exertional heat stroke (EHS). Patients suffering from EHE often complain of dizziness, nausea, cramping and headache. Vital signs can show mild tachycardia and normal to low blood pressure. EHS is defined by elevated core body temperature >40°C (104°F) and organ failure. Rapid cooling is critical in the setting of EHS, but not EHE. In the setting of EHE, the patient should be placed in a cool, shaded area and given fluids. Studies suggest that the presence of carbohydrate (<8%) in combination with electrolytes mildly promotes fluid retention better than drinking water alone.
43- Surgical repair of the injury shown in the MRI scans in Figures 1 through 4 through a single-incision approach has a higher incidence of

Question 20

A 23-year-old college basketball player reports persistent lateral ankle pain after sustaining an inversion injury 6 months ago. Examination reveals pain over the anterolateral ankle, absence of swelling, and no clinical instability. Management consisting of vigorous physical therapy fails to provide relief, and a intra-articular corticosteroid injection provides only temporary relief. Radiographs obtained at the time of injury and subsequent AP and varus stress views are normal. A recent MRI scan fails to show any abnormalities. Management should now include

Explanation

DISCUSSION: Because the patient has failed to respond to appropriate nonsurgical management and imaging studies are normal, the use of arthroscopy not only aids in the diagnosis of chronic ankle pain, but is also helpful in its treatment. In patients with this condition, typical findings include synovitis in the lateral gutter and fibrosis along the talofibular articulation; syndesmosis chondromalacia of the talus and ankle also may be found. In patients with anterior soft-tissue impingement, approximately 84% who have a poor response to nonsurgical management will have a good to excellent response after arthroscopic synovectomy and debridement.
REFERENCES: Ferkel RD, Fasulo GJ: Arthroscopic treatment of ankle injuries. Orthop Clin North Am 1994;25:17-32.
Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP: Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 1991;19:440-446.

Question 21

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Explanation

The Physician Payments Sunshine Act requires all payments by corporations to physicians beyond $10 per year to be reported to the Centers for Medicare and Medicaid Services.
Under this Act, all manufacturers of drugs and devices covered under Medicare, Medicaid, and SCHIP are obliged to federally report payments beyond $10 annually to physicians and academic centers. The Act was first introduced in 2007, enacted in 2010, and in 2014 the first data (from 2012) was reported publicly online in the Open Payment Program of the Centers for Medicare and Medicaid Services website.
Samuel et al analyze orthopedic surgeons available data from the Sunshine Act regarding industry payments and find over 110 million USD paid to approximately 15,000 orthopedic surgeons over the 5-month study period. No long term data exists to determine if these payments have any affect in healthcare.
Incorrect Answers:

Question 22

A study is conducted to measure the difference in bone mineral density between postmenopausal women taking a drug treatment versus those taking a placebo. What is the most important result to be reported from this study?

Explanation

DISCUSSION: A complete answer necessarily includes the means and standard deviations of bone mineral density in both groups. Given these, which are the basic results of the study, the P-value can be calculated if desired. All of the other options preclude assessment of the actual data, that is, the information collected by the study. P-values and confidence intervals should be perceived as additional information, which help to assess the certainty of relating the study’s findings to the general population, but they should not be reported instead of the results

(ie, the means and standard deviations).
REFERENCE: Ebramzadeh E, McKellop H, Dorey F, et al: Challenging the validity of conclusions based on P-values alone: A critique of contemporary clinical research design and methods. Instr Course Lect 1994;43:587-600.

Question 23

A 72-year-old woman is scheduled to undergo right total hip arthroplasty. Her preoperative radiograph is shown in Figure below. To avoid increasing this patient’s combined offset while maintaining her leg length, what is the most appropriate surgical plan?

Explanation

DISCUSSION:
The management of patients with proximal femoral deformity can be difficult. Appropriate implant selection and preoperative templating are critical. In this patient, it would be difficult to avoid increasing the combined offset by too much, which could contribute to the overtensioning of the soft tissues and trochanteric pain. By medializing the acetabular component (decreasing the combined offset), using a low offset femoral component or a cemented component placed more valgus (decreasing the combined offset), and making a longer neck cut (to avoid shortening of the lower extremity), restoration of the patient’s native offset and leg length can be achieved.

Question 24

03 Which of the following findings is one of the diagnostic criteria for diffuse idiopathic skeletal hyperostosis?

Explanation

back answer
Diffuse idiopathic skeletal hyperostosis is a common disease, most prevalent in those over 50 years of age. The usual presentation is a middle-aged or older patient with chronic mild pain in the middle to lower back, spinal stiffness, and typical radiographic changes in the thoracic spine. Diffuse idiopathic skeletal hyperostosis is predominantly a radiographic diagnosis with 3 major diagnostic criteria. 1. Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae. 2. Preservation of disk height in the involved vertebral segment; the relative absence of significant degenterative changes, such as marginal sclerosis in vertebral bodies or vacuum phenomenon. 3.
Absence of facet-joint ankylosis; absence of sacroiliac erosion, sclerosis, or intra-articular osseous fusion. Treatment is typically non-operative, with anti-inflammatories, activity modification and PT.
back to this question next question

Question 25

A 48-year-old male is involved in a motorycycle accident and arrives in the trauma bay in hypovolemic shock. He receives 6 units of packed red blood cells during his resuscitation. Which of the following viral microbes is he most at risk of exposure from the transfusions?

Explanation

DISCUSSION: According to the article by Wang et al the risk of viral transmission following a screened blood donation is: 1 in 1.9 million donations for human immunodeficiency virus (HIV), 1 in 1.8 million donations for hepatitis C virus (HCV), and 1 in 205,000 donations for hepatitis B virus (HBV). West Nile and Human T-cell leukemia viruses are even more rare in the general population, and both are screened in blood banks. Hepatitis A virus is not a blood borne viral disease. It is contracted by the fecal-oral route. Staph Aures is a bacteria, not a virus.

Question 26

A 15-year-old girl reports a 6-month history of activity-related knee pain and swelling. A radiograph, MRI scan, and biopsy specimen are shown in Figures 21a through 21c. What is the most likely diagnosis?

Explanation

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 27

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?

A. Improved longevity in comparison to the linked prosthesis

B. A significantly larger flexion-extension arc

C. A higher incidence of postsurgical instability

D. Lower frequency of ulnar nerve dysfunction

TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 28

A 65-year-old woman with rheumatoid arthritis is undergoing revision total knee arthroplasty (TKA) during which the medial collateral ligament (MCL) is damaged. Suture anchors are used to attempt primary repair, and a varus-valgus constrained insert also is used. Postsurgically she experiences instability that does not respond to bracing with a 3+ opening to valgus stress (Figure 120). What is the most appropriate surgical option?

Explanation

DISCUSSION
MCL repair or reconstruction may be considered in younger, more active patients, but this intervention is technically demanding and produces variable results. Rotating-hinge TKA is associated with good results in a number of small series that include cases performed with MCL insufficiency or absence. A rotating hinge is preferable over a fixed hinge because of decreased stresses on implants imposed by fixed-hinge devices.

Question 29

What is the most common site of metastases from a soft-tissue sarcoma?

Explanation

DISCUSSION: The most common site of metastases from a soft-tissue sarcoma is the lungs and occurs in 40% to 60% of patients. The second most common site of metastases in soft-tissue sarcomas is the lymph nodes. Nodal metastases are seen with regularity in synovial sarcoma, epithelioid sarcoma, and rhabdosarcoma. The liver, brain, bone, and muscle are occasional sites of spread, but the occurrence is very rare.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 255-259.

Question 30

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Explanation

The high prevalence of latex allergy in patients with myelomeningocoele is thought to result from a heavy degree of latex exposure throughout life, including closure of the spinal defect, multiple orthopedic, urologic, and neurologic procedures, and repeat bladder catheterization. As many as 50% of these patients may have the allergy. Appropriate perioperative management includes utilization of a latexfree protocol.

Question 31

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

Explanation

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

Question 32

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Explanation

DISCUSSION: A ganglion cyst compressing the suprascapular nerve results in poorly localized pain in the shoulder girdle. Sensation is intact, with weakness of external rotation and abduction. Supraspinatus and infraspinatus atrophy is often noted when viewed from behind. These cysts are typically associated with labral tears. Deltoid weakness is associated with an axillary nerve injury, and scapular winging results from injury to the long thoracic nerve.
REFERENCES: Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg 2002;11:600-604.
Inokuchi W, Ogawa K, Horiuchi V: Magnetic resonance imaging of suprascapular nerve palsy.

J Shoulder Elbow Surg 1998;7:223-227.

Question 33

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Explanation

DISCUSSION: Infantile idiopathic scoliosis occurs more commonly in boys, with a 3 to 1 male to female ratio. Neural axis abnormalities, hip dysplasia, and congenital heart disease are all associated with the condition; spontaneous correction frequently occurs. Curve progression can be predicted by the rib vertebral angle difference or the phase of the rib head. Rib overlap of the apical vertebral body or a rib vertebral angle difference of greater than 20 degrees indicates that the curve is likely to progress. Gender, family history, and age at presentation have not been found to be risk factors for progression.
REFERENCES: Mehta MH: The rib-vertebra angle in the early diagnosis between resolving and progressive infantile scoliosis. J Bone Joint Surg Br 1972;54:230-243.
Fischgrund JS (ed): Orthopedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008, p 697.

Question 34

A 12-year-old girl with juvenile rheumatoid arthritis (JRA) has had chronic pain and synovitis about the knee that is now well-controlled medically. Examination reveals 20° of valgus at the knee. Knee range of motion shows 10° to 90° of flexion. Treatment should consist of

Explanation

DISCUSSION: Children with JRA frequently have valgus in association with hypervascularity because of chronic inflammation. This is normally caused by overgrowth of the medial femoral epiphysis. Staple hemiepiphyseodesis, if done early, can reverse the deformity. Osteotomy is usually unnecessary at this age, and there is a risk of stiffness of the knee following the procedure. Synovectomy may be helpful but will not prevent or correct a deformity.
REFERENCE: Rydholm U, Brattstrom H, Bylander B, Lidgren L: Stapling of the knee in juvenile chronic arthritis. J Pediatr Orthop 1987;7:63-68.

Question 35

Figures A and B show routine postoperative radiographs obtained 2 weeks after anterior cruciate ligament (ACL) reconstruction with autologous patellar tendon graft. Based on these findings, what is the next most appropriate action? Review Topic

Explanation

The radiographs reveal an intra-articular position of the femoral bone plug; therefore, revision ACL surgery is indicated. Recognized early, this graft may be suitable to use for the revision, but an alternate should be available.

Question 36

A 36-year-old woman with familial neurofibromatosis has an enlarging mass in the posterior thigh. The lesion has slowly increased in size and is now constantly painful. Pressure on the mass causes dysesthesias in the foot. Figures 44a through 44c show T 1 -weighted, STIR, and T 1 -weighted fat-saturated gadolinium scans, respectively. Figure 44d shows a PET scan. What does this lesion most likely represent?

Explanation

DISCUSSION: The images reveal a large mass in the posterior thigh arising from the sciatic nerve. The lesion is edematous, and the gadolinium image reveals rim enhancement, suggesting necrosis, given that the STIR image is not uniformly bright as would be seen in a cystic lesion. The PET scan has increased uptake, in this case a standard unit value (SUV) of greater than 2.0. These findings are all very suggestive of a malignant process. The history of neurofibromatosis makes a malignant peripheral nerve sheath tumor, or neurofibrosarcoma, the most likely diagnosis. The term “peripheral nerve sheath tumor” has replaced neurolemmoma and schwannoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 225-230.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4218-4235.

Question 37

A 35-year-old man sustained an injury to his lower extremity after falling 10 feet from a ladder; initial management was nonsurgical. He now reports chronic hindfoot and anterior ankle pain. Radiographs are shown in Figures 22a and 22b. Surgical reconstruction of this painful process should consist of

Explanation

DISCUSSION: The radiographs reveal a hindfoot deformity that developed following a severe, comminuted, intra-articular fracture of the calcaneus. There is deformity of the calcaneal body and collapse of the talus into the calcaneus, leading to dorsiflexion of the talus and anterior ankle joint impingement. Distraction bone block subtalar joint arthrodesis will assist with correction of the calcaneal height and will allow for an improved talar declination angle. With this procedure, care must be taken to avoid placing the hindfoot into further varus. A similar reconstruction option not listed would be a calcaneal osteotomy and arthrodesis as described by Romash. Talectomy and tibiocalcaneal arthrodesis are not warranted because the primary structure of the talus and ankle joint is well preserved. In situ subtalar joint arthrodesis will not correct the deformity, and symptoms about the ankle and hindfoot would most likely persist. Lateral wall calcaneal exostectomy may decrease pain from subfibular impingement but will not deal directly with subtalar joint arthrosis and deformity.
REFERENCES: Carr JB, Hansen ST , Benirschke SK: Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle 1988;9:81-86.
Juliano TJ, Myerson MS: Fractures of the hindfoot, in Myerson MS (ed): Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1297-1340.
Romash MM: Reconstructive osteotomy of the calcaneus with subtalar arthrodesis for malunited calcaneal fractures. Clin Orthop 1993;290:157-167.

Question 38

A 50-year-old man undergoes revision total knee arthroplasty (TKA). The tibial component shown in Figure 153 was retrieved at the time of revision. The wear damage demonstrated on the backside of the tibial component is most likely related to which wear mechanism(s)?

Explanation

DISCUSSION
Pitting and delamination seen in tibial component retrievals on the bearing surface of a TKA is related to fatigue wear. Backside wear is shown in the photograph; this is where the lot numbers usually are present, but now they are not distinguishable because of backside wear. This wear mechanism is attributable to adhesive and abrasive wear. The nanometer-size particles created by this wear mechanism account for the higher prevalence of osteolysis associated with modular tibial components.
CLINICAL SITUATION FOR QUESTIONS 154 AND 155
Five weeks ago, an 82-year-old man underwent revision total knee arthroplasty (TKA). Three weeks after surgery he had a dental cleaning. The patient now reports 2 days of worsening pain following a long physical therapy session. His C-reactive protein (CRP) level is 15.0 mg/L (reference range, 0.08-3.1 mg/L). Upon examination, there is no drainage and slight effusion, and he has a passive range of motion to 110 degrees. Radiographs are unremarkable.

Question 39

A year-old woman underwent an uncemented medial/lateral tapered femoral placement during a total hip arthroplasty. The orthopaedic surgeon noticed a nondisplaced vertical fracture in the calcar region of the femoral neck during final implant insertion. What is the most appropriate treatment?

Explanation

DISCUSSION:
The recognized treatment for a proximal periprosthetic fracture is to first identify the extent and then optimize the correction of the fracture. Several studies indicate that proximal cerclage wiring is adequate to create "barrel hoop" stability of the proximal femur. Braided cables offer superior stability compared with twisted wires or Luque wires. Finally, the appropriate postoperative treatment is protected
weight bearing for 6 weeks, with periodic radiographs taken at 2-week intervals. Other options such as
cementing the femoral stem and using a revision arthroplasty device are indicated for unstable fractures.

Question 40

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Explanation

RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 41

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Explanation

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 42

Figure 26 shows the MRI scan of a 60-year-old man who has had groin pain for the past 2 months. The patient reports pain with ambulation, and examination reveals an antalgic gait. He denies any history of steroid or alcohol abuse. Plain radiographs are normal. Management should include

Explanation

DISCUSSION: The patient has transient osteoporosis of the hip. Transient osteoporosis is usually a self-limited condition that is most frequently seen in women in the third trimester of pregnancy and in men in the sixth decade of life. Transient osteoporosis is best treated with protected weight bearing.
REFERENCE: Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis from avascular necrosis of the hip. J Bone Joint Surg Am 1995;77:616-624.

Question 43

Figure 35 is the radiograph of a 37-year-old woman who began having right forefoot pain about 4 weeks ago after increasing her daily running mileage. She denies any specific injury. Upon examination she has tenderness over the medial forefoot with mild swelling. In addition to her activity level, what is the primary etiology of the radiograph finding?

Explanation

DISCUSSION
Stress fractures are the result of physiological bone response to increased stress. Increased stress on bone triggers an increase in remodeling, which begins with resorption of bone at the site of stress. Ongoing stress can overwhelm bone strength, resulting in a fracture. In the foot this most commonly is seen in the second metatarsal at the junction of the middle and distal thirds. Contributing factors to increased loading of the second metatarsal include hallux valgus (decreased hallux loading transfers to the second metatarsal head), hallux rigidus (offloading of the hallux attributable to pain increases second metatarsal loading), and a long second metatarsal (increased duration of contact during push-off in the stance phase).
RECOMMENDED READINGS
Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, Ellis SJ.
Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg. 2012 Mar;20(3):167-

Question 44

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made using

Explanation

EXPLANATION:
Compartment syndrome of the hand can result from a variety of factors, including a traumatic event such as crush injury, fracture, vascular insult, a high-pressure injection injury, or an insect or spider bite. The treatment involves decompressive fasciotomy of the involved compartments. The diagnosis of hand compartment syndrome is determined by history, examination, and objective testing. Patients experience pain out of proportion to the injury, along with swelling and tense skin. Pain may occur with passive motion of the metacarpophalangeal joints as the intrinsic muscles are stretched. Invasive intracompartmental pressures can be measured in the compartments of the hand but not in the fingers. Arterial Doppler studies assess arterial blood flow, and an abnormality would be a late finding. MRI would show edema of the hand and fingers, but the decision to perform surgical release is less likely made from the findings. The most appropriate method of determining the need for finger fasciotomy is the history and physical examination.

Question 45

A 24-year-old professional football player underwent surgery for a symptomatic cervical disk herniation with radiculopathy 9 months ago. A current radiograph is shown in Figure 17. He has normal neurologic findings, no pain, and full range of motion. A CT scan shows a solid fusion. When can he expect to return to play?

Explanation

DISCUSSION: The radiograph shows that the two-level anterior cervical diskectomy and fusion has healed. In addition, the patient has good range of motion and the neurologic examination is normal. Based on these findings, the patient can return to play immediately. Patients with one- or two-level anterior cervical diskectomies and fusions that have healed fully can return to play. Any loss of motion, persistent neurologic deficit, or significant adjacent segment degeneration may preclude a player from returning.
REFERENCES: Thomas B, McCullen GM, Yuan HA: Cervical spine injuries in football players. J Am Acad Orthop Surg 1999;7:338-347.
Torg JS, Ramsey-Emrhein JA: Management guidelines for participation in collision activities with congenital, developmental, or post-injury lesions involving the cervical spine. Clin Sports Med 1997;16:501-530.

Question 46

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Explanation

DISCUSSION: The figure is a stress-strain diagram representing specific metal subjected to increasing tensile stress. The portion of the curve from A to B is a straight line demonstrating a proportional increase in strain for each increase in tensile stress. If the stress is removed at any point between A and C, the material will return to its original shape, returning back along the original curve without permanent deformation. This is termed elastic behavior. If the applied stress causes strain beyond point C, then permanent deformation occurs and returns along a different path to a different zero stress point. This is termed plastic behavior. The point C at which the material stops behaving in an elastic manner and begins behaving in a plastic manner is the elastic limit or yield point. Point D represents a point on the curve of plastic deformation. Point E is the fracture point when the stress on the material creates enough strain that the material fractures.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 45-46.
El-Ghannam A, Ducheyne P: Biomaterials, in Mow VC, Huiskes R (eds): Basic Orthopaedic Biomechanics and Mechano-Biology, ed 3. Philadelphia, PA, Lippincott-Raven, 2005, pp 501-503.

Question 47

Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Explanation

[Radiograph: Well positioned G-H joint. Mild degenerative changes.]
Late onset of pain (average 13 years) was noted following this procedure in a small number of patients. The pain is attributed to excessive G-H compressive forces due to limited external rotation. NSAIDS and PT are first line treatments. If these fail, the authors demonstrated good results with release of the anterior structures. Choices 3 & 4 would probably be reserved for patients older than 50 with more advanced signs of degenerative disease.

Question 48

What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?

Explanation

DISCUSSION
Radiography is the best initial study. Vacuum phenomenon may be found within the disk space. Other possible sources for back pain such as osteoporotic collapse, osteolytic collapse, and deformity also can be evaluated. The other tests may be beneficial and are more appropriate as later imaging options.
RECOMMENDED READINGS
Yu WD, Williams SL. Spinal imaging: Radiographs, computed tomography, and magnetic resonance imaging. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine

Question 49

A Trendelenburg gait is most likely to be seen in association with

Explanation

DISCUSSION: A Trendelenburg gait results from weakness of the gluteus medius, which is innervated by the L5 nerve root. A paracentral disk herniation at L4-L5 most commonly results in an L5 radiculopathy and thus weakness of the gluteus medius. A paracentral herniation at L5-S1 most commonly affects the S1 nerve root. A paracentral herniation at L3-L4, a central herniation at L3-L4, and a far lateral herniation at L4-L5 all affect the L4 root.
REFERENCES: Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 323-332.
Andersson GB, Deyo RA: History and physical examination in patients with herniated lumbar discs. Spine 1996;21:10S-18S.

Question 50

Figure 1 shows the radiograph and Figure 2 shows the MRI scan obtained from a 37-year-old woman with a month history of left hip pain. Which combination of a single symptom and examination finding is most likely in this scenario?

Explanation

MRI reveals an anterior labral tear, and the radiograph shows minimal arthritis with possible dysplasia. The most common location of pain in patients with a labral tear is the groin, and the most common physical finding is a positive impingement test result. Pain during sitting, clicking, and buttock pain are frequently described by patients with a labral tear, but these symptoms are less common than groin pain. A positive posterior impingement test finding is more common in patients with a posterior labral tear. Although age over 40 years and a body mass index higher than 30 can adversely affect clinical outcomes after joint preservation procedures such as PAO, hip arthroscopy, and femoral acetabular impingement surgery, the presence of hip arthritis on presurgical radiographs is the most commonly mentioned cause of failed hip joint preservation surgery. Tönnis grade is a radiographic measure of hip arthritis. A higher Outerbridge score is associated with more frequent poor outcomes after hip arthroscopy; however, the Outerbridge cartilage score is determined by direct visualization at the time of surgery. The Outerbridge score cannot be determined presurgically.

Question 51

A 22-year-old college basketball player who was hit from behind while going up for a rebound is rendered immediately quadraparetic for approximately 10 minutes, followed by complete resolution of motor loss and return of full sensation. The radiograph and MRI scan of the cervical spine shown in Figures 2a and 2b reveal a canal diameter of 13 mm, loss of cerebrospinal fluid space about the spinal cord, and no signal change within the cord. What is the best course of action?

Explanation

DISCUSSION: The correct decision on return to sports participation after episodes of transient quadraparesis is controversial. Cantu and Mueller feel strongly that the loss of cerebrospinal fluid space about the spinal cord signifies an unacceptable risk for future spinal cord injury if the athlete returns to sports. However, Watkins and Torg and Lasgow have reported no evidence of increased spinal cord injury in athletes with narrow spinal canals, even in football. These authors suggest judgment be used in advising return to contact or high-energy sports and that the physician’s responsibility is to give accurate and relevant information, allowing the athlete to make his or her own choice regarding return to sports participation.
REFERENCES: Cantu R, Mueller FO: Catastrophic spine injuries in football (1977-1989).

J Spinal Disord 1990;3:227-231.
Watkins RG: Neck injuries in football players. Clin Sports Med 1986;5:215-246.
Torg JS, Lasgow SG: Criteria for return to contact activities following cervical spine injury. Clin Sports Med 1991;1:12-26.
Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.

Question 52

A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint. He denies any history of similar symptoms. What is the first step in evaluation?

Explanation

DISCUSSION: The patient’s symptoms are typical for gouty arthropathy, and the diagnosis can only be confirmed with aspiration and visualization of the crystals. A concomitant infection also must be ruled out; therefore, it is important to obtain a cell count and culture. Colchicine may have a role in gouty management, but the diagnosis must be confirmed. Allopurinol is not effective in acute gouty arthropathy. Measurement of serum uric acid levels is often not helpful in making a definitive diagnosis. Steroid injections should be deferred until cell count and culture results indicate no accompanying infection.
REFERENCES: Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 172-173.
Jahss MH: Disorders of the Foot and Ankle, ed 2. Philadelphia, PA, WB Saunders, 1991,

pp 1712-1718.

Question 53

What procedure can eliminate a sulcus sign?

Explanation

DISCUSSION: A sulcus sign represents inferior subluxation of the shoulder. The elimination of this sign and correction of the inferior subluxation is best achieved through either an open or arthroscopic rotator interval closure. A SLAP repair stabilizes the biceps anchor but does not affect the sulcus sign. A Bankart repair, which corrects anterior-inferior laxity, is not sufficient to eliminate a sulcus sign. Subacromial decompression and supraspinatus repairs have no effect on inferior subluxation.
REFERENCES: Field LD, Warren RF, O’Brien SJ, et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 1995;23:557-563.
Cole BJ, Rodeo SA, O’Brien SJ, et al: The anatomy and histology of the rotator interval capsule of the shoulder. Clin Orthop 2001;390:129-137.

Question 54

A year-old woman had a primary total hip arthroplasty 7 years ago that included a proximally coated titanium stem, a cobalt alloy femoral head, a titanium hemispherical acetabular component, and a polyethylene liner. She did well for 4 years but has now had two dislocations and reports pain and weakness around the left hip. She denies any fevers, chills, or constitutional symptoms. On examination, the patient walks well without any signs of an antalgic or Trendelenburg gait. Her abductor mechanism demonstrates good strength. Her erythrocyte sedimentation rate and C-reactive protein level are normal. On radiographs, all components appear well fixed and in good alignment. What is the most appropriate treatment at this time?

Explanation

DISCUSSION:
Trunnionosis is a recently recognized complication following total hip arthroplasty and can occur when a cobalt alloy femoral head is used on a titanium alloy or cobalt alloy femoral stem. Patients often present with pain or swelling around the hip but at times can present with instability. Certain femoral stem designs have been associated with increased reports of trunnionosis. In a patient with a cobalt alloy femoral head who presents with instability, swelling, and weakness around the hip, the potential for trunnionosis and
an adverse local tissue reaction should be considered.

Question 55

Which of the following is a function of siRNA (small interfering RNA)?

Explanation

siRNA functions by causing mRNA to be broken down after transcriptions, resulting in an inability to undergo translation.
siRNA are short (usually 20 to 24-bp) double-stranded RNA (dsRNA) sequences with phosphorylated 5' ends and hydroxylated 3' ends. Because of their ability to block a gene of interest, they have been generating interest in the treatment of disease processes that involve gene expression.
Noh et al. study the affects of PD98059, an extracellular signal-regulated kinase 1/2 (ERK1/2) inhibitor, on osteosarcoma. They found that blocking the ERK1/2 pathway with PD98059 induces osteosarcoma cell death by inhibiting a potential drug-resistance mechanism.
Illustration A shows how siRNA works to block translation of mRNA. Incorrect Answers:

Question 56

Figures 55a through 55c are the clinical photograph and radiographs of a 5-year-old boy who fell and injured his right elbow. His radial pulse is thready. Which neurologic deficit most commonly is associated with this injury?

Explanation

DISCUSSION
This injury is a type III supracondylar humerus fracture with posterolateral displacement. The area of ecchymosis is anteromedial, corresponding to the proximal spike of the humeral metaphysis. The brachial artery is likely tented over this spike, leading to diminished perfusion. The median nerve also resides in this area, and any neurological deficit is likely in its most vulnerable fibers, those of the anterior interosseous nerve (AIN). The AIN contains no sensory fibers, and its motor function involves flexion of both the thumb IP joint and the index distal IP joint.
First dorsal web space anesthesia and an inability to extend the fingers would indicate radial nerve neuropraxia, which would be more likely with posteromedially displaced fractures and lead to anterolateral ecchymosis. Finger abduction is controlled by the ulnar nerve, which most often is injured in flexion injuries and iatrogenically by medially placed pins.

Question 57

Figures 61a and 61b show the CT and MRI scans of a 40-year-old man who has hip pain. He undergoes total hip arthroplasty and curettage and cementation of the lesion as shown in Figure 61c. Histopathologic photomicrographs of the curettage specimen are shown in Figures 61d and 61e. What is the best course of treatment?

Explanation

DISCUSSION: The definitive surgery would be removal of the entire resection bed, and in this case of dedifferentiated chondrosarcoma, a hemipelvectomy was performed. The MRI and CT scans show an aggressive cartilage lesion. The histology, representative of a dedifferentiated chondrosarcoma, shows a bimorphic low-grade cartilage lesion with high-grade spindle cell sarcoma. The cartilage lesion is usually an enchondroma or low-grade chondrosarcoma. The dedifferentiated portion is typically a malignant fibrous histocytoma, osteosarcoma, or fibrosarcoma.
REFERENCES: Weber KL, Pring ME, Sim FH: Treatment and outcome of recurrent pelvic chondrosarcoma. Clin Orthop Relat Res 2002;397:19-28.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642

Question 58

-A likely candidate for treatment with a thoracic lumbosacral orthosis scoliosis brace is seen in

Explanation

Question 59

Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition?

Explanation

Factor V Leiden is a disease caused by an abnormality of factor V in which a single amino acid substitution of glutamine for arginine in the protein C cleavage region leads to decreased inactivation of factor V and thus a greater tendency to form clots. More than half of all individuals with Factor V Leiden will develop deep venous thrombosis in the presence of a single additional risk factor such as long bone fracture or total joint arthroplasty.

Question 60

A 25-year old right-hand dominant professional baseball pitcher complains of posteromedial right elbow pain that is worsened by throwing. He also reports occasional paresthesias in his small and ring finger after lengthy bullpen sessions. On examination, he is tender along the medial olecranon and complains of pain when extending the elbow >- 20° of extension. He has negative valgus stress, moving valgus stress, and milking maneuver tests. He is stable to varus stress, chair rise, and lateral pivot shift tests. Radiographs reveal a small osteophyte along the posteromedial border of the olecranon. What is the most likely diagnosis?

Explanation

A patient sustains a displaced diaphyseal humerus fracture following a motor vehicle accident. Open reduction internal fixation is indicated due to concomitant lower extremity trauma and is planned through an anterior approach. Which intramuscular interval is exploited during the deep dissection of the mid-humerus in this approach?
A. Lateral head of triceps (radial nerve) and brachialis (musculocutaneous nerve)
B. Lateral head of the triceps (radial nerve) and biceps brachii (musculocutaneous nerve)
C. Lateral brachialis (radial nerve) and medial brachialis (musculocutaneous nerve)
D. Brachialis (musculocutaneous nerve) and coracobrachialis (musculocutaneous nerve)

Question 61

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?

Explanation

DISCUSSION: Mechanical loosening and infection can occur as complications after surgery, but the most common cause of osteoarticular allograft failure is graft collapse during revascularization. Clinical rejection because of an immune response is an unusual means of failure.
REFERENCES: Meyers MH, Akeson W, Convery FR: Resurfacing of the knee with fresh osteochondral allograft. J Bone Joint Surg Am 1989;71:704-713.
Beaver RJ, Mahomed M, Backstein D, Davis A, Zukor DJ, Gross AE: Fresh osteochondral allografts for posttraumatic defects in the knee: A survivorship analysis. J Bone Joint Surg Br 1992;74:105-110.

Question 62

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Explanation

DISCUSSION: In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome.
REFERENCES: Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137.
Hahn M, Strauss E, Yang EC: Gunshot wounds to the forearm. Orthop Clin North Am 1995;26:85-93.

Question 63

Video 1 shows a 20-year-old right-hand dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

Explanation

A 53-year-old woman is experiencing thumb weakness. She has a remote history of a wrist fracture treated with a cast. She cannot lift her thumb off of a table when her hand is lying flat, palm-down. What is the most appropriate course of treatment?
A. Abductor pollicis longus reconstruction with palmaris autograft
B. Extensor pollicis brevis repair
C. Extensor pollicis longus (EPL) repair
D. Extensor indicis proprius (EIP) to extensor pollicis longus tendon transfer
The EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.
15- Figure 1 is the clinical photograph of a very functional 17-year-old boy with cerebral palsy and quadriplegia. He has no active supination but has full passive supination. His ability to determine position and sensibility without visual input are good. Radiographs show no osseous malalignment. Which treatment can best improve this patient's function?
A. Physical therapy for supination strengthening
1- Figures 1 through 3 are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?

A. Observation only
B. Fluoroscopic-guided intralesional steroid injection followed by serial radiographs
C. Immediate curettage without bone grafting
D. Splint immobilization with curettage and possible grafting after the fracture has healed
This patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized.

Question 64

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

Explanation

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

Question 65

In the anterior approach (Smith-Petersen) to the hip, dissection is carried out between muscles innervated by the

Explanation

DISCUSSION: In the Smith-Petersen approach to the hip, dissection is carried out between the tensor fascia lata laterally (supplied by the superior gluteal nerve) and the sartorius and rectus femoris medially (both supplied by the femoral nerve).
REFERENCES: Crenshaw AH Jr: Surgical techniques and approaches, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 9. St Louis, MO, Mosby-Year Book, 1998, vol 1, pp 82-85.
Williams PL, Warwick R, Dyson M, Bannister LH: Myology, in Gray’s Anatomy, ed 37. Edinburgh, Scotland, Churchill Livingstone, 1989, pp 638-639.

Question 66

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Explanation

DISCUSSION: Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.
Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of compartment syndrome."
Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

Question 67

A 30-year-old patient reports chronic medial knee pain and swelling. Figure 9a shows an articular cartilage lesion observed during arthroscopy. The surgeon decides to treat the lesion with the microfracture technique seen in Figure 9b. A biopsy of the repaired tissue 1 year after treatment is likely to show which of the following findings?

Explanation

DISCUSSION: Microfracture is a marrow stimulation technique where stem cells from the underlying subchondral bone marrow can form at the base of the lesion. The rationale for this technique is based on these cells differentiating into cells that will produce an articular cartilage repair. Biopsy findings in animals and humans have demonstrated primarily a fibrocartilagenous repair tissue and not articular cartilage. The collagen type found in hyaline or articular cartilage is of the type II variety. Fibrocartilage possesses mostly type I and III cartilage.
REFERENCES: Buckwalter JA, Mankin HJ: Articular cartilage: Degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect 1998;47:487-504.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 471-488.

Question 68

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty? Review Topic

Explanation

The theoretic advantage of a metal-to-bone articulation with the acromion is that there is a greater arc in which a smooth metal surface contacts the glenoid and acromion. This may improve pain and function, but no studies have evaluated this to date. One study showed results comparable to that of a standard hemiarthroplasty. There are no other biomechanic advantages.

Question 69

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

Explanation

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

Question 70

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

Explanation

EXPLANATION:

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

Question 71

A 63-year-old woman has a femoral neck fracture. A biopsy specimen obtained from the fracture site at the time of her hemiarthroplasty reveals metastatic carcinoma. Seven days after surgery, she becomes confused and lethargic. Which of the following laboratory values is most likely implicated in the patient’s symptoms at this time?

Explanation

DISCUSSION: Although many hematologic and electrolyte abnormalities may be present in a patient with advanced metastatic cancer, an elevated serum calcium level is most commonly associated with confusion. Treatment with hydration, diuretics, and bisphosphonates is recommended.
REFERENCES: Clohishy D: Management of skeletal metastasis in clinical orthopaedics, in Craig E (ed): Operative Orthopaedics. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 994-997.
Mundy GR: Hypercalcemia of malignancy revisited. J Clin Invest 1988;82:1-6.

Question 72

Figure 2 shows the radiograph of a 26-year-old auto mechanic who injured his right dominant elbow in a fall during a motocross race. Examination reveals pain and catching that limits his range of motion to 45 degrees of supination and 20 degrees of pronation. The interosseous space and distal radioulnar joint are stable. Management should consist of

Explanation

DISCUSSION: The radial head is an important secondary stabilizer of the elbow, helping to resist valgus forces. There has been a movement toward open reduction and internal fixation of the radial head when technically feasible, especially in a relatively high-demand athlete or laborer. The examination and radiograph suggest that displacement of the fragment is great enough to create a mechanical block. Extended splinting would only serve to encourage arthrofibrosis. Early range of motion is appropriate if there is minimal displacement of the radial head fragement, it is stable, and there is no mechanical block to motion. Fragments larger than one third of the joint surface should be excised only if it is not possible to reduce and repair the fragment. Primary excision of the radial head should be avoided if possible. Complications after excision of the radial head include muscle weakness, wrist pain, valgus elbow instability, heterotopic ossification, and arthritis.
REFERENCES: Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.
Esser RD, Davis S, Taavao T: Fractures of the radial head treated by internal fixation: Late results in 26 cases. J Orthop Trauma 1995;9:318-323.

Question 73

All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:

Explanation

DISCUSSION: Compartment syndrome can often be difficult to diagnosis in the pediatric patient. Mechanism of injury is not the best predictor of compartment syndrome development or diagnosis in pediatric patients. It is important to note that functional outcome following compartment syndrome in patients is inversely related to the duration of elevated tissue pressures before surgical fasciotomy.
Level 4 evidence by Bae et al reviewed 33 children with compartment syndrome. They found that all 10 compartment syndrome patients that had access to nurse or patient controlled analgesia (PCAs), during their initial evaluation, demonstrated an increasing requirement for pain medication.
Matsen et al reviewed 24 children with compartment syndrome with the most common causes being fracture, vascular injury, and tibial osteotomy. The study concluded that is imperative that a compartment syndrome be identified and treated as promptly as possible.

Question 74

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

Explanation

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

Question 75

The AP radiograph of a 5-year-old boy shows a 20-degree left thoracic scoliosis. He was noted by his pediatrician to have asymmetry on a forward bend test. On examination he is neurologically intact except for decreased sensation on the lateral aspect of both flanks and to pinprick in both hands. He has no pain. What is the best initial step in treatment at this time? Review Topic

Explanation

This patient has atypical scoliosis, given his young age and left thoracic curve. In addition, he has abnormal neurologic findings. MRI scan to evaluate for neural axis abnormalities is indicated. Abnormal MRI findings are present in 2% to 3.8% of all patients with presumed idiopathic scoliosis. Abnormal MRI findings are more likely if specific clinical factors are present, such as absence of thoracic apical segment lordosis, atypical curve pattern, an abnormal neurologic examination, male gender, and age younger than 11. In a patient with an atypical curve and neurologic indicators, the yield of MRI scan for a neuraxis abnormality has been shown to be 25%. This patient had both syringomyelia and a Chiari malformation that were treated neurosurgically. Observation would have missed these findings. Bracing or spinal instrumentation may eventually be treatment options for scoliosis given his young age, but establishing a diagnosis first with an MRI scan of the spine is the most appropriate initial step.

Question 76

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Explanation

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,

pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,

pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,

pp 2461-2564.

Question 77

An obese (BMI = 35) 72-year-old woman with diabetes mellitus, hyptertension and a 22-pack-year smoking history is scheduled to undergo posterior spinal fusion from T10 to S1 with a pedicle subtraction osteotomy at L3 for the spinal deformity seen in Figure 1. Which of the following risk factors is most predictive of major complication following surgery Review Topic

Explanation

The patients age (> 60 years) is the most significant risk factor for a major perioperative complication during posterior spinal fusion for adult spinal deformity correction.
The surgical treatment of adult spinal deformity often requires multilevel arthrodesis with complex osteotomies including three column osteotomies such as pedicle
subtraction (PSO) and vertebral column resection (VCR). They can involve both anterior and posterior surgical approaches. Surgical time, blood loss, length of hospital stay, and length of recovery can be greater than it is for the more common degenerative conditions.
Auerbach et al. characterized the risk factors for the development of major complications in patients undergoing 3-column osteotomies for adult spinal deformity correction. They also aimed to determine whether the presence of complications affected the ultimate clinical outcome. They found age > 60 years, > or = 3 comorbid conditions and preoperative sagittal imbalance of = 40mm was associated with a major complication. However, the presence of a major complication did not affect the ultimate clinical outcomes at 2 years or more.
Daubs et al. conducted a retrospective analysis of forty-six patients = 60 years of age who underwent major spinal deformity surgery requiring a minimum 5-level arthrodesis procedure to determine the rate of complication and outcomes. The overall complication rate was 37% and the major complication rate was 20%. Increasing age was a significant factor (p<0.05) in predicting the presence of a complication, while presence of comorbidities was found to have no association.
Figure A is a standing preoperative lateral radiograph of the spine demonstrating a thoracic kyphosis of ~25° and thoracolumbar kyphosis of ~25°. Illustration A demonstrates proper sagittal balance after spinal fusion from T10 to S1 and L3 PSO.
Incorrect Answers:

Question 78

Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

Explanation

Cavovarus feet are characterized by plantar flexion of the first metatarsal and hindfoot varus. A rigid cavovarus hindfoot does not correct on Coleman block testing. Correction of these rigid deformities requires either lateral displacement or lateral closing wedge osteotomies of the calcaneus and dorsiflexion osteotomies of the involved metatarsals. Lateral column lengthening procedures are used to correct painful flatfoot deformities.

Question 79

Which of the following enzymes is used to resorb bone by mature osteoclasts?

Explanation

Osteoclasts resorb bone. Osteoclasts are derived from monocytes and macrophages that fuse to form multinucleated cells in response to receptor activator of nuclear factor kappa b (RANKL) and macrophage colony stimulating factor (MCSF). Osteoclasts attach to bone surfaces through a specific cell attachment receptor called an integrin (av¯3 or vitronectin receptor). The ruffled border refers to multiple invaginations of plasma membrane against the bone matrix surface. Lysosomes move to the ruffled border of osteoclasts and discharge lysosomal enzymes into the resorption region. These enzymes include cathepsin K, matrix metalloproteinase, and carbonic anhydrase (CA II).

Question 80

An 8-year-old boy sustains a 100% displaced extension-type supracondylar humerus fracture. Examination reveals no sensory deficit. Capillary refill is approximately 1 second. The patient is unable to flex the index distal interphalangeal joint and the thumb interphalangeal joint. The remainder of the motor examination is normal. Which of the following best explains these physical findings? Review Topic

Explanation

Preoperative nerve deficit is common in children with displaced extension-type supracondylar humerus fractures (approximately 20%). Commonly injured nerves include the anterior interosseous nerve (a branch of the median nerve), the median nerve, and the radial nerve. The physical examination findings are most consistent with an anterior interosseous nerve palsy. The ulnar nerve is the most likely nerve to be injured in flexion-type supracondylar humerus fractures.

Question 81

An active 47-year-old woman with rheumatoid arthritis reports forefoot pain and deformity and has difficulty with shoe wear. Examination reveals hallux valgus and claw toes. A radiograph is shown in Figure 10. What is the most appropriate surgical treatment?

Explanation

DISCUSSION: Rheumatoid arthritis commonly affects the metatarsophalangeal joints, which become destabilized with time resulting in hallux valgus and dislocated lesser claw toes. The result is metatarsalgia as the dislocated claw toes “pull” the fat pad distally. Severe hallux valgus reduces first ray load, which compounds the metatarsalgia because the load is transferred to the lesser metatarsal heads. First metatarsophalangeal arthrodesis restores weight bearing medially and corrects the painful bunion. Metatarsal head resection slackens the toe tendons to allow correction of the claw toes by whatever means necessary and decreases plantar load over the forefoot. Rheumatoid arthritis in the first metatarsophalangeal joint will continue to progress if osteotomies or a Lapidus procedure are performed. Keller resection arthroplasty increases transfer metatarsalgia and reduces push-off power during gait. Flexor-to-extensor tendon transfer of the lesser toes does not address the metatarsalgia and does not correct the dislocation of the metatarsophalangeal joint.
REFERENCES: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, p 572.
Abdo RV, Iorio LJ: Rheumatoid arthritis of the foot and ankle. J Am Acad Orthop Surg 1994;2:326-332.

Question 82

During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?

Explanation

DISCUSSION: The flexor hallucis longus tendon provides the best, most direct route of transfer for filling Achilles tendon gaps. The tendon lies lateral to the neurovascular structures, making it safe for harvest and providing a direct route for transfer into the calcaneus without crossing these important structures. The flexor hallucis longus tendon also has muscle belly that extends distal on the tendon itself, often beyond the actual tibiotalar joint. When the tendon is transferred, this muscle belly brings excellent blood supply to the anterior portion of the reconstruction.
REFERENCES: Wilcox DK, Bohay DR, Anderson JG: Treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. Foot Ankle Int 2000;21:1004-1010.
Wapner K, Pavlock GS, Hecht PJ, Naselli F, Walther R: Repair of chronic Achilles tendon rupture with flexor hallucis longus tendon transfer. Foot Ankle Int 1993;14:443-449.

Question 83

The mother of a 5-year-old child reports that he has had a fever of 103°F (39.4°C), leg swelling, and has been unwilling to bear weight on his right lower leg for the past 7 days. Examination reveals point tenderness at the distal femur. Aspiration at the metaphysis yields 10 mL of purulent fluid, and a Gram stain reveals gram-positive cocci. In addition to hospital admission, management should include

Explanation

DISCUSSION: The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.
REFERENCE: Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1996, pp 149-161.

Question 84

What factor is considered one of the early changes in osteoarthritic cartilage?

Explanation

DISCUSSION:
The normal regulation of a cartilage surface is a delicate balance of degradation and synthesis. When this normal regulation of the cartilage is disturbed, a proinflammatory state tips the cellular pathway in the direction of degradation. The proinflammatory state upregulates the production of cytokines and proteolytic enzymes, specifically matrix metalloproteinases. These enzymes attack the proteoglycan content of the cartilage, leading to an overall reduction in the proteoglycan content. This reduction in content leads to increased permeability of the cartilage substrate. With increased permeability, water is able to move into the cartilage itself, thereby increasing the overall water content within the cartilage in an arthritic state. Finally, because of the increased permeability and increased water content, the overall load or pressure placed on the underlying solid matrix is increased. Increased water content, decreased proteoglycan content, and an increased load on the solid matrix are typical of an osteoarthritic process within normal cartilage. Therefore, the only correct option is that the cartilage has an increased amount of permeability in osteoarthritis.

Question 85

A patient reports hyperesthesia over the base of the thenar eminence following volar locked plating of a distal radius fracture. A standard volar approach of Henry was used. What is the most likely cause of the hyperesthesia?

Explanation

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 86

An 80-year-old woman notes a painless mass posterior to her left knee. MRI scans are shown in Figures 31a and 31b. What is the best course of action?

Explanation

DISCUSSION: The MRI scans show a popliteal cyst (Baker’s cyst) in its most common location. The cyst emerges from the knee joint between the medial head of the gastrocnemius muscle and the tendon of the semimembranosus muscle. These images are diagnostic; therefore, no further work-up is indicated. Since the patient is asymptomatic, no treatment is necessary.
REFERENCES: Dlabach JA: Nontraumatic soft tissue disorders, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philidelphia, PA, Mosby, 2003, vol 1, pp 885-969.
Fritschy D, Fasel J, Imbert JC, et al: The popliteal cyst. Knee Surg Sports Traumatol Arthrosc 2006;14:623-628.

Question 87

Which of the following findings is a prerequisite for a high tibial valgus osteotomy for medial compartment gonarthrosis?

Explanation

DISCUSSION: The indications for high tibial valgus osteotomy include a physiologically young age, arthritis confined to the medial compartment, 10 to 15 degrees of varus alignment on weight-bearing radiographs, a preoperative arc of motion of at least 90 degrees, flexion contracture of less than 15 degrees, and a motivated, compliant patient. Contraindications include lateral compartment narrowing of the articular cartilage, lateral tibial subluxation of greater than 1 cm, medial compartment bone loss, ligamentous instability, and inflammatory arthritis.
REFERENCES: Naudie D, Bourne RB, Rorabeck CH, Bourne TT: The Insall Award: Survivorship of the high tibial valgus osteotomy. A 10- to 22-year followup study. Clin Orthop 1999;367:18-27.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,
pp 255-264.

Question 88

Which of the following medications has been shown to improve skeletal muscle regeneration and decrease fibrosis following muscle injury in an animal model? Review Topic

Explanation

Angiotensin II receptor blockade (e.g. losartan) administered after injury has been shown to improve muscle regeneration and decrease fibrosis in normal skeletal muscle.
Skeletal muscle undergoes a natural process of healing and regeneration after injury. The formation of fibrous tissue in place of normal muscle is also part of this process. However, fibrous tissue in place of muscle can predispose the area to re-injury and impaired function. Administration of angiotensin II receptor blockade medications (e.g. losartan) after skeletal muscle injury has been shown to decrease the apoptotic cascade response and the formation of fibrous tissue. The mechanism of benefit is thought to be associated with blockade of insulin-like growth factor.
Terada et al. looked at the affect of platelet-rich plasma (PRP) and losartan on muscle healing after contusion injuries. They showed that PRP plus losartan combination
therapy improved overall skeletal muscle healing by enhancing angiogenesis and follistatin expression as well as reducing the expression of phosphorylated Smad2/3 and the development of fibrosis.
Bedair et al. used a rat model to investigate the effect of angiotensin receptor blockade on muscle fibrosis after injury. They found that angiotensin receptor blockade therapy significantly reduced fibrosis and led to an increase in the number of regenerating myofibers in acutely injured skeletal muscle.
Incorrect

Question 89

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

Explanation

DISCUSSION: The appropriate staging studies should consist of MRI and a radiograph of the primary lesion and CT of the chest. MRI is superior to CT for soft-tissue imaging. CT may be useful for evaluating the cortex of bone for invasion by tumor. Bone scans are not commonly used because soft-tissue sarcomas rarely metastasize to bone. CT of the abdomen and pelvis is not typically ordered except for possible liposarcoma. With liposarcoma, there may be a synchronous or metastatic retroperitoneal liposarcoma.
REFERENCES: Demetri GD, Pollock R, Baker L, et al: NCCN sarcoma practice guidelines: National Comprehensive Cancer Network. Oncology (Huntingt) 1998;12:183-218.
Pollock R, Brennan M, Lawrence W Jr: Society of Surgical Oncology practice guidelines: Soft-tissue sarcoma surgical practice guidelines. Oncology (Huntingt) 1997;11:1327-1332.

Question 90

Figure 125 is the anteroposterior knee radiograph of a 65-year-old man who has been treated for knee pain for 6 years. His pain is constant and is worse when walking up and down stairs and when sitting for a prolonged period. He has medial joint line tenderness and a positive patellofemoral grind test finding. His knee is stable to varus and valgus stress. A Lachman test result is 2+. He had a trial of nonsteroidal anti-inflammatory medications with good relief until 4 months ago. Physical therapy has provided minimal relief, and he has undergone a series of intra-articular injections with corticosteroids. The last 2 injections each provided 1 week of pain relief. What is the most appropriate next treatment option?

Explanation

DISCUSSION
Osteoarthritis is a complex disease. Multiple studies have demonstrated a genetic predisposition and critical role of proinflammatory cytokines in the disease process. Osteoarthritis of the knee has a multifactorial pathogenesis. It is age related and affects women more commonly than men. It is also influenced by such factors as obesity, trauma, repetitive use, muscle weakness, and joint laxity. The treatment of osteoarthritis is multimodal.
Nonsurgical treatments include nonsteroidal anti-inflammatory medications, intra-articular injections, weight loss, and physical therapy. Surgical treatments include osteotomy and unicompartmental and TKA.

Question 91

Local administration of recombinant bone morphogenetic protein-2 (rhBMP-2) to patients with type III-A and III-B open tibial shaft fractures at the time of initial surgery has shown all of the following when compared to standard treatment EXCEPT:

Explanation

DISCUSSION: The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. Swiontkowski et al showed when compared to the control group (intramedullary nail fixation and routine soft-tissue management), the group receiving the rhBMP-2 required fewer bone-grafting procedures (p = 0.0005), fewer invasive secondary interventions (p = 0.0065), and there was a lower rate of infection (p = 0.0234). A shorter-term study by Govender et al showed significantly more patients treated with rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months (p = 0.0008). Govender et al found similiar results in regards to a decreased need of secondary procedures, improvement in time to union, improved wound healing and decreased infection rate in those who received BMP-2.

Question 92

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Explanation

DISCUSSION: Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-3% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture. Recommended treatment in the pre-rupture setting includs a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be
clinically satisfactory.
The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.

Question 93

Figures 18a through 18c show the clinical photograph, radiograph, and CT scan of a 21-year-old man who reports persistent pain after injuring his right shoulder 4 months ago. What is the most likely factor associated with this patient’s diagnosis?

Explanation

DISCUSSION: The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.
REFERENCES: Lazarus MD, Seon C: Fractures of the clavicle, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, vol 2, pp 1241-1242.
White RR, Anson PS, Kristiansen T, et al: Adult clavicle fractures: Relationship between mechanism of injury and healing. Orthop Trans 1989;13:514-515.

Question 94

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

Explanation

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

Question 95

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Explanation

DISCUSSION: The maximum stress in a bone occurs at the periosteal surface (the greatest distance from the center of the bone). The magnitude of the stress is equal to the magnitude of the applied moment (M) multiplied by the distance to the surface (roughly the radius of the bone, r) divided by the area moment of inertia (I), so that stress = Mr/I. Of the possible answers, only area moment of inertia of the cross section contains any of these three items. The stress can also depend on the length of the bone, but it cannot be determined without knowing the location at which the bending load is applied, information that was not given in the problem. The type of structural support may influence local stresses where the support contacts the bone, but it has little effect on the maximum stress in the bone. The cross-sectional area is not as important as the area moment of inertia because the stress is not evenly distributed over the cross-section. Plastic modulus is a material property, not a geometric or structural property, and it does not affect stress.
REFERENCES: Hayes WC, Bouxsein ML: Biomechanics of cortical and trabecular bone: Implications for assessment of fracture risk, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 76-82.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 161-167.

Question 96

Which ligament attaches to the bony fragment identified by the CT image arrows in Figures 42a and 42b?

Explanation

DISCUSSION
The distal tibiofibular syndesmosis is a ligamentous complex that consists of the AITFL, PITFL, intertransverse ligament (ITL), and IOL. The PITFL originates on the posterior inferior aspect of the tibia (Volkmann tubercle) and inserts on the lateral malleolus. The AITFL originates on the anterolateral aspect of the tibia (Chaput tubercle) and inserts on the distal anterior aspect of the fibula (Wagstaffe tubercle). The ITL is a group of fibers running transversely just inferior to the PITFL. As a group, these structures maintain the appropriate tibial plafond and talus relationship throughout physiologic range of motion.
RECOMMENDED READINGS
Carr JB. Malleolar fractures and soft tissue injuries of the ankle. In: Browner BD, Alen LM, Peter TG, Jupiter JB, et al. Skeletal Trauma. 3rd ed. Philadelphia, PA: Saunders; 2003:2309. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg.2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46

A 46-year-old healthy right-hand-dominant man falls and sustains the injury shown in Figures 43a and 43b.

Question 97

Which of the following is considered a disadvantage of knee disarticulation when compared with transfemoral amputation?

Explanation

The decision to perform a transfemoral amputation versus a knee disarticulation remains controversial because there are advantages and disadvantages to each procedure. One potential advantage of the knee disarticulation is that energy expenditure during walking may be less than that for a transfemoral amputee. Another advantage is that the knee disarticulation provides for an end-bearing residual limb. The knee disarticulation also includes complete preservation of the thigh muscles, leading to better muscular balance, and the bulbous shape of the residual limb leads to increased stability of the prosthesis. Disadvantages of knee disarticulation include limitations in knee-joint prosthetic components and concerns regarding the cosmesis of the prosthesis, as well as the asymmetry of the knee joint with respect to sitting and gait. Because knee disarticulations are relatively uncommon compared to transfemoral amputations, many prosthetists may have less familiarity with the fabrication and fit of this prosthesis. One of the more important issues with respect to knee
disarticulation versus transfemoral amputation is the degree of trauma involving the soft tissue around the knee, as increased tissue trauma may lead to painful residual limbs and eventually the need for revision amputation at a higher level. If the residual limb of the knee disarticulation is unable to accommodate the distal-end weight bearing of the socket, then patients with a knee disarticulation may experience decreased levels of function compared with patients undergoing transfemoral amputation.

Question 98

Figure 4 shows the MRI scan of a patient who has had bilateral leg pain, weakness, diffuse numbness, and urinary retention for the past week. Examination reveals that motor strength is diffusely decreased, although it may be secondary to pain. The patient is numb throughout both legs, and reflexes in the lower extremities are absent. Rectal examination shows decreased tone, but voluntary tightening is present. Management should consist of

Explanation

DISCUSSION: The patient has a cauda equina syndrome. The fact that he has decreased rectal tone and urinary retention suggests the need for urgent surgery. Patients who are left untreated will have a poor prognosis for return of function. Although most patients who have insidious onset of symptoms with urinary retention will regain normal motor function following decompression, nearly one third will continue to have abnormal voiding patterns or sexual dysfunction of varying degrees.
REFERENCES: Kostuik JP, Harrington I, Alexander D, Rand W, Evans D: Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am 1986;68:386-391.
Wisneski RJ, Garfin SR, Rothman RH, Lutz GE: Lumbar disk disease, in Herkowitz HN, Garfin SR, Balderston RA, et al (eds): The Spine, ed 4. Philadelphia, PA,WB Saunders, 1992, vol 1,

pp 613-679.

Question 99

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Explanation

The recent experience of a large clinical cohort revealed the most likely risk factors as being female gender, age younger than 40, small components, and a diagnosis of hip dysplasia causing osteoarthritis. Failure was least likely among men and after procedures involving larger components. These data have prompted some authors to caution against using metal-on-metal hip resurfacing in women and to primarily target candidates who are men younger than age 50. Small components may be more prone to failure because of malpositioning and edge loading, which have been noted to be more common in dysplasia cases.

Question 100

While under a physician’s care, a 45-year-old man verbally abuses the staff and nurses who are attempting to carry out orders. A decision to discharge the patient is best carried out by

Explanation

The other foils in this answer would be both unethical and would be a violation of “anti-dumping” laws. This would further open the physician, hospital and staff to possible litigation.

Full Question & Answer Text (for Search Engines)

Question 1:

What is the most accurate description of the relationship between gender and knee loading during landing while playing basketball?

Options:

Males have greater total valgus knee loading.
Females have greater total valgus knee loading.
Males have greater total varus knee loading.
Females have greater total varus knee loading.
There is no gender difference in total varus or valgus knee loading.

Correct Answer: Females have greater total valgus knee loading.

Explanation:

Question 2:

Figures 54a and 54b show the radiograph and MRI scan of a 7-year-old boy who has a painful right thoracic scoliosis that measures 35°. Neurologic examination is normal. Management should consist of

Options:

repeat radiographs in 6 months.
a technetium Tc 99m bone scan.
posterior spinal fusion.
anterior and posterior spinal fusion.
a neurosurgical consultation.

Correct Answer: a neurosurgical consultation.

Explanation:

Question 3:

Figure 46 shows the AP radiograph of a patient with right shoulder pain. What is the most likely diagnosis?

Options:

Periosteal sleeve injury
Acute type 2 acromioclavicular joint separation
Rickets
Traumatic osteolysis
Distal clavicle fracture

Correct Answer: Traumatic osteolysis

Explanation:

Question 4:

Options:

conversion to a longer side plate with the same compression screw and tube angle.
in situ bone grafting.
hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.
hardware removal and retrograde femoral nailing.
revision reconstruction with cerclage wiring.

Correct Answer: hardware removal and reconstruction with an intramedullary device that provides fixation into the femoral head and neck.

Explanation:

Question 5:

A 50-year-old woman undergoes an L4-S1 laminectomy and noninstrumented fusion for degenerative spondylolisthesis.

Options:

Postoperative deep surgical site infection
Proximal junctional kyphosis
Pedicle screw cut-out
Pseudarthrosis
Sagittal imbalance

Correct Answer: Pseudarthrosis

Explanation:

Question 6:

An ulnar nerve palsy at the level of the wrist is typically associated with deficits in the palmaris brevis, the hypothenar muscles, and what other groups of muscles?

Options:

Volar interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and the deep head of the flexor pollicis brevis
Dorsal interossei, adductor pollicis, and both heads of the flexor pollicis brevis
All of the interossei and the abductor pollicis brevis
All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Correct Answer: All of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis

Explanation:

DISCUSSION: The intrinsic muscles innervated by the ulnar nerve include the palmaris brevis, hypothenar muscles, all of the interossei, adductor pollicis, and the deep head of the flexor pollicis brevis. The superficial head of the flexor pollicis brevis is innervated by the
median nerve.
REFERENCES: Goldfarb CA, Stern PJ: Low ulnar nerve palsy. JASSH 2003;3:14-26.
Omer G: Ulnar nerve palsy, in Green DP, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, Churchill Livingstone, 1999, pp 1526-1541.

Question 7:

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

Options:

Proximal femur
Proximal humerus
Proximal tibia
Distal femur
Distal humerus

Correct Answer: Proximal tibia

Explanation:

Question 8:

What are the five major compartments of the foot?

Options:

Medial, lateral, central, interosseous, and calcaneal
Medial, lateral, central, interosseous, and dorsal
Medial, lateral, central, dorsal, and calcaneal
Medial, lateral, dorsal, interosseous, and calcaneal
Dorsal, lateral, central, interosseous, and calcaneal

Correct Answer: Medial, lateral, central, interosseous, and calcaneal

Explanation:

Question 9:

The best patient-related outcomes, following the surgical treatment of cauda equina syndrome secondary to a large L5-S1 disk herniation, are most closely related to which of the following?

Options:

Extent of bowel and bladder dysfunction
Extent of the motor deficit
Extent of the perianal saddle anesthesia
Timing of surgery
Location of the herniation

Correct Answer: Timing of surgery

Explanation:

DISCUSSION: The most predictable positive outcome from spinal surgery due to a cauda equina syndrome is early surgical intervention before any significant neurologic deficit develops. Meta-analysis studies demonstrate that surgical intervention more than 48 hours after the onset of cauda equina syndrome show an increased risk for poor outcomes.
REFERENCES: Ahn UM, Ahn NU, Buchowski JM, et al: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 2000;25:1515-1522.
Kohles SS, Kohles JD, Karp AP, et al: Time-dependent surgical outcomes following cauda equina syndrome diagnosis: Comments on meta-analysis. Spine 2004;29:1281-1287.

Question 10:

Which of the following zones of articular cartilage has the highest concentration of proteoglycans?

Options:

Superficial
Transitional
Deep
Calcified
Tidemark

Correct Answer: Deep

Explanation:

Question 11:

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

Options:

Amenorrhea
Osteoporosis
Low LDL levels
Decreased immune function
Insufficient caloric intake

Correct Answer: Amenorrhea

Explanation:

Question 12:

Options:

significant quadricep weakness in the pateller tendon compared with the hamstring.
significant quadricep weakness in the hamstring compared with the pateller tendon.
significant weakness in the hamstring compared with the patellar tendon.
significant hamstring weakness in the pateller tendon compared with the hamstring.
no significant difference between the hamstring and the pateller tendon.

Correct Answer: no significant difference between the hamstring and the pateller tendon.

Explanation:

Question 13:

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:

Question 14:

Osteopenia is defined by the World Health Organization (WHO) as a bone mineral density (BMD) that is

Options:

within 1 standard deviation of aged-matched normals.
within 1 and 2.5 standard deviations below aged-matched normals.
within 1 standard deviation of young normals.
within 1 and 2.5 standard deviations below young normals.
more than 2.5 standard deviations below aged-matched normals.

Correct Answer: within 1 and 2.5 standard deviations below young normals.

Explanation:

DISCUSSION: Osteopenia, decreased bone mass without fracture risk as defined by the WHO criteria for diagnosis of osteoporosis, is when a woman’s T-score is within -1 to -2.5 SD.
The T-score represents a comparison to young normals or optimum peak density. The Z-score represents a comparison of BMD to age-matched normals. Measurements of bone mineral density (BMD) at various skeletal sites help in predicting fracture risk. Hip BMD best predicts fracture of the hip, as well as fractures at other sites.
REFERENCE: Kanis JA, Johnell O, Oden A, et al: Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000;27:585-590.

Question 15:

Sclerostin and dickkopf-1 (Dkk-1) are direct inhibitors of what pathway related to bone and/or cartilage regulation?

Options:

Bone morphogenetic protein (BMP)/SMAD pathway
Receptor activator of nuclear factor kappa beta (RANK)/RANK ligand (RANKL) pathway
Wnt/Beta-catenin (β-catenin) pathway
Parathyroid hormone (PTH) pathway DISCUSSION.Dkk-1 and sclerostin are proteins that inhibit the binding of the Wnt molecule to receptors LRP5/6. In the absence of sclerostin and Dkk-1, Wnt binds to its receptor, which in turn inhibits phosphorylation of the β-catenin. The unphosphorylated β-catenin then builds up in the cytoplasm of the cell, allowing it to be transported to the nucleus of the cell. Once in the nucleus, β-catenin will lead to upregulation of a series of proteins involved in osteoblast formation differentiation. Knocking out or inhibiting sclerostin or Dkk-1 results in increased bone mass secondary to constitutive activation of the Wnt/β-catenin pathway.The other responses are not directly affected by Dkk-1 or sclerostin. RANKL and RANK are expressed on osteoblasts and osteoclasts, respectively, and are involved in osteoblast-mediated osteoclast activation.BMPs work through SMADs to cause osteoblastic differentiation, and there is reported crosstalk between the Wnt and BMP pathways (but this is an indirect link). Finally, PTH at physiologic levels binds to osteoblasts, causing a series of events that lead to osteoblast-mediated osteoclast activation and subsequent increased bone resorption.

Correct Answer: Wnt/Beta-catenin (β-catenin) pathway

Explanation:

RESPONSES FOR QUESTIONS 3 THROUGH 6
Adhesive wear
Abrasive wear
Fatigue wear
Delamination
For each scenario below, please choose the most likely dominant mechanism of wear from the list
above.

Question 16:

Options:

Acute periprosthetic infection
Aseptic loosening of her right acetabular component
Wear debris of a polyethylene liner in the right hip
Pseudotumor in the right hip attributable to trunnionosis

Correct Answer: Wear debris of a polyethylene liner in the right hip

Explanation:

Question 17:

Options:

Diagnostic arthroscopy of the hip
Hip bone scan
Hip MRI arthrogram
Hip ultrasonography

Correct Answer: Hip MRI arthrogram

Explanation:

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. Ultrasonography may be useful in the diagnosis of dysplasia or for dynamic assessment of a snapping hip, but ultrasonography 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 in 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 18:

Options:

ACL injuries are more common in men younger than 30 years of age.
ACL injuries are more common in women younger than 30 years of age.
ACL injuries are usually the result of contact sports.
The incidence of ACL injuries can be decreased by a neuromuscular training program.
ACL injuries are rarely associated with meniscal injury.

Correct Answer: ACL injuries are more common in women younger than 30 years of age.

Explanation:

Question 19:

Options:

Hip arthroscopy with labral repair, rim trimming and femoral osteochondroplasty
Hip arthroscopy with labral repair and periacetabular osteotomy with femoral osteochondroplasty
Open surgical hip dislocation with labral repair, rim trimming and femoral osteochondroplasty
Hip arthroscopy with labral repair and reverse periacetabular osteotomy with femoral osteochondroplasty The radiographs show a large cam lesion on the anterosuperior aspect of the femoral head, and this is confirmed by high alpha angle (76). Cam and pincer lesions commonly cause labral tears and lead to femoroacetabular impingement. After failure of nonoperative treatment, surgery involves hip arthroscopy, labral repair or debridement, rim trimming (resection of acetabulum), and femoral osteochondroplasty. A periacetabular osteotomy is the preferred surgery in dysplastic patients. Dysplasia is defined as undercoverage of the femoral head, typically a center-edge angle <25. Reverse periacetabular osteotomy is used for a true retroverted acetabulum. Lastly, open dislocation is the preferred method when the hip deformity is too severe to treat arthroscopically or when the femoral head is significantly overcovered by the acetabulum (center-edge angle >40).

Correct Answer: Open surgical hip dislocation with labral repair, rim trimming and femoral osteochondroplasty

Explanation:

Question 20:

Options:

cast immobilization.
arthroscopy.
continued physical therapy.
a repeat corticosteroid injection.
a short course of oral steroids.

Correct Answer: arthroscopy.

Explanation:

Question 21:

Which specific legislative Act in the United States was created to require reporting of annual monetary gifts or compensation of more than $10 by orthopaedic implant companies to physicians?

Options:

Patient Protection and Affordable Care Act
Medicare Payment Reform Act
Physician Financial Transparency Act
Physician Payments Sunshine Act
Health Insurance Portability and Accountability Act

Correct Answer: Physician Financial Transparency Act

Explanation:

Question 22:

Options:

The P-value from a t-test comparing the mean densities
The P-value from a Wilcoxon rank test comparing the densities
The difference between the mean bone mineral densities of the two groups
The ratio of the mean mineral density of the experimental group to that of the control group, along with the P-value
The means and standard deviations of the bone mineral densities for the two groups

Correct Answer: The means and standard deviations of the bone mineral densities for the two groups

Explanation:

DISCUSSION: A complete answer necessarily includes the means and standard deviations of bone mineral density in both groups. Given these, which are the basic results of the study, the P-value can be calculated if desired. All of the other options preclude assessment of the actual data, that is, the information collected by the study. P-values and confidence intervals should be perceived as additional information, which help to assess the certainty of relating the study’s findings to the general population, but they should not be reported instead of the results
(ie, the means and standard deviations).
REFERENCE: Ebramzadeh E, McKellop H, Dorey F, et al: Challenging the validity of conclusions based on P-values alone: A critique of contemporary clinical research design and methods. Instr Course Lect 1994;43:587-600.

Question 23:

Options:

Lateralize the acetabular component, use a low offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut
Lateralize the acetabular component, use a high offset femoral component, and make a shorter neck cut
Medialize the acetabular component, use a high offset femoral component, and make a longer neck cut

Correct Answer: Medialize the acetabular component, use a low offset femoral component, and make a longer neck cut

Explanation:

Question 24:

03 Which of the following findings is one of the diagnostic criteria for diffuse idiopathic skeletal hyperostosis?

Options:

Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae
Disk space collapse in the involved vertebral segments
Marginal syndesmophytes over four contiguous vertebrae
Sacroiliac erosion or sclerosis
Facet joint ankylosis Question 64.03

Correct Answer: Flowing ossification along the anterolateral aspect of at least four contiguous vertebrae

Explanation:

Question 25:

Options:

HIV
Staph Aureus
Hepatitis A
Hepatitis B
Hepatitis C

Correct Answer: HIV

Explanation:

Question 26:

Options:

Enchondroma
Giant cell tumor
Chondroblastoma
Osteoblastoma
Chondromyxoid fibroma

Correct Answer: Chondroblastoma

Explanation:

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 27:

Options:

ixation of the coronoid fragment
Radial head arthroplasty
Repair or reconstruction of the lateral collateral ligament (LCL) complex
Repair or reconstruction of the medial collateral ligament (MCL) This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer: Repair or reconstruction of the lateral collateral ligament (LCL) complex

Explanation:

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?
A. Improved longevity in comparison to the linked prosthesis
B. A significantly larger flexion-extension arc
C. A higher incidence of postsurgical instability
D. Lower frequency of ulnar nerve dysfunction
TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 28:

Options:

Femoral revision with distal augment
MCL allograft reconstruction
Ultracongruent insert
Rotating-hinge TKA

Correct Answer: Rotating-hinge TKA

Explanation:

Question 29:

What is the most common site of metastases from a soft-tissue sarcoma?

Options:

Liver
Bone
Lymph nodes
Lungs
Muscle

Correct Answer: Lungs

Explanation:

DISCUSSION: The most common site of metastases from a soft-tissue sarcoma is the lungs and occurs in 40% to 60% of patients. The second most common site of metastases in soft-tissue sarcomas is the lymph nodes. Nodal metastases are seen with regularity in synovial sarcoma, epithelioid sarcoma, and rhabdosarcoma. The liver, brain, bone, and muscle are occasional sites of spread, but the occurrence is very rare.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 255-259.

Question 30:

A 12-year-old child with L4 myelomeningocele who is schedules for foot surgery has a functioning ventriculoperitoneal shunt and has no history of allergies. Management should include

Options:

Use of regional rather than general anesthesia
Observation of a latex-avoidance protocol
Latex skin allergen testing
Premedication with corticosteroids and antihistamines
Avoidance of prophylactic antibiotics derived from penicillin

Correct Answer: Observation of a latex-avoidance protocol

Explanation:

Question 31:

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

Options:

Oxycodone hydrochloride
Hydrocodone/acetaminophen
Tramadol
Imipramine
Ketorolac

Correct Answer: Ketorolac

Explanation:

Question 32:

Figure 52 shows the MRI scan of a 28-year-old baseball pitcher. Examination will most likely reveal which of the following findings?

Options:

Weakness of the deltoid
Numbness in the C7 dermatomal distribution
Winging of the scapula
A positive lift-off test
Clinical findings similar to a large rotator cuff tear

Correct Answer: Clinical findings similar to a large rotator cuff tear

Explanation:

Question 33:

In infantile idiopathic scoliosis, which of the following factors suggests progression?

Options:

Age at presentation
Rib overlap of the apical vertebra
Rib vertebral angle difference of greater then 10 degrees
Male gender
Family history

Correct Answer: Rib overlap of the apical vertebra

Explanation:

Question 34:

Options:

arthroscopic synovectomy.
open synovectomy.
staple hemiepiphyseodesis.
knee arthrodesis.
varus osteotomy.

Correct Answer: staple hemiepiphyseodesis.

Explanation:

Question 35:

Options:

CT
Routine ACL rehabilitation
Modified ACL rehabilitation to limit weight bearing
Modified ACL rehabilitation to limit flexion
Revision ACL surgery

Correct Answer: Revision ACL surgery

Explanation:

Question 36:

Options:

Peripheral nerve sheath tumor
Malignant peripheral nerve sheath tumor
Malignant fibrous histiocytoma
Liposarcoma
Synovial sarcoma

Correct Answer: Malignant peripheral nerve sheath tumor

Explanation:

DISCUSSION: The images reveal a large mass in the posterior thigh arising from the sciatic nerve. The lesion is edematous, and the gadolinium image reveals rim enhancement, suggesting necrosis, given that the STIR image is not uniformly bright as would be seen in a cystic lesion. The PET scan has increased uptake, in this case a standard unit value (SUV) of greater than 2.0. These findings are all very suggestive of a malignant process. The history of neurofibromatosis makes a malignant peripheral nerve sheath tumor, or neurofibrosarcoma, the most likely diagnosis. The term “peripheral nerve sheath tumor” has replaced neurolemmoma and schwannoma.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 225-230.
Resnick D (ed): Diagnosis of Bone and Joint Disorders. Philadelphia, PA, WB Saunders, 2002, pp 4218-4235.

Question 37:

Options:

talectomy and tibiocalcaneal arthrodesis.
in situ subtalar joint arthrodesis.
distraction bone block subtalar joint arthrodesis.
lateral wall exostectomy of the calcaneus.
tibiotalar joint arthrodesis.

Correct Answer: distraction bone block subtalar joint arthrodesis.

Explanation:

Question 38:

Options:

Abrasive wear
Fatigue wear
Adhesive wear
Adhesive and abrasive wear

Correct Answer: Adhesive and abrasive wear

Explanation:

Question 39:

Options:

Removal of the press-fit implant and cementing of the same femoral stem
Removal of the uncemented femoral component and placement of a revision modular taper- fluted femoral stem
Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant
Final seating of the uncemented femoral component without additional measures

Correct Answer: Removal of the implant, placement of a cerclage wire around the femoral neck above the lesser trochanter, and reinsertion of the implant

Explanation:

Question 40:

What is the most appropriate way to communicate instructions to a family when there is a language barrier?

Options:

Use a translation program to print out instructions in the family’s native language and ask if they have questions
Have the patient translate the instructions if his or her English skills are adequate
Use a member of the hospital’s nonmedical staff to translate
Use a professional medical interpreter

Correct Answer: Use a professional medical interpreter

Explanation:

DISCUSSION
Ideally, professional medical interpreters should be used in situations involving language difficulties. Printed instructions are helpful, but, if there is a language barrier, these instructions cannot substitute for conversing and answering questions. Asking the child to translate (no matter how fluent he or she may be) is suboptimal. Nonmedical staff may not be fluent enough to adequately translate medical terms.
RESPONSES FOR QUESTIONS 14 THROUGH 16
Aspiration, cultures, surgical irrigation and debridement, and intravenous (IV) nafcillin
Aspiration, cultures, surgical irrigation and debridement, and IV vancomycin
Aspiration, cultures, Lyme serology, and oral amoxicillin
Biopsy, culture, curettage, bone graft, and possible internal fixation
Physical therapy, ibuprofen, and an antinuclear antibody test
Select the most appropriate treatment above to address each clinical scenario below.

Question 41:

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Options:

Space available for the cord of less than 8 mm
Ossification of the posterior longitudinal ligament
Fixed cervical kyphosis
Previous posterior surgery
Concomitant cervical radiculopathy

Correct Answer: Fixed cervical kyphosis

Explanation:

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 42:

Options:

core decompression.
a vascularized fibula graft.
intraosseous steroid injection.
total hip replacement.
protected weight bearing.

Correct Answer: protected weight bearing.

Explanation:

Question 43:

Options:

Osteoporosis
Hallux valgus deformity
Hallux rigidus
A relatively long second metatarsal

Correct Answer: A relatively long second metatarsal

Explanation:

Question 44:

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made using

Options:

clinical examination.
invasive pressure measurement.
arterial Doppler study.
MRI.

Correct Answer: clinical examination.

Explanation:

Question 45:

Options:

Immediately
In three games
After anterior plate removal
Next season
Cannot return

Correct Answer: Immediately

Explanation:

Question 46:

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Options:

Elastic limit
Nonproportional behavior
Plastic behavior
Elastic behavior
Fracture point

Correct Answer: Elastic behavior

Explanation:

Question 47:

- Figures 38a & 38b show radiographs of a 40 year old man who underwent a Putti-Platt repair for recurrent dislocations at age 22. He reports increasing pain in the shoulder and limited motion for five years. Examination reveals 130 degrees of elevation and 15 degrees of external rotation. Non-surgical treatment has failed. Treatment should now consist of what?

Options:

Manipulation Under Anesthesia
Arthroscopic acromioplasty
Arthroscopic debridement of G-H joint
Replacement of the humeral head
Lengthening of the subscapularis and release of the anterior capsule

Correct Answer: Lengthening of the subscapularis and release of the anterior capsule

Explanation:

Question 48:

What is the most appropriate initial diagnostic imaging study for a patient with presumed diskogenic low-back pain?

Options:

MRI
Discography
CT discography
Radiography

Correct Answer: Radiography

Explanation:

Question 49:

A Trendelenburg gait is most likely to be seen in association with

Options:

a central disk herniation at L3-L4.
an ipsilateral paracentral disk herniation at L3-L4.
an ipsilateral paracentral disk herniation at L4-L5.
an ipsilateral paracentral disk herniation at L5-S1.
an ipsilateral far lateral disk herniation at L4-L5.

Correct Answer: an ipsilateral paracentral disk herniation at L4-L5.

Explanation:

Question 50:

Options:

Pain during sitting; flexion abduction and external rotation of the hip
Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°
Clicking; abductor lurch
Buttock pain; pain with hip extension, adduction, and external rotation while prone

Correct Answer: Groin pain; pain with internal rotation and adduction while supine with the hip and knee flexed 90°

Explanation:

Question 51:

Options:

Cease participation in all sports.
Allow a return to noncontact sports after surgical decompression and stabilization.
Allow a return to basketball 1 week after resolution of all symptoms.
Discuss the relative risks with the player, parents, and coach regarding participation in the athlete’s sport of choice.
Advise participation in noncontact sports only.

Correct Answer: Discuss the relative risks with the player, parents, and coach regarding participation in the athlete’s sport of choice.

Explanation:

DISCUSSION: The correct decision on return to sports participation after episodes of transient quadraparesis is controversial. Cantu and Mueller feel strongly that the loss of cerebrospinal fluid space about the spinal cord signifies an unacceptable risk for future spinal cord injury if the athlete returns to sports. However, Watkins and Torg and Lasgow have reported no evidence of increased spinal cord injury in athletes with narrow spinal canals, even in football. These authors suggest judgment be used in advising return to contact or high-energy sports and that the physician’s responsibility is to give accurate and relevant information, allowing the athlete to make his or her own choice regarding return to sports participation.
REFERENCES: Cantu R, Mueller FO: Catastrophic spine injuries in football (1977-1989).
J Spinal Disord 1990;3:227-231.
Watkins RG: Neck injuries in football players. Clin Sports Med 1986;5:215-246.
Torg JS, Lasgow SG: Criteria for return to contact activities following cervical spine injury. Clin Sports Med 1991;1:12-26.
Morganti C, Sweeney CA, Albanese SA, Burak C, Hosea T, Connolly PJ: Return to play after cervical spine injury. Spine 2001;26:1131-1136.

Question 52:

A 47-year-old man has an acute swollen, red, painful first metatarsophalangeal joint. He denies any history of similar symptoms. What is the first step in evaluation?

Options:

Serum uric acid level studies and administration of indomethacin
Administration of colchicine
Administration of allopurinol
Aspiration with evaluation of crystals, cell count, and culture
Aspiration with evaluation of crystals and steroid injection

Correct Answer: Aspiration with evaluation of crystals, cell count, and culture

Explanation:

Question 53:

What procedure can eliminate a sulcus sign?

Options:

Rotator interval closure
SLAP repair
Bankart repair
Supraspinatus repair
Subacromial decompression

Correct Answer: Rotator interval closure

Explanation:

Question 54:

Options:

Physical therapy to improve hip stability
Use of an abduction brace to limit the patient’s range of motion
Conversion to a constrained acetabular liner
Cobalt and chromium serum metal ion level testing

Correct Answer: Cobalt and chromium serum metal ion level testing

Explanation:

Question 55:

Which of the following is a function of siRNA (small interfering RNA)?

Options:

Identifies proteins
Blocks transcription of DNA
Separates DNA based on size
Blocks translation of mRNA
Identifies DNA sequences

Correct Answer: Blocks transcription of DNA

Explanation:

Question 56:

Options:

Anesthesia in the first dorsal web space
Inability to extend the fingers
Inability to abduct the fingers
Inability to flex the thumb interphalangeal (IP) joint

Correct Answer: Inability to flex the thumb interphalangeal (IP) joint

Explanation:

Question 57:

Options:

Observation
Revision and removal of any remaining gross disease
Hemipelvectomy
Exploration and repeat curettage
Hip disarticulation

Correct Answer: Hemipelvectomy

Explanation:

DISCUSSION: The definitive surgery would be removal of the entire resection bed, and in this case of dedifferentiated chondrosarcoma, a hemipelvectomy was performed. The MRI and CT scans show an aggressive cartilage lesion. The histology, representative of a dedifferentiated chondrosarcoma, shows a bimorphic low-grade cartilage lesion with high-grade spindle cell sarcoma. The cartilage lesion is usually an enchondroma or low-grade chondrosarcoma. The dedifferentiated portion is typically a malignant fibrous histocytoma, osteosarcoma, or fibrosarcoma.
REFERENCES: Weber KL, Pring ME, Sim FH: Treatment and outcome of recurrent pelvic chondrosarcoma. Clin Orthop Relat Res 2002;397:19-28.
Pring ME, Weber KL, Unni KK, et al: Chondrosarcoma of the pelvis: A review of sixty-four cases. J Bone Joint Surg Am 2001;83:1630-1642

Question 58:

-A likely candidate for treatment with a thoracic lumbosacral orthosis scoliosis brace is seen in

Options:

Figure 178a.
Figure 178b.
Figure 178c.
Figure 178d.
Figure 178e.

Correct Answer: Figure 178d.

Question 59:

Familial (Leiden) thrombophilia is of importance in joint arthroplasty because of an abnormality in the clotting cascade. Which of the following statements best describes the condition?

Options:

It is a disease caused by an abnormality of platelets that leads to increased blood clotting.
It is a disease caused by an abnormality of vascular endothelium that leads to increased blood clotting.
It is a disease caused by an abnormality of hepatic metabolism that leads to decreased production of factor V and decreased blood clotting.
It is a disease caused by an abnormality of factor V that leads to decreased inactivation of factor Va by activated protein C (aPC) and increased blood clotting.
It is a familial, genetic disease that requires placement of a Greenfield filter in all individuals who have the abnormality, prior to surgery.

Correct Answer: It is a disease caused by an abnormality of factor V that leads to decreased inactivation of factor Va by activated protein C (aPC) and increased blood clotting.

Explanation:

Question 60:

Options:

Valgus extension overload
Varus posteromedial rotatory instability (VPMRI)
Valgus posterolateral rotatory instability (VPLRI)
Olecranon bursitis The patient has valgus extension overload. This is a spectrum of pathologies, often seen in pitchers, that begins with posteromedial impingement between the medial olecranon and posterior trochlea during forceful elbow extension. As a result, a medial olecranon osteophyte is typically the first notable imaging finding. As pathology increases, there can be progressive damage to the medial collateral ligament (MCL), degeneration of the radiocapitellar articulation, and neuritis of the ulnar nerve. VPMRI is often associated with a large anteromedial coronoid fracture and posterior band MCL rupture. VPLRI occurs when the lateral collateral ligament complex is ruptured. Olecranon bursitis presents with focal swelling or a fluid collection over the posterior aspect of the olecranon.

Correct Answer: Valgus extension overload

Explanation:

Question 61:

Which of the following mechanisms is considered the most common cause of failure of osteoarticular allografts used for articular reconstruction?

Options:

Osteocyte surface antigens that trigger an immune rejection
Chondrocyte surface antigens that trigger an immune rejection
Graft collapse during revascularization
Mechanical loosening at the bone-bone junction
Infection via graft contamination

Correct Answer: Graft collapse during revascularization

Explanation:

Question 62:

A 19-year-old man sustains a low-velocity gunshot wound to the forearm. What factor most strongly correlates with the development of compartment syndrome after this injury?

Options:

Fracture comminution
Fracture of both the radius and ulna
Fracture of the proximal third of the forearm
Fracture displacement of more than 10 mm
Retained bullet fragments

Correct Answer: Fracture of the proximal third of the forearm

Explanation:

Question 63:

Options:

Lunotriquetral fusion
Distal radioulnar joint (DRUJ) tenodesis
Triangular fibrocartilage complex (TFCC) repair
Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Correct Answer: Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Explanation:

Question 64:

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

Options:

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

Correct Answer: posterolateral to the PCL.

Explanation:

Question 65:

In the anterior approach (Smith-Petersen) to the hip, dissection is carried out between muscles innervated by the

Options:

superior gluteal nerve laterally and the obturator nerve medially.
superior gluteal nerve laterally and the femoral nerve medially.
superior gluteal nerve medially and the femoral nerve laterally.
superior gluteal nerve medially and the inferior gluteal nerve laterally.
femoral nerve laterally and the obturator nerve medially.

Correct Answer: superior gluteal nerve laterally and the femoral nerve medially.

Explanation:

Question 66:

Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?

Options:

pulselessness
palor
paresthesia
paralysis
increasing analgesia requirement

Correct Answer: pulselessness

Explanation:

Question 67:

Options:

Fibrous tissue
Bone
Articular cartilage
Fibrocartilage
Type II collagen

Correct Answer: Fibrocartilage

Explanation:

Question 68:

An extended head hemiarthroplasty (rotator cuff tear arthropathy head) has what theoretic advantage when compared to a standard hemiarthroplasty? Review Topic

Options:

Improved superior stability
Fixed fulcrum kinematics
Creates a metal-to-bone articulation with the acromion
Increased deltoid moment arm
Increased glenohumeral offset

Correct Answer: Creates a metal-to-bone articulation with the acromion

Explanation:

Question 69:

Options:

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

Correct Answer: a physical therapy program

Explanation:

Question 70:

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

Options:

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

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

Explanation:

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

Question 71:

Options:

Hemoglobin level of 9.0 g/dL (normal value 11-15 g/dL)
Sodium level of 132 mEq/L (normal value 135-145 mEq/L)
Potassium level of 5.0 mEq/L (normal value 4.0-5.2 mEq/L)
Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)
Serum uric acid level of 10 mg/dL (normal value 2.7-7.3 mg/dL)

Correct Answer: Calcium level of 15 mg/dL (normal value 8.5-10.5 mg/dL)

Explanation:

Question 72:

Options:

splinting for 3 weeks, followed by range-of-motion exercises.
aspiration of the hemarthrosis, followed by range-of-motion exercises the following day.
fragment excision.
open reduction and internal fixation.
radial head excision.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 73:

All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:

Options:

Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children
Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome
Mechanism of injury is the best predictor of compartment syndrome development
Traditional hallmarks of adult compartment syndrome may be unreliable in the diagnosis of pediatric compartment syndrome
Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome

Correct Answer: Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children

Explanation:

Question 74:

Options:

Aseptic loosening
Mortality
Infection
Bleeding
Limited motion requiring manipulation

Correct Answer: Mortality

Explanation:

Question 75:

Options:

Observation
Initiate bracing
MRI scan of the entire spine
Spinal instrumentation with growing rod construct

Correct Answer: MRI scan of the entire spine

Explanation:

Question 76:

Figure 39 shows the radiograph of a 4-month old infant who has been undergoing weekly casting since birth for a congenital equinovarus deformity. Management should now consist of

Options:

surgical correction.
continued casting.
botulinum toxin injection into the gastrocnemius-soleus complex.
an ankle-foot orthosis.
observation with no further treatment.

Correct Answer: surgical correction.

Explanation:

DISCUSSION: The radiograph shows the development of a rocker-bottom foot deformity. A rocker-bottom foot occurs in the treatment of clubfoot when casting is continued in the presence of a very tight gastrocnemius-soleus complex and an uncorrected hindfoot. While there are some preliminary reports on using Botox injection and continued casting for the equinus deformity, most authors recommend posterior or posterior medial release. Percutaneous tenotomy has been recently recommended with the resurgence of the Ponsetti technique.
REFERENCES: Lehman WB, Atar D: Complications in the management of talipes equinovarus, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992,
pp 135-136.
Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002,
pp 927-935.
Tachdjian MO: Pediatric Orthopedics, ed 2. Philadelphia, PA, WB Saunders, 1990,
pp 2461-2564.

Question 77:

Options:

Age > 60 years
> or = 2 comorbid conditions
History of tobacco use
BMI > 30 kg/m²
Using a pedicle subtraction osteotomy

Correct Answer: > or = 2 comorbid conditions

Explanation:

Question 78:

Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

Options:

lateral column lengthening through the calcaneal anterior process.
a medial displacement calcaneal osteotomy.
first metatarsal-cuneiform fusion in increased plantar flexion.
dorsiflexion osteotomy of the first metatarsal and a medial displacement calcaneal osteotomy.
dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

Correct Answer: dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

Explanation:

Question 79:

Which of the following enzymes is used to resorb bone by mature osteoclasts?

Options:

Alkaline phosphatase
Cathepsin K
Tissue inhibitor of metalloproteinase (TIMP)
Osteonectin
Osteopontin

Correct Answer: Cathepsin K

Explanation:

Question 80:

Options:

Volkmann ischemic contracture
Radial nerve palsy
Ulnar nerve palsy
Median nerve palsy
Anterior interosseous nerve palsy

Correct Answer: Anterior interosseous nerve palsy

Explanation:

Question 81:

Options:

Distal chevron osteotomy bunionectomy with lesser metatarsal head resections
Proximal first metatarsal osteotomy with flexor-to-extensor tendon transfer for the lesser toes
First metatarsophalangeal arthrodesis with lesser metatarsal head resections
First tarsometatarsal realignment arthrodesis (Lapidus procedure) with flexor-to-extensor tendon transfer for the lesser toes
Resection of the base of the hallux proximal phalanx (Keller procedure) with flexor-to-extensor tendon transfer for the lesser toes

Correct Answer: First metatarsophalangeal arthrodesis with lesser metatarsal head resections

Explanation:

Question 82:

During reconstruction of insertional gaps of a chronic Achilles tendon rupture, what tendon provides the most direct route of transfer?

Options:

Flexor hallucis longus
Flexor digitorum longus
Peroneus longus
Posterior tibial
Quadratus planti

Correct Answer: Flexor hallucis longus

Explanation:

Question 83:

Options:

IV antibiotics.
IV antibiotics and immobilization of the lower extremity.
IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.
IV antibiotics and repeated aspirations of the metaphyseal region.
oral antibiotics with careful monitoring of blood levels.

Correct Answer: IV antibiotics, surgical incision and drainage of the abscess, and immobilization of the lower extremity.

Explanation:

Question 84:

What factor is considered one of the early changes in osteoarthritic cartilage?

Options:

Decreased water content
Increased proteoglycan content
Decreased loading of the solid matrix
Increased cartilage tissue permeability

Correct Answer: Increased cartilage tissue permeability

Explanation:

Question 85:

Options:

Complex regional pain syndrome
Wartenberg’s syndrome
Carpal tunnel syndrome
Palmar cutaneous nerve injury
C7 radiculopathy

Correct Answer: Palmar cutaneous nerve injury

Explanation:

DISCUSSION: The palmar cutaneous branch of the median nerve separates from the median nerve approximately 4 to 6 cm proximal to the wrist crease and travels between the median nerve and the flexor carpi radialis tendon. It supplies the skin of the thenar region. This nerve is at risk for injury with retraction of the digital flexor tendons in plating the distal radius. Wartenberg’s syndrome is compression of the superficial radial nerve which innervates the dorsum of the thumb and the first dorsal web space. Carpal tunnel syndrome causes dysesthesias of the thumb, index, and/or middle fingers. C7 radiculopathy affects the index and middle fingers.
REFERENCES: Jupiter JB, Fernandez DL, Toh CL, et al: Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am 1996;78:1817-1828.
Hoppenfield S, deBoer P (eds): Surgical Exposures in Orthopaedics: The Anatomic Approach, ed 2. Philadelphia, PA, JB Lippincott, 1994, pp 156-176.

Question 86:

An 80-year-old woman notes a painless mass posterior to her left knee. MRI scans are shown in Figures 31a and 31b. What is the best course of action?

Options:

Observation
Medical management
Needle biopsy
Incisional biopsy
Resection

Correct Answer: Observation

Explanation:

DISCUSSION: The MRI scans show a popliteal cyst (Baker’s cyst) in its most common location. The cyst emerges from the knee joint between the medial head of the gastrocnemius muscle and the tendon of the semimembranosus muscle. These images are diagnostic; therefore, no further work-up is indicated. Since the patient is asymptomatic, no treatment is necessary.
REFERENCES: Dlabach JA: Nontraumatic soft tissue disorders, in Canale ST (ed): Campbell’s Operative Orthopaedics, ed 10. Philidelphia, PA, Mosby, 2003, vol 1, pp 885-969.
Fritschy D, Fasel J, Imbert JC, et al: The popliteal cyst. Knee Surg Sports Traumatol Arthrosc 2006;14:623-628.

Question 87:

Which of the following findings is a prerequisite for a high tibial valgus osteotomy for medial compartment gonarthrosis?

Options:

Inflammatory arthritis
Ligamentous instability
Lateral tibial subluxation
Preoperative arc of motion of at least 90 degrees
Narrowing of the lateral compartment cartilaginous joint space

Correct Answer: Preoperative arc of motion of at least 90 degrees

Explanation:

Question 88:

Which of the following medications has been shown to improve skeletal muscle regeneration and decrease fibrosis following muscle injury in an animal model? Review Topic

Options:

Aspirin
Allopurinol
Acetaminophen
Losartan
Bupropion

Correct Answer: Aspirin

Explanation:

Question 89:

An adult patient has an 8- x 4- x 10-cm soft-tissue mass located within the adductor compartment of the thigh. Staging studies should consist of

Options:

MRI and a radiograph of the thigh and CT of the chest.
MRI of the thigh, a chest radiograph, and a CT of the pelvis.
MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the pelvis.
MRI of the thigh, a total body bone scan, a chest radiograph, and a CT of the abdomen and pelvis.
a CT of the chest and thigh, a total body bone scan, and a chest radiograph.

Correct Answer: MRI and a radiograph of the thigh and CT of the chest.

Explanation:

Question 90:

Options:

Repeat intra-articular injection
High tibial osteotomy
Total knee arthroplasty (TKA)
Unicompartmental knee arthroplasty

Correct Answer: Total knee arthroplasty (TKA)

Explanation:

Question 91:

Options:

shorter hospital stay
fewer bone-grafting procedures
lower infection rate
fewer secondary invasive interventions
faster early fracture healing

Correct Answer: shorter hospital stay

Explanation:

Question 92:

Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?

Options:

Nondisplaced distal radius fracture
Nondisplaced Rolando fracture
Second metacarpal base fracture
Boxer's fracture
Nondisplaced radial styloid fracture

Correct Answer: Nondisplaced distal radius fracture

Explanation:

Question 93:

Options:

Shortening of 3 cm
Severity of trauma
Duration of immobilization
Type of immobilization
Closed reduction

Correct Answer: Severity of trauma

Explanation:

DISCUSSION: The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.
REFERENCES: Lazarus MD, Seon C: Fractures of the clavicle, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, vol 2, pp 1241-1242.
White RR, Anson PS, Kristiansen T, et al: Adult clavicle fractures: Relationship between mechanism of injury and healing. Orthop Trans 1989;13:514-515.

Question 94:

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

Options:

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

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

Explanation:

Question 95:

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Options:

Length of the bone
Type of structural support
Size of cross-sectional area
Plastic modulus of material used
Area moment of inertia of the cross section

Correct Answer: Area moment of inertia of the cross section

Explanation:

Question 96:

Which ligament attaches to the bony fragment identified by the CT image arrows in Figures 42a and 42b?

Options:

Posterior tibiotalar ligament
Posterior-inferior tibiofibular ligament (PITFL)
Interosseous ligament (IOL)
Anterior-inferior tibiofibular ligament (AITFL) ?

Correct Answer: Posterior-inferior tibiofibular ligament (PITFL)

Explanation:

DISCUSSION
The distal tibiofibular syndesmosis is a ligamentous complex that consists of the AITFL, PITFL, intertransverse ligament (ITL), and IOL. The PITFL originates on the posterior inferior aspect of the tibia (Volkmann tubercle) and inserts on the lateral malleolus. The AITFL originates on the anterolateral aspect of the tibia (Chaput tubercle) and inserts on the distal anterior aspect of the fibula (Wagstaffe tubercle). The ITL is a group of fibers running transversely just inferior to the PITFL. As a group, these structures maintain the appropriate tibial plafond and talus relationship throughout physiologic range of motion.
RECOMMENDED READINGS
Carr JB. Malleolar fractures and soft tissue injuries of the ankle. In: Browner BD, Alen LM, Peter TG, Jupiter JB, et al. Skeletal Trauma. 3rd ed. Philadelphia, PA: Saunders; 2003:2309. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg.2007 Jun;15(6):330-9. Review. PubMed PMID: 17548882.
View
Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
A 46-year-old healthy right-hand-dominant man falls and sustains the injury shown in Figures 43a and 43b.

Question 97:

Which of the following is considered a disadvantage of knee disarticulation when compared with transfemoral amputation?

Options:

Increased energy expenditure
Worse end-bearing surface
Asymmetry of the prosthetic knee joint
More pain with weight bearing
More stump complications in pediatric patients

Correct Answer: Asymmetry of the prosthetic knee joint

Explanation:

Question 98:

Options:

physical therapy and nonsteroidal anti-inflammatory drugs for 4 to 6 weeks.
physical therapy, nonsteroidal anti-inflammatory drugs for 4 to 6 weeks, and methylprednisolone.
epidural steroid injections.
elective surgery.
urgent surgery.

Correct Answer: urgent surgery.

Explanation:

Question 99:

What factor is associated with a high risk of developing pseudotumors after metal-on-metal hip resurfacing?

Options:

Large-diameter components
Age 40 or older for men
Age 40 or younger for women
Diagnosis of primary osteoarthritis

Correct Answer: Age 40 or younger for women

Explanation:

Question 100:

- While under a physician’s care, a 45-year-old man verbally abuses the staff and nurses who are attempting to carry out orders. A decision to discharge the patient is best carried out by

Options:

Asking the legal staff to seek a court injunction
Copying the patient’s chart and giving it to him as he leaves
Having the patient sign a written legal contract that specifies acceptable behavior
Continuing care of the patient until an appropriate referral can be arranged
Transferring the patient to another orthopaedic surgeon without disclosing the real reason for why the patient is being transferred

Correct Answer: Continuing care of the patient until an appropriate referral can be arranged

Explanation:

The other foils in this answer would be both unethical and would be a violation of “anti-dumping” laws. This would further open the physician, hospital and staff to possible litigation.

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

OITE & ABOS Orthopedic Board Exam MCQs: Spine, Lower Extremity, & Shoulder | Part 160

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 160

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index