Orthopedic Board Review MCQs: OITE & AAOS Prep Part 162

About This Board Review Set

This is Part 162 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.
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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 162

This module focuses heavily on: Dislocation, Foot, Fracture, Knee, Revision, Scoliosis, Shoulder, Spine, Trauma.

Sample Questions from This Set

Sample Question 1: -A 14-year-old girl has idiopathic scoliosis with a 52-degree right thoracic curve and a 36-degree left lumbar curve. The rotation of the apical vertebra appears greater in the thoracic curve. A sagittal view radiograph shows the spine to b...

Sample Question 2: A 12½-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full...

Sample Question 3: A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?...

Sample Question 4: Figure 2a shows the radiograph of a 48-year-old man who was involved in a motorcycle accident. A CT scan is shown in Figure 2b. The patient underwent pelvic angiography for persistent hypotension despite resuscitation. What vessel is most l...

Sample Question 5: A 17-year-old high school football player sustains a traumatic anterior shoulder dislocation, resulting in a small bony Bankart lesion and small Hill-Sachs lesion. The patient undergoes an arthroscopic Bankart repair with incorporation of t...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 14-year-old girl has idiopathic scoliosis with a 52-degree right thoracic curve and a 36-degree left lumbar curve. The rotation of the apical vertebra appears greater in the thoracic curve. A sagittal view radiograph shows the spine to be virtually straight. The iliac apophyses are Risser 2. Treatment should consist of

Explanation

The patient’s curve is beyond the limit for bracing to be effective (40 degrees). Therefore, surgical treatment should be utilized. King type II curves (predominant thoracic curve with secondary lumbar curve) historically has used selective posterior thoracic fusion with segmental hook systems and rotation maneuvers to correct the thoracic curve and compensatory lumbar curve. The patient’s primary curve is thoracic and lumbar fusion would be contraindicated.

Question 2

A 12½-year-old boy reports intermittent knee pain and limping that interferes with his ability to participate in sports. He actively participates in football, basketball, and baseball. He denies any history of injury. Examination shows full range of motion without effusion. Radiographs reveal an osteochondritis dissecans (OCD) lesion on the lateral aspect of the medial femoral condyle. MRI scans are shown in Figures 14a and 14b. Initial treatment should consist of Review Topic

Explanation

Agenesis of the anterior cruciate ligament
Thickened medial plica
Grade IV chondral flap
Pigmented villonodular synovitis
Abnormal meniscal morphology
This child presents with an asymptomatic click in the knee. It is associated with widening of the lateral joint space of the knee on X-ray. These features are highly suggestive of a discoid lateral meniscus in this age category.
The principal diagnostic feature of a discoid meniscus is the complaint of snapping or clicking in the knee. Children are usually asymptomatic. Although, less frequently, children may present with pain that is largely secondary to an underlying meniscal tear. MRI scans of the knee have show to have the greatest sensitivity for identifying discoid menisci. The presence of a contiguous central meniscus on three consecutive slices is usually indicative of the diagnosis. Treatment is mostly focused on conservative modalities. Surgical intervention is reserved for symptomatic cases with recurrent locking, swelling or persistent pain is present in older children.
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Figure A shows an AP radiograph of a pediatric knee. There is an increased lateral joint space suggestive of a discoid meniscus.
Illustrations A-C show an MRI of the knee with 3 consecutive coronal cuts showing an abnormal appearing discoid meniscus.
Incorrect Answers:

Question 3

A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?

Explanation

DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 4

Figure 2a shows the radiograph of a 48-year-old man who was involved in a motorcycle accident. A CT scan is shown in Figure 2b. The patient underwent pelvic angiography for persistent hypotension despite resuscitation. What vessel is most likely to be injured?

Explanation

DISCUSSION: The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common. When arterial injury follows a lateral compression injury, it is usually related to injury of a more anterior vessel like the obturator artery or a branch of the external iliac artery.
REFERENCES: O’Neill PA, Riina J, Sclafani S, et al: Angiographic findings in pelvic fractures. Clin Orthop 1996;329:60-67.
Belley G, Gallix BP, Derossis AM, et al: Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture. J Trauma 1997;43:703-705.

Question 5

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

Explanation

A failed bony Bankart repair with multiple dislocations can further erode the anteroinferior glenoid, changing the sagittal morphology of the glenoid into an “inverted pear.” Quantitative bone loss is best evaluated by CT scan with 3-D reconstructions and subtraction of the humeral head. MRI and ultrasonography can assist in evaluating soft-tissue injury, but they are not as helpful in determining bone loss compared with a CT scan. An arthrogram alone is not sufficient to evaluate bone loss. Bone loss >30% necessitates glenoid augmentation with either a Latarjet procedure or iliac crest bone grafting. A revision arthroscopic or open Bankart repair with capsular shift or remplissage do not address bone loss. The Latarjet procedure can effectively restore stability with glenoid bone loss and after failed stabilizing procedures. Patients with pain before surgery are
more likely to have pain after surgery. Age and activity level are lesser influences on satisfaction.

Question 6

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

Explanation

DISCUSSION: The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint.
REFERENCES: Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214.
McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.
Ouzounian TJ: Metatarsophalangeal arthrodesis for salvage of failed hallux valgus surgery. Foot Ankle Clin 1997;2:741-752.

Question 7

A 25-year-old man is brought to the emergency department following a motor vehicle accident. Extrication time was 2 hours, and in the field he had a systolic blood pressure by palpation of 90 mm Hg. Intravenous therapy was started, and on arrival in the emergency department he has a systolic blood pressure of 90 mm Hg with a pulse rate of 130. Examination reveals a flail chest and a femoral diaphyseal fracture. Ultrasound of the abdomen is positive. The trauma surgeons take him to the operating room for an exploratory laparotomy. At the conclusion of the procedure, he has a systolic pressure of 100 mm Hg with a pulse rate of 110. Oxygen saturation is 90% on 100% oxygen, and he has a temperature of 95.0° F (35° C). What is the recommended treatment of the femoral fracture at this time?

Explanation

DISCUSSION: This is a “borderline trauma” patient where serious consideration for damage control orthopaedic surgery is required. His prolonged hypotension, abdominal injury, and chest injury put him at higher risk for serious postinjury complications. Further surgery, such as definitive fracture fixation, adds metabolic load and injury to his system. It is prudent to consider femoral fracture stabilization with an external fixator until he is physiologically recovered as evidenced by a normal base excess and/or lactate acid levels, as well as all other parameters of resuscitation. A borderline patient has been described as polytrauma with an ISS > 20 and thoracic trauma (AIS > 2); polytrauma and abdominal/pelvic trauma (Moore > 3) and hemodynamic shock (initial BP < 90 mm Hg); ISS > 40; bilateral lung contusions on radiographs; initial mean pulmonary arterial pressure > 24 mm Hg; pulmonary artery pressure increase during intramedullary nailing > 6 mm Hg. Factors that worsen the situation following surgery include multiple long bones and truncal injury (AIS > 2), estimated surgery time of more than 6 hours, arterial injury and hemodynamic instability, and exaggerated inflammatory response (eg, Il-6 > 800 pg/mL). It is incumbent on the orthopaedic surgeon who is a member of the trauma team to make sure that he or she is aware of these factors and guides the team to the best patient care.
REFERENCES: Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopaedic surgery. J Trauma 2002;53:452-461.
Bosse M, Kellam JF: Orthopaedic decision making in the multiple trauma patient, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 133-146.

Question 8

Figures 15a through 15d

Explanation

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160. View Abstract at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901. View Abstract at PubMed

Question 9

A 58-year-old woman with rheumatoid arthritis has progressive neck pain, upper extremity and lower extremity weakness, and difficulty with fine motor movements. Examination reveals hyperreflexia with mild to moderate objective weakness but the patient has no difficulty with ambulation for short distances. What is the most important preoperative imaging finding that predicts full neurologic recovery with surgical stabilization?

Explanation

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 10

What is the best initial screening test for a patient with a limb-length discrepancy?

Explanation

DISCUSSION: With the patient standing, add blocks under the short leg until the pelvis is level, then measure the blocks to determine the discrepancy. This method is an accurate, simple, and inexpensive way to assess limb-length discrepancy. Differences of less than 2 cm need no treatment. Increasing discrepancy in a growing child should be followed clinically. Radiographic examination can include scanography, CT scanography, or a standing pelvic radiograph with the pelvis leveled. CT scanography is the most accurate diagnostic test when hip, knee, or ankle contractures are present.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopedics, ed 4. Philadelphia, PA, WB Saunders, 2002, pp 1041-1045.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 1120-1122.
Stanitski DF: Limb-length inequality: Assessment and treatment options. J Am Acad Orthop Surg 1999;7:143-153.
Aaron A, Weinstein D, Thickman D, Eilert R: Comparison of orthoroentgenography and computed tomography in the measurement of limb-length discrepancy. J Bone Joint Surg Am 1992;74:897-902.

Question 11

A 64-year-old woman has left wrist pain and deformity after falling on her hand. Examination shows intact skin and no neurologic or vascular injuries. Radiographs are shown in Figures 43a and 43b. What is the most appropriate management for the injury?

Explanation

DISCUSSION: The patient has a volar displaced two-part intra-articular distal radial fracture-dislocation of the wrist. Although a closed reduction is usually easily obtained, it is very difficult to maintain the reduction without internal fixation. The approach is determined by the direction of the dislocation, in this case volar. Stabilization with a buttress plate neutralizes the axial loading forces on the fractured fragment. A dorsal placed angular stable plate will not provide this buttress effect and will make the reduction difficult.
REFERENCE: Cohen M, McMurtry RY, Jupiter JB: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1328-1335.

Question 12

Figure 11a shows the AP pelvis radiograph of a 25-year-old man who sustained a spinal cord injury 10 years ago. A bone scan and a CT scan are shown in Figures 11b and 11c. To prevent recurrence after resection, management should consist of

Explanation

DISCUSSION: The studies reveal significant heterotopic ossification that appears to be mature. Following resection, the most reliable way to prevent recurrence is with low-dose external-beam radiation therapy. Bisphosphonate therapy can be considered; however, when terminated, heterotopic bone may reform. Heterotopic ossification is unrelated to the patient’s endocrine status and is not associated with any metabolic abnormalities.
REFERENCES: Moore K, Goss K, Anglen J: Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fracture. J Bone Joint Surg Br 1998;80:259.
Stover S, Niemann K, Tullos J: Experience with surgical resection of heterotopic bone in spinal cord injury patients. Clin Orthop 1991;263:71-77.

Question 13

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Explanation

The rotator cuff interval is located between the supraspinatus and subscapularis and the biceps tendon is deep to the interval. It is a triangular area where the base is the coracoid process and the apex is the transverse humeral ligament at the biceps sulcus. Closure or tightening of this area is often helpful in patients with shoulder instability. Conversely, this area is often contracted in patients with adhesive capsulitis and may need to be released.

Question 14

Figure 18a shows the clinical photograph of a 2-year old boy who has a deformity of the right leg. Examination reveals eight cutaneous markings similar to those shown in Figure 18b. Radiographs are shown in Figure 18c. Management should consist of

Explanation

DISCUSSION: The diagnosis of neurofibromatosis may be based on the presence of at least six cafe-au-lait spots larger than 5 mm in diameter and the osseous lesion shown in Figure 18c. Neurofibromatosis occurs in 50% of patients who have an anterolateral bowing deformity of the tibia, and this bowing may be the first clinical manifestation of this disorder. The patient has anterolateral bowing of the tibia and fibula that warrants concern for a possible fracture and pseudarthrosis; therefore, the limb should be protected in a total contact orthosis to prevent fracture. In contradistinction to posteromedial bowing of the tibia and fibula, spontaneous remodeling of an anterolateral bowing deformity is not expected. Intramedullary nailing or the use of a vascularized fibula is reserved for the treatment of a congenital pseudarthrosis of the tibia.
REFERENCES: Crawford AH Jr, Bagamery N: Osseous manifestations of neurofibromatosis in childhood. J Pediatr Orthop 1986;6:72-88.
Schoenecker PL, Rich MM: The lower extremity, in Morrissy RT, Weinstein SL (eds): Lovell and Winter’s Pediatric Orthopaedics, ed 5. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, vol 2, pp 1059-1104.

Question 15

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

Explanation

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

Question 16

A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?

Explanation

DISCUSSION: The MRI scan shows a ganglion cyst in the region of the spinoglenoid notch. These are difficult to diagnose clinically but are readily apparent on MRI. They usually cause compression of the suprascapular nerve and weakness of the infraspinatus and supraspinatus muscles.
REFERENCES: Resnick D, Kang HS (eds): Internal Derangements of Joints: Emphasis on MR Imaging. Philadelphia, PA, WB Saunders, 1997, pp 306-309.
Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.

Question 17

Plate fixation without bone grafting

Explanation

(3787) Q2-7569:
Which of the following stress fractures most often requires internal fixation:

Question 18

A patient with a documented allergy to nickel requires a total knee arthroplasty. Which of the following prostheses is most likely to provide long-term success in this individual?

Explanation

DISCUSSION: Nickel allergy is not an infrequent preoperative finding. The ramifications of such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a good surface for the articulating portion of the femoral component because of its propensity for metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to nickel. A modular titanium tibial component or an all-polyethylene tibial component would be satisfactory for these patients.
REFERENCES: Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee arthroplasty. Clin Orthop 2003;416:191-196.
Nasser S, Campbell PA, Kilgus D, et al: Cementless total joint arthroplasty prostheses with titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 1990;261:171-185.

Question 19

In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?

Explanation

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 20

A 57-year-old woman experiences pain 1 year after total knee arthroplasty (TKA). She reports sharp anterior pain and a painful catching sensation that is aggravated by rising from a chair or climbing stairs. Physical examination reveals a mild effusion and a range of motion of 2° to 130°, with patellar crepitus. The symptoms are reproduced by resisted knee extension. Radiographs show a well-aligned posterior- stabilized TKA without evidence of component loosening. What is the most likely cause of this patient's pain?

Explanation

DISCUSSION:
Patellar clunk syndrome is caused by the development of a fibrous nodule on the posterior aspect of the quadriceps tendon at its insertion into the patella. It causes a painful catching sensation when the extensor mechanism traverses over the trochlear notch as the knee extends from 45° of flexion to 30° from full extension. It characteristically occurs in posterior stabilized total knee arthroplasties and appears to be related to femoral component design. The syndrome can usually be prevented by excising the residual synovial fold just proximal to the patella. Flexion gap instability can also cause a painful total knee arthroplasty but is less common in posterior stabilized implants. Femoral component malrotation can cause pain attributable to a flexion gap imbalance or patellar tracking problems. Polyethylene wear would be unlikely after just 1 year. Patellar clunk syndrome can usually be addressed successfully with arthroscopic synovectomy. Recurrence is uncommon. Physical therapy may help to strengthen the quadriceps following synovectomy but would not resolve the clunk syndrome symptoms. Femoral or tibial insert revision is not indicated if patellar clunk syndrome is the only problem resulting in a painful
total knee arthroplasty.

Question 21

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

Explanation

DISCUSSION: Treatment of a chronic nonunion of the proximal humerus in the elderly should be treated with arthroplasty when possible. Critical attention should be paid to correct all deformities: tuberosity positioning, articular surface realignment, soft tissue balancing, rotator cuff repair (when needed), and treatment of soft tissue contractures. Attempts at internal fixation should be performed with caution in this patient population, due to general osteopenia and significant rates of loss of fracture reduction.
The referenced article by Cheung et al reviews treatment options for proximal humeral nonunions and reports successful use of arthroplasty in treating elderly osteoporotic proximal humeral nonunions as a pain relieving procedure.
Dines reported a case series of 20 chronic post-traumatic proximal humerus fractures including nonunions that were treated with shoulder arthroplasty achieving fair to excellent results in 90% at mid-term follow-up

Question 22

Figure 25 shows an arthroscopic thermal capsular shrinkage device being used in the anterior inferior quadrant of a patient with a subluxating shoulder. Which of the following neurologic complications is most frequently reported with this technique?

Explanation

DISCUSSION: The axillary nerve lies within millimeters of the anterior inferior capsule. The inferior capsule is of varying thickness, and thermal energy used in shortening the ligament can cause damage to the sensory fibers of the axillary nerve. Clinically, this is manifested as a burnt skin sensation in the axillary nerve distribution area. The motor branch of the axillary nerve is usually spared. The suprascapular nerve and the radial nerve are far from the shrinkage zone. The musculocutaneous nerve, frequently at risk with open procedures, lies well anterior.
REFERENCES: Fanton GS: Arthroscopic electrothermal surgery of the shoulder. Op Tech Sports Med 1998;6:157-160.
David TS, Drez DJ Jr: Electrothermally-assisted capsular shift. IEEE Eng Med Biol Mag 1998;17:102-104.

Question 23

An 11-year-old boy has had a fever and pain and swelling over the lateral aspect of his right ankle for the past 3 days. Examination reveals warmth, swelling, and tenderness over the lateral malleolus, and he has a temperature of 103.2 degrees F (39.5 degrees C). Laboratory studies show a WBC count of 13,200/mm 3 with 61% neutrophils, an erythocyte sedimentation rate of 112 mm/h, and a C-reactive protein of 15.7. Radiographs and a T 2 -weighted MRI scan are shown in Figures 13a through 13c. Aspiration yields 1 mL of purulent fluid. Management should now consist of

Explanation

DISCUSSION: The initial signs and symptoms of acute hematogenous osteomyelitis vary widely but usually include fever, bone pain, and impaired use of the involved extremity. In lower extremity infections, the child may limp or refuse to walk. Examination often reveals bone tenderness. In more advanced cases, erythema, warmth, and swelling may be present. The WBC and neutrophil counts are not always elevated, but the erythocyte sedimentation rate will be abnormal in more than 90% of patients. When the infection is diagnosed early, before a subperiosteal abscess has formed, antibiotics alone may be adequate to treat the infection. This patient has a more advanced infection, however, with the MRI scan revealing a subperiosteal abscess that was confirmed by aspiration. When an abscess is present, surgical drainage is generally indicated to remove devitalized tissue and to enhance the efficacy of the antibiotics. Further studies, such as bone or indium scans, are not necessary and will delay

definitive treatment.
REFERENCES: Scott RJ, Christofersen MR, Robertson WW Jr, et al: Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-652.
Vaughan PA, Newman NM, Rosman MA: Acute hematogenous osteomyelitis. J Pediatr Orthop 1987;7:652-655.

Question 24

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

Explanation

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

Question 25

What type of brace is shown in Figures 22a and 22b?

Explanation

DISCUSSION: The figures show a Charcot restraining orthotic walker (CROW). This brace has been used as a customized total contact fit removable brace to maintain foot alignment as the patient evolves from Eichenholz stage 1 to Eichenholz stage 3 Charcot arthropathy.
REFERENCES: Mehta JA, Brown C, Sargeant N: Charcot restraint orthotic walker. Foot Ankle Int 1998;19:619-623.
Morgan JM, Biehl WC III, Wagner FW Jr: Management of neuropathic arthropathy with the Charcot restraint orthotic walker. Clin Orthop 1993;296:58-63.

Question 26

Which of the following is not a reported mode of failure for a constrained acetabular component?

Explanation

DISCUSSION: There is no evidence of increased polyethylene wear in constrained acetabular components. The rates of wear appear to be the same using standard or constrained liners.
REFERENCES: Lachiewicz PF, Kelley SS: Constrained components in total hip arthroplasty. J Am Acad Orthop Surg 2002;10:233-238.
Anderson MJ, Murray WR, Skinner HB: Constrained acetabular components. J Arthroplasty 1994;9:17-23.
Fisher DA, Kiley K: Constrained acetabular cup disassembly. J Arthroplasty 1994;9:325-329.

Question 27

A 25-year-old male sustains the isolated injury shown in Figure A. Antegrade intramedullary nailing is planned for definite fixation within the next 12 hours. After obtaining lateral radiographs of the injury site, what would be the next best step in management of this patient?

Explanation

This patient has sustained a femoral shaft fracture. The next best step in management would be to CT scan the hip to assess for an associated femoral neck fracture.
Femoral neck fractures are seen less than 10% of the time with femoral shaft fractures, but they are frequently missed on initial evaluation. The neck fracture line is almost vertical and nondisplaced, or minimally displaced. Therefore fine (2-mm) cut CT scan through the femoral neck should be ordered in the preoperative workup of these patients.
Tornetta et al. reported that they reduced the delay in diagnosis of concomitant femoral neck fractures by 91% by instituting a protocol that included: dedicated AP internal rotation plain radiograph, a fine (2-mm) cut CT scan through the femoral neck, an intraoperative fluoroscopic lateral radiograph prior to fixation, as well as postoperative AP and lateral radiographs of the hip in the operating room prior to awakening the patient.
Figure A shows a trauma view lower extremity radiograph with an isolated left midshaft femur fracture.
Incorrect Answers:
setting of fracture. Answer 5: The age, injury and fracture pattern are not consistent with a pathologic femur fracture.

Question 28

A 3-year-old child has refused to walk for the past 2 days. Examination in the emergency department reveals a temperature of 102.2 degrees F (39 degrees C) and limited range of motion of the left hip. An AP pelvic radiograph is normal. Laboratory studies show a WBC count of 9,000/mmP3P, an erythrocyte sedimentation rate (ESR) of 65 mm/h, and a C-reactive protein level of 10.5 mg/L (normal < 0.4). What is the next most appropriate step in management? Review Topic

Explanation

No further treatment
Continue Pavlik Harness treatment
Convert to semi-rigid abduction brace
Perform a hip arthrogram with closed vs. open reduction under general anesthesia
Perform a pelvic osteotomy
This is a 4 week old infant with DDH who has failed Pavlik harness treatment for 3 weeks. Figure A is an ultrasound image demonstrating a dislocated hip.
Initial treatment for an infant with a dislocated, but reducible ("Ortolani positive") hip is bracing in a Pavlik Harness. The Pavlik harness is a dynamic brace that requires normal muscle function and tone to help keep the hip in a reduced position. If this treatment fails to hold the hip reduced after three weeks of treatment, the harness should be discontinued to prevent "Pavlik Harness Disease" which involves erosion of the posterior acetabulum as the femoral head is inappropriately being held against it.
After failure of Pavlik harness treatment, if the hip remains subluxated, the next step in treatment is to convert to a semi-rigid orthosis of another 2-3 weeks. If the semi-rigid brace likewise fails to keep the hip reduced, then hip arthrogram with closed vs. open reduction and spica-cast placement can be planned.
Swaroop and Mubarak present a study using a protocol of initial pavlik harness treatment with weekly ultrasound assessment for 3 weeks. If the hip remained unstable but reducible, then semi-rigid abduction bracing with continues weekly ultrasounds were done for an additional 2-3 weeks. This treatment protocol had a 93% success rate, which compared favorably to protocols not including the abduction
brace.
Hedequist et al. presented a review of 15 patients treated similarly with intial pavlik harness treatment for 3-4 weeks, and then abduction bracing if the remained unstable but reducible. They found that abduction bracing produced a stable hip within 1-2 months.
Illustration A shows a baby wearing a semi-rigid orthosis. Illustration B is the hip ultrasound image from Figure A with labels added. Illustration C is an ultrasound of a hip that is not dislocated.
Incorrect answers:

Question 29

Figure 1 shows the radiograph of an 11-year-old boy who stubbed his great toe while playing soccer barefoot. He is able to walk home despite a small amount of bleeding at the nail fold. Management should consist of

Explanation

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of

the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 30

A 42-year-old man reports a 3-day history of worsening lower back pain. He denies any history of recent trauma or infections. He also reports difficulty urinating and fecal incontinence in the last 24 hours. Examination reveals generalized lower extremity weakness, diminished sensation in a saddle distribution, and loss of rectal tone. What is the most appropriate management at this time? Review Topic

Explanation

Cauda equina syndrome is a medical emergency that must be quickly diagnosed and treated to avoid long-term complications. Cauda equina syndrome typically presents with low back pain, unilateral or bilateral sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss. Although a number of pathologies can cause cauda equine syndrome, disk herniation is the most common cause of acute onset cauda equina syndrome. Cauda equina syndrome should be evaluated on an emergent basis and admission for work-up is appropriate. Emergent MRI to evaluate the level of spinal compression and acute decompression surgery is the most appropriate treatment in this situation. Nonsurgical management consisting of medications, bed rest, and a home exercise program are not appropriate. Whereas radiographs could be useful in a patient with traumatic onset of symptoms, MRI is the best study for evaluation of the spinal canal. Office follow-up and outpatient diagnositc testing are also inappropriate in this scenario.

Question 31

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Explanation

The patient presents with MRI suggestive of far lateral disc herniation at the L3-L4 disc space. He would be expected to have symptoms in L3 nerve distribution, near the medial epicondyle of the femur. Associated motor manifestations may include quadriceps weakness and/or diminished patellar reflex.
Far lateral disc herniations constitute approximately 5-10 percent of disc hernations in the lumbar spine. Given the more vertical anatomy of lumbar nerve roots, at a given disc level, a central or paracentral herniation will affect the traversing nerve root (e.g. nerve root of level below) and a far lateral herniation will affect the exiting nerve root (e.g. nerve root of the level above). Similar to the more common central and paracentral herniations, approximately 90% of patients will improve without surgical intervention. When surgical intervention is needed, the paraspinal approach of Wiltse is utilized.
Marquadt et al. reported long term outcomes of surgical management of far lateral disc herniations. At an average of 146 months follow up, 56.3% of patients had complete relief of symptoms and 27.6% had permanent residual symptoms. Over 75% of patients subjectively rated their outcomes as excellent.
Figure A and B are T2 and T1 axial MRI images, respectively, showing the L3-L4 disc space with a left far lateral disc herniation. Figure C is a left parasagittal T2 MRI image showing impingement on the L3 nerve root. Structures are labeled in illustration A. Illustration B shows the dermatomes of the lower extremity.
Incorrect Answers:

Question 32

A 30-year-old patient has had severe left hip pain and difficulty ambulating, necessitating the use of a cane, for the past 6 months. A photomicrograph of the femoral head sectioned at the time of surgery is shown in Figure 31. What is the most likely diagnosis?

Explanation

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 33

Figures 14a and 14b show the clinical photographs of a patient who was stranded in a subzero region for several days. The photographs were taken the morning after arrival in the hospital. The patient is otherwise healthy and fit, and takes no medication. He has no clinical signs of sepsis. He reports burning pain and tingling in both feet. What is the best treatment?

Explanation

DISCUSSION: The patient has no clinical or observed signs of sepsis. The skin just proximal to the gangrenous tissue appears somewhat hyperemic and is clearly viable. These wounds should be managed much like burn wounds. Moist dressings should be used until the tissue clearly demarcates. Much of the insult may simply be superficial and only require late debridement.
REFERENCES: McAdams TR, Swenson DR, Miller RA: Frostbite: An orthopedic perspective.

Am J Orthop 1999;28:21-26.
Taylor MS: Cold weather injuries during peacetime military training. Milit Med 1992;157:602-604.

Question 34

What is the primary mechanism of degradation of calcium phosphate cement?

Explanation

DISCUSSION
To treat depressed tibial plateau fractures, surgeons must elevate the depressed segments, which results in a metaphyseal bone void. This void can be filled with multiple materials, including autograft and allograft bone. The addition of BMP-2 or BMP-7 is not recommended to fill contained bone defects. These materials are indicated for application between bone and soft tissue and they do not provide the volume or strength to fill closed defects. Calcium phosphates have been use to fill these voids, demonstrating improved strength and resistance to subsidence when compared to autograft. Although polymethylmethacrylate is commonly used to fill bone voids in patients with cancer, it is not preferred in the setting of acute fracture because of the exothermic reaction that may compromise local bone healing. Although hydroxyapatite may be degraded by macrophage and giant-cell-mediated processes, the calcium phosphate degrades mainly by an osteoclast-mediated method. The calcium phosphate is not soluble in interstitial fluid, so simple dissolution does not occur.
RECOMMENDED READINGS
Bajammal SS, Zlowodzki M, Lelwica A, Tornetta P 3rd, Einhorn TA, Buckley R, Leighton R, Russell TA, Larsson S, Bhandari M. The use of calcium phosphate bone cement in fracture treatment. A meta-analysis of randomized trials. J Bone Joint Surg Am. 2008 Jun;90(6):1186-

Question 35

…The patient underwent an uneventful arthroscopic repair and did well until 1 year later when she crashed during a race. She tore her anterior cruciate ligament (ACL) and underwent reconstruction. Followup after her successful ACL reconstruction reveals complaints of new shoulder pain and posterior instability from using crutches after her ACL surgery. A new MRI scan is shown in Figure 24. What factors are most likely associated with this patient’s recurrence?

Explanation

Question 36

A 55-year-old man sustained an elbow dislocation in a fall. Postreduction radiographs are shown in Figures 40a and 40b. What is the best course of management?

Explanation

DISCUSSION: The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, factures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.
REFERENCES: Hildebrand KA, Patterson SD, King GJ: Acute elbow dislocations: Simple and complex. Orthop Clin North Am 1999;30:63-79.
O’Driscoll SW, Jupiter JB, King GJ, et al: The unstable elbow. Instr Course Lect

2001;50:89-102.

Question 37

A 75-year-old woman is undergoing a T10-S1 lumbar decompression and fusion for severe degenerative scoliosis. During the deformity corrective maneuver, intraoperative neuromonitoring revealed a sustained 80% decrease in somatosensory-evoked potential (SSEP) amplitudes. Appropriate lead placement and

Explanation

The most appropriate management is discontinuation of the spinal instrumentation procedure, including releasing any distractive forces. Given the ongoing changes, proceeding with the procedure and/or resetting the baseline amplitudes is inadvisable. If the SSEPS amplitudes fail to return in a timely fashion, it is strongly recommended to consider a wake-up test. The purpose of intraoperative neuromonitoring is to provide a real-time assessment of the functional integrity of the central and peripheral nervous systems during surgery to prevent iatrogenic injury. Sustained decreased SSEP amplitudes of greater than 50% and transcranial electric Motor-Evoked Potentials (tceMEP) amplitudes of greater than 75% are indicative of a possible significant intraoperative neurologic complication. Although intraoperative corticosteroids might be helpful, especially in the event of a continued SSEP change, the most important next step would be to release the distractive forces and reevaluate the patient's neurologic status.

Question 38

-A 37-year-old woman has a 2-month history of weakness in thumb and finger extension, but has normal radial deviation during extension of the wrist. An MRI scan of her forearm shows no abnormality. She does not recall any traumatic event. Needle electromyography findings show fibrillations and reduced

Explanation

Question 39

Figure A is a pelvic radiograph of a healthy 20-month old girl with a limb leg discrepancy. A hip arthrogram under general anesthesia reveals concentric reduction of the left hip ONLY when the hip is positioned in 70 to 80 degrees of abduction. The next best step in treatment would be: Review Topic

Explanation

Figure A shows left hip subluxation consistent with late presenting developmental hip dysplasia (DDH). The most appropriate treatment at this stage would be open hip
capsulorrhaphy, +/- femoral osteotomy +/- pelvic osteotomy
In children older than 18 months, open reduction is the preferred treatment for hip dysplasia. Open reduction is also considered when concentric closed reduction cannot be achieved or when excessive abduction (>60 degrees) is required to maintain reduction (due to increasing risk of avascular necrosis). The goal of open reduction is to remove the blocks to reduction and to increase stability by preforming soft-tissue or bone procedures.
Wenger et al. reviewed the surgical treatment of DDH. They say that the impediment to congruent reduction are the iliopsoas muscle, joint capsule, ligamentum teres, pulvinar, labrum, and transverse acetabular ligament. The most commonly used approaches are anterior and medial/anteromedial to the hip.
Gholve et al. reviewed DDH and the factors that contribute to secondary procedures. In their study, neither age nor unilateral vs bilateral dislocation had a direct influence on the outcome or the need for secondary procedures. The variable that significantly influenced the need for a secondary procedure was the concomitant use of a femoral osteotomy during initial surgical treatment. Of the 27 patients who did not have concurrent femoral osteotomy at index surgery, 19/27 (73%) required a secondary procedure (P<0.001).
Figure A shows an AP pelvic radiograph of an infant. Focusing on the left hip, there is lateral and superior subluxation of the femoral head, with the femoral head lateral to Perkin's line. The medial joint space is increased. The acetabular index is increased
>30 degrees. Shenton's line is disrupted. These are all features of DDH.
Incorrect Answers:

Question 40

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Explanation

DISCUSSION: Failure of the scalene block, necessitating general anesthesia or the immediate administration of narcotic medications, is the most common complication, occurring in 3% to 18% of patients. Cardiac arrest or cardiovascular collapse has been reported in anecdotal occurrences. Seizure that is the result of intravascular injection of local anesthetic is a rare complication, with an incidence reported of 0% to 6%. Neurologic complications, including laryngeal and phrenic nerve injuries, are rare although parathesias lasting up to 2 weeks have been reported in up to 3% of patients.
REFERENCES: Weber SC, Jain R: Scalene regional anesthesia for shoulder surgery in a community setting: An assessment of risk. J Bone Joint Surg Am 2002;84:775-779.
Conn RA, Colfield RH, Byer DE, Lindstromberg JW: Interscalene block anesthesia for shoulder surgery. Clin Orthop 1987;216:94-98.

Question 41

The 'Risser sign' is one of the most commonly used markers for skeletal maturation and growth potential in patients with adolescent idiopathic scoliosis. What 'Risser sign' has been shown to correlate with the greatest velocity of skeletal linear growth? Review Topic

Explanation

There are two stages of life where the velocity of postnatal skeletal growth is most rapid. These are: (1) during the first year of life and (2) puberty. Both correlate with a Risser sign of 0. Risser 0 covers the first 2/3rd of the pubertal growth spurt and correlates with the greatest velocity of skeletal linear growth.
Risser grades range from 0 to V and are a measure of the progression of ossification in the pelvis. The Risser sign is usually referenced in clinical decision-making regarding adolescent idiopathic scoliosis.
Biondi et al. examined 111 patients to determine the relationship between the accuracy of the Risser sign and bone age determinations. They found that the iliac crest apophysis maturation correlated with skeletal age assessment. They suggest that Risser sign is a reliable method for assessing skeletal bone age.
Illustration A shows an AP pelvis radiograph of a patient that is a Risser II based on the iliac crest apophysis maturation scale. Illustration B shows a chart showing the rate of growth correlated with the Risser staging system. Illustration C shows the Risser staging system from 0 - V.
Risser I: is given when the ilium calcification measures 25%. As this stage the velocity of linear skeletal growth is on a descending slope.
Risser II: the greater trochanteric apophysis unites with the femur and Ilium calcification measures 50%. There is usually 3 cm of sitting growth remaining and no further growth in the lower extremities.
Risser III: Ilium calcification measures 75%. There is usually 2 cm of sitting growth remaining.
Risser IV: Ilium calcification is almost complete. There is usually 1 cm of sitting growth remaining.
Risser V marks complete skeletal maturation.
Incorrect Answers:

Question 42

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

Explanation

DISCUSSION: The dislocation is between the medial and middle cuneiform. Although the first and second tarsometatarsal joints are aligned, there is a gap between the cuneiforms. The radiograph shows a Lisfranc dislocation variant. In a healthy active individual, open reduction and internal fixation yields the best results. The reestablishment of the normal arch and medial column support with anatomic reduction is critical to obtaining the best possible outcome from these injuries.
REFERENCES: Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of the tarsal-metatarsal fracture dislocation. Foot Ankle Int

2002;23:922-926.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.

Question 43

A 29-year-old man sustained an injury when he was playing basketball, landing on his left knee while jumping for a rebound. He had vague pain in the anterior aspect of the knee for several weeks. The initial radiographs were negative with the exception of a large traumatic effusion. Examination reveals no apparent ligament instability but a significant extension lag of 30 degrees. There was a palpable defect above the superior pole of the patella. What is the most appropriate management? Review Topic

Explanation

This is the classic presentation of a tendon disruption in an active athlete that may represent chronic strain or weakening of the tendon insertion. The factors that lead to this condition are multitude, including biomechanic and cytologic, but there is little evidence that inflammation is an active factor. Surgical treatment is straightforward and logical. Suture anchors have been compared with simple holes made in the patella for suturing the tendon, with no apparent biomechanic advantage.

Question 44

A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Which of the following imaging techniques best describes the correct utilization of intraoperative flouroscopy for percutaneous iliosacral screw placement across S1?

Explanation

DISCUSSION: The outlet view best guides superior-inferior screw orientation during percutaneous S1 screw placement. This is due to the relative forward flexion of the sacrum and pelvis due to pelvic incidence. A lateral sacral
view and an inlet pelvis view would best guide anterior-posterior screw orientation.
Routt et al did a review of percutaneous techniques of pelvic surgery. Although anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation, iliosacral screws have the advantage of stabilizing pelvic disruptions directly while diminishing operative blood loss and operative time. They stress importance of a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations for surgical success.
Routt et al also looked at the complications that can result from percutaneous iliosacral screw placement. Complications ranged from inability for adequate imaging due to patient obesity, L5 nerve root injuries, fixation failure, and sacral nonunions. They support quality triplanar fluoroscopic imaging during iliosacral screw insertions to help accurately reduce injured posterior pelvic rings.
Illustration A shows the radiographic technique used to shoot an outlet pelvis view and illustration of the pelvic view. Illustration B is an example of an outlet view image status post anterior pelvic ring plating and percutaneous iliosacral screw. This outlet view allows superior S1 neural foramen visualization to help guide screw placement and avoid nerve injury.

Question 45

A 5-year-old boy is seen in the emergency department with a 2-day history of refusing to walk. Examination shows that he has a temperature of 102.2 degrees F (39 degrees C) and limited range ot motion of the right hip. The AP pelvic radiograph is normal. The WBC count is normal but the C-reactive protein and erythrocyte sedimentation rate (ESR) are elevated. What is the next step in management?

Explanation

DISCUSSION: The history, physical examination, and laboratory studies suggest a septic hip. Recent studies indicate that a child with elevated ESR, a WBC count of greater than 12,000/mm3, a temperature of greater than 38.5 degrees, and unwillingness to walk is very likely to have septic arthritis of the hip versus toxic synovitis. The best way to confirm the diagnosis is by hip aspiration. No medications should be started until a diagnosis is made. Toxic synovitis is common, but significantly less likely if three of the above criteria are present. This condition usually responds well to ibuprofen, but requires close observation. Septic hips are considered urgent conditions and therefore a repeat evaluation in 2 weeks is inappropriate.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 2109-2113.
Abel MF (ed): Orthopaedic Knowlede Update: Pediatrics 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 62-65.
Kocher MS, Mandiga R, Murphy JM, et al: A clinical practice guideline for treatment of septic arthritis
in children: Efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am 2003;85:994-999.
Kocher MS, Mandiga R, Zurakowski D, et al: Validation of a clinica l prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am 2004;86:1629-1635.

Question 46

Which of the following best describes the recommended treatment for a 13-year-old pitcher with a painful chronic stress injury to the proximal humeral physis as confirmed on an MRI scan? Review Topic

Explanation

Little Leaguer's shoulder is a chronic stress injury to the proximal humerus growth plate. Imaging findings demonstrate widening of the proximal humeral growth plate. Treatment consists of rest and avoidance of pitching for the remainder of the season. Surgery is not indicated.

Question 47

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Explanation

EXPLANATION:
The ultrasound shows a homogeneous anechoic mass consistent with a ganglion cyst. As a benign lesion, no further workup or biopsy is required prior to a marginal surgical excision other than age-appropriate laboratory studies. An MRI study with contrast would provide no diagnostic benefit.

Question 48

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Explanation

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 49

Figure 38 shows the radiograph of a 16-year-old wrestler who injured his elbow when he was thrown to the mat by his opponent. To minimize additional trauma to the medial soft tissues, the elbow should be reduced in

Explanation

DISCUSSION: The elbow dislocates by a three-dimensional movement of supination and valgus during flexion. Additional trauma during reduction is minimized by recreating the deformity and reducing the elbow in supination. The actual maneuver includes full supination (actually hypersupination) of the elbow in a valgus position. This is followed by pushing the olecranon distally in line with the long axis of the ulna while swinging the elbow into varus, and then relaxing the supination torque. Postreduction stability is enhanced in pronation, except when the soft-tissue disruption is extensive.
REFERENCES: O’Driscoll SW: Elbow dislocations, in Morrey BF (ed): The Elbow and Its Disorders, ed 2. Philadelphia, PA, WB Saunders, 1993, p 414.
Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.

Question 50

A 52-year-old man has had back pain radiating to the left leg for the past 5 weeks. A radiograph, MRI scans, and biopsy specimens are shown in Figures 23a through 23f. What is the most likely diagnosis?

Explanation

DISCUSSION: The histology shows cells with bubbly, abundant clear cytoplasm typical of physaliphorous cells; therefore, the most likely diagnosis is chordoma. These tumors arise from notocord rests in the upper and lower spine.
REFERENCE: Mirra J: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989, vol 1, ch 8.

Question 51

Figures 1 and 2 demonstrate the radiographs obtained from a 35-year-old woman with end-stage debilitating osteoarthritis of the right hip. She is contemplating total hip arthroplasty (THA). She has a history of right hip dysplasia and underwent hip osteotomy as an adolescent. Over the years, nonsurgical treatment, including weight loss, activity modifications, and intra-articular injections, has failed. Her infection work-up reveals laboratory findings within defined limits. Which bearing surface is contraindicated for this patient?

Explanation

DISCUSSION:
THA has proven durable and reliable for pain relief and improving function for patients with end-stage arthritis. Appropriate bearing selection is critical to minimize wear and hip complications. A metal-on- metal articulation is associated with excellent wear rates in vitro. With its capacity to offer a low wear rate with large femoral heads, it is an attractive bearing choice for THA. However, local soft-tissue reactions, pseudotumors, and potential systemic reactions including renal failure, cardiomyopathy, carcinogenesis, and potential teratogenesis with potential transfer of metal ions across the placental barrier make metal-on-metal bearings less desirable and relatively contraindicated for younger women of child- bearing age. The workup of a painful metal-on-metal hip arthroplasty necessitates a systematic approach. Several algorithms have been proposed. Routine laboratory studies including sedimentation rate, CRP, and serum cobalt and chromium ion levels should be obtained for all patients with pain. Advanced imaging including MARS MRI should be performed to evaluate for the presence of fluid collections, pseudotumors, and abductor mechanism destruction. Infection can coexist with metal-on-metal reactions, so, when indicated (if the CRP level is elevated), a hip arthrocentesis should be obtained. However, in this setting, a manual cell count and differential should be obtained because an automated cell counter may provide falsely elevated cell counts. The results of revision surgery for a failed metal-on-metal hip prosthesis can be variable. The amount of local tissue destruction and the integrity of the hip abductor mechanism can greatly influence outcomes. Instability is the most common complication following revision of failed metal-on-metal hip replacements.

Question 52

The primary effect of deep freezing on musculoskeletal allografts is a reduction of

Explanation

Deep freezing alters biological and immunological properties. Many investigators have shown that frozen bone is less immunogenic than fresh bone and freeze-dried is even less. Freezing does increase shelf-life but has no effect on strength, stiffness, or risk of HIV.

Question 53

Examination of a 30-year-old professional singer who has persistent neck and shoulder pain reveals a positive Hoffman’s sign and clonus because of anterior C2-3 cord compression. The MRI scan shown in Figure 11a and the cervical CT scan shown in Figure 11b reveal focal anterior cord compression at the C2-3 level. Which of the following surgical approaches would least affect her professional career?

Explanation

DISCUSSION: Protection of the superior laryngeal nerve is critical in a professional singer. The nerve is easily injured with retraction when using vertical extension of common anterior surgical approaches to gain exposure to the C2-3 level. McAfee and associates reported on 17 patients with C1-2 and C2-3 pathology. They used a modified submandibular approach as an anterior retropharyngeal exposure with modification of the superior extension of the Smith-Robinson technique that allows visualization of the superior laryngeal nerve and surrounding structures. No incidences of superior laryngeal nerve injury were recorded. The transoral approach should be avoided because of the high rate of infection and limited exposure.
REFERENCES: McAfee PC, Bohlman HH, Reilly LH Jr, Robinson RA, Southwick WO, Nachlas NE: The anterior retropharyngeal approach to the upper part of the cervical spine. J Bone Joint Surgery Am 1987;69:1371-1383.
Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach to the cervical spine: Surgical anatomy. Orthopedics 2000;23:841-845.

Question 54

A 23-year-old man cut the dorsal and ulnar aspects of his long finger on a table saw. The dorsal and ulnar skin over the middle phalanx is missing, with a 2-cm x 2-cm area of loss. There is a 50% loss of the extensor tendon (ulnar), and the remaining tendon has no tenosynovium. The physician should recommend irrigation and debridement and

Explanation

EXPLANATION:
The patient has exposed bone and tendon and a partial tendon injury. The remaining radial tendon is satisfactory and no tendon repair is required. The exposed bone and tendon necessitate vascularized tissue coverage. A reversed cross-finger flap from the ring finger is suitable for coverage of the dorsal surface of an adjacent digit.

Question 55

A 20-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow for which surgical reconstruction is necessary. The goal of surgery is anatomic restoration of the MCL. Which statement best describes the kinematics of the native MCL?

Explanation

The anterior bundle is the most important portion of the complex when treating valgus instability of the elbow. The ligament originates from the anteroinferior surface of the medial epicondyle. The anterior bundle inserts on the medial border of the coronoid at the sublime tubercle. The anterior bundle of the medial collateral ligament (MCL) is the primary restraint to valgus stress, and the radial head is a secondary restraint. With anterior bundle sectioning, the resultant instability is most substantial between 60° and 70° and is lowest at
full extension and full flexion. True lateral radiographs reveal that the flexion-extension axis, or center of rotation, of the elbow lies in the center of the trochlea and capitellum. The origin of the anterior bundle of the MCL lies slightly posterior to the rotational center of the elbow. The anterior bundle is further divided into an anterior band and a posterior band. The eccentric origin of these anterior bundle components in relation to the rotational center through the trochlea creates a CAM effect during flexion and extension. The anterior band tightens during extension, and the posterior band tightens during flexion. This reciprocal tightening of the two functional components of the anterior bundle allows the ligament to remain taut throughout the full range of flexion. Cadaver dissection studies have identified the origin and insertion of both the medial and lateral stabilizing elbow ligaments. The anterior bundle of the MCL is isometric throughout the flexion/extension arc of motion, making Response C incorrect. The posterior bundle of the MCL elongates with elbow flexion, so Responses B and D are incorrect. The posterior bundle of the MCL also demonstrates the most change in
length from extension to flexion of all the elbow ligaments.

Question 56

A 21-year-old basketball player reports increased left shoulder pain with all lifting and overhead activities. He denies any history of dislocations. Axial MRI arthrogram images are seen in Figures 34a and 34b. An expected finding on physical examination of the shoulder would be positive findings for which of the following tests? Review Topic

Explanation

An MRI arthrogram is a sensitive imaging study used to identify intra-articular shoulder pathology, especially abnormalities of the labrum. Posterior labral tears, although generally less common than anterior tears, can cause significant morbidity, especially in the athlete. Pain, grinding, or gross subluxation often can be elicited with a "jerk" test of the involved shoulder. This test consists of placing an axial load through the humerus, with the shoulder forward flexed to 90 degrees. The shoulder is
then abducted, while maintaining the axial load, and the patient's subjective and objective response is observed. Comparison to the contralateral shoulder is important, especially if painless subluxation is noted, to determine potential evidence of generalized joint laxity.

Question 57

-A 12-year-old boy who plays multiple sports has had insidious-onset heel pain while running for 4 months. On examination, he had ankle dorsiflexion of 5 degrees. The squeeze test result was positive and the Thompson test result was negative. He has no pain with forced ankle plantar flexion. What is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 58

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

Explanation

The patient has chronic tibial osteomyelitis that is due to low virulent bacteria. The history and studies do not suggest the need for an amputation or a free-flap procedure. This is a localized tibial infection that is in a healed bone; there is no need to resect the entire area of the tibia bone around the infection. The most appropriate treatment is curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics. Studies have shown that in cases of localized osteomyelitis that are of low virulence, as little as 1 week of IV antibiotics followed by 6 weeks of oral antibiotics is successful.

Question 59

Figure 80a shows an arthroscopic view from an infralateral portal of a right knee. Figure 80b shows a coronal MRI scan, and Figures 80c through 80e show consecutive sagittal images of the knee. The images show what anatomic finding? Review Topic

Explanation

The arthroscopic view and the coronal MRI scan show a discoid lateral meniscus covering almost the entire lateral tibial plateau. The sagittal views show a contiguous meniscus or "bow tie" sign on three consecutive images, pathognomonic for a discoid meniscus. Lateral discoid menisci are much more common than medial. There is no evidence of abnormal signal to indicate meniscal tearing. A transverse meniscal ligament is best seen anterior to the anterior horn of the lateral meniscus on multiple views. There is no evidence of a loose body on the arthroscopic or MRI images.

Question 60

Which of the following infectious organisms may be associated with underlying malignancy?

Explanation

DISCUSSION: Evidence implicates an association, albeit unexplained, between Clostridium septicum infection and malignancy, particularly hematologic or intestinal malignancy. The malignancy is often at an advanced stage, compromising survival of the patients. A bowel portal of entry is postulated for most patients. In the absence of an external source in the patient with clostridial myonecrosis or sepsis, the cecum or distal ileum should be considered a likely site of infection. Increased awareness of this association between Clostridium septicum and malignancy, and aggressive surgical treatment, may result in improvement in the present 50% to 70% mortality rate. Other organisms associated with malignancy include group Clostridium streptococci that are occasionally associated with upper gastrointestinal malignancies.
REFERENCES: Schaaf RE, Jacobs N, Kelvin FM, et al: Clostridium septicum infection associated with colonic carcinoma and hematologic abnormality. Radiology 1980;137:625-627.
Katlic MR, Derkac WM, Coleman WS: Clostridium septicum infection and malignancy. Ann Surg 1981;193:361-364.

Question 61

A 21-year-old minor league pitcher reports decreasing velocity and ability to target his pitches over the last 2 months. He notes that his arm will start to feel heavy in the later innings and notes pain in the posterior aspect of his shoulder in the late cocking phase of his motion. He denies any specific event that initiated his symptoms. Examination reveals symmetric rotator cuff strength and no increased anterior or posterior translation of either shoulder. Supine range of motion of the right shoulder in 90 degrees of abduction reveals external rotation to 100 degrees and internal rotation to 25 degrees. The left shoulder has 95 degrees of external rotation and 60 degrees of internal rotation. He has pain with an O'Brien's maneuver and a negative apprehension sign. What is the next most appropriate step in management? Review Topic

Explanation

The patient has glenohumeral internal rotation deficit with posterior capsular tightness; therefore, initial management should be directed at physical therapy and posterior capsular stretching. The total arc of motion (external rotation + internal rotation) should be equal between the shoulders. He has a deficit of 30 degrees in his throwing shoulder. A "sleeper stretch" is a common way for patients to stretch the posterior capsule and involves lying on the involved side with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and pushing the forearm toward the table. Subacromial injection is not indicated because the pathology of an internal rotation contracture is located within the glenohumeral joint space and not the subacromial space. A sling might be useful for comfort but will not resolve his symptoms. There is no indication for arthroscopy, SLAP repair, or anterior-inferior capsulolabral plication at this time.

Question 62

An eversion mechanism of injury is associated with which of the following ankle conditions?

Explanation

DISCUSSION: A fracture of the anterior colliculus is typically the result of an eversion mechanism resulting in a bony avulsion of the deltoid ligament from the anterior colliculus of the medial malleolus. An inversion ankle injury typically involves ligamentous damage to the lateral ligaments of the ankle to include the anterior talofibular ligament and calcaneofibular ligament. Acute and particularly chronic ankle sprains also can have associated injuries. The inversion mechanism has been implicated in osteochondral and transchondral talar dome lesions, producing splits in the peroneus tendons, and in the development of meniscoid and soft-tissue impingement lesions in the anterolateral ankle. An inversion mechanism can also stretch the superficial peroneal nerve, leading to pain and paresthesias along its distribution.
REFERENCES: Casillas MM: Ligament injuries of the foot and ankle in the athlete, in DeLee JC, Drez D, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2323-2357.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 233-245.

Question 63

A 44-year-old man was involved in a low speed rear-end motor vehicle accident 4 weeks ago. He predominantly reports pain in the back of the neck, with occasional radiation into the trapezius region bilaterally. He denies any extremity pain. The pain has not changed in intensity, but is worse with neck range of motion. Cervical spine radiographs were negative for acute osseous trauma or instability. What is the next most appropriate step in management? Review Topic

Explanation

The patient was involved in a low speed rear-end collision and sustained a whiplash-type injury, with management most often being nonsurgical. After 4 weeks of persistent pain, continued observation is not reasonable. Studies have shown that treatment including NSAIDs, activity modification and a brief duration of physical therapy allows for improved outcomes after whiplash-type injuries when compared with observation alone. An MRI scan of the cervical spine is not indicated at this time and represents an unnecessary expense. Cervical epidural and facet injections are not indicated in the treatment of patients with whiplash injuries.

Question 64

A 52-year-old man has shoulder pain and stiffness after undergoing a “mini-lateral” rotator cuff repair 6 months ago. Examination reveals that he is afebrile with normal vital signs. There is slight erythema but no drainage from the incision. Range of motion is limited in all planes, and there is weakness with resisted external rotation and abduction. Radiographs show a well-positioned metal implant within the greater tuberosity. Laboratory studies reveal a WBC count of 8,400/ mm 3 (normal 3,500 to 10,500/ mm 3 ) and an erythrocyte sedimentation rate of 63 mm/h (normal up to 20 mm/h). What is the next most appropriate step in management?

Explanation

DISCUSSION: Deep sepsis of the shoulder following rotator cuff repair is an uncommon problem. Patients with infections of this type typically report persistent pain and are not systemically ill. They may have signs of local wound problems such as erythema, drainage, and dehiscence. Laboratory studies can be helpful in making an accurate diagnosis. Most patients will not show a significant elevation of the WBC count; however, an elevated erythrocyte sedimentation rate is nearly always present and should alert the clinician to the presence of infection. Aspiration of both subacromial and glenohumeral joint spaces is necessary to confirm the diagnosis. The most effective treatment for deep shoulder sepsis following rotator cuff repair involves extensive surgical debridement, removing all suspicious soft tissue as well as implants. Administration of appropriate antibiotic therapy is needed for complete control of the infection.
REFERENCES: Mirzayan R, Itamura JM, Vangsness CT, et al: Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am 2000;82:1115-1121.
Settecerri JJ, Pitnu MA, Rock MG, et al: Infection after rotator cuff repair. J Shoulder Elbow Surg 1994;8:105.
Herrera MF, Bauer G, Reynolds F, et al: Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg 2002;11:605-608.

Question 65

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 66

A 62-year-old man with a long history of right shoulder pain and weakness is scheduled to undergo hemiarthroplasty. Based on the radiographs shown in Figures 6a through 6c, what preoperative factor will most affect postoperative functional outcome?

Explanation

DISCUSSION: The radiographs reveal osteoarthritis and proximal humeral head migration. Integrity of the rotator cuff must be questioned based on these radiographic changes. The status of the rotator cuff is the most influential factor affecting postoperative function in shoulder hemiarthroplasty. The coracoacromial ligament provides a barrier to humeral head proximal migration in the face of a rotator cuff tear. The radiographs do not indicate significant humeral head or glenoid erosion. Acromioclavicular arthritis is often asymptomatic.
REFERENCES: Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2003;85:251-258.
Hettrich CM, Weldon E III, Boorman RS, et al: Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty. J Bone Joint Surg Am 2004;86:1446-1451.

Question 67

Figure 10 shows the radiograph of a 9-year-old girl who injured her left lower leg after being thrown from a horse. Examination reveals no other injuries. Which of the following forms of management will provide the lowest rate of complications and the earliest return to function?

Explanation

DISCUSSION: Because the patient has a transverse midshaft fracture with no evidence of comminution, the treatment of choice is closed reduction and stabilization with flexible intramedullary nails. Transverse fractures treated with an external fixator heal with poor callus and have a high refracture rate. In addition, the pin tracks produce undesirable and excessive scarring. Femoral pin traction is safe and effective but results in considerable muscle wasting and a slow return to function. Interlocking nails run the risk of greater trochanteric growth disturbance and/or osteonecrosis of the femoral head in this age group. Plate fixation, while effective, requires considerable tissue dissection with large scar formation. It also requires a rather extensive dissection for later plate removal.
REFERENCES: Ligier JN, Metaizeau JP, Prevot J, Lascombes P: Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:74-77.
Heinrich SD, Drvaric D, Darr K, MacEwen GD: Stabilization of pediatric diaphyseal femoral fractures with flexible intramedullary nails (a technique paper). J Orthop Trauma 1992;6:452-459.

Question 68

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Explanation

DISCUSSION: Inflammation, overload, or decreased matrix production may lead to cartilage degeneration. During the second stage of articular cartilage degeneration with osteoarthritis, there is increased chondrocyte activity with proliferation and increased production of extracellular matrix. At the same time, there is an increase in catabolic activity with removal of damaged matrix to facilitate matrix remodeling. Chondrocyte repair response decreases with aging. Matrix degradation includes decreased proteoglycan production, less aggregation, and shorter glycosaminoglycan chains.
REFERENCE: Buckwalter JA, Mankin HJ, Grodzinsky AJ: Articular cartilage and osteoarthritis. Instr Course Lect 2005;54:465-480.

Question 69

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

Explanation

DISCUSSION: Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).
REFERENCE: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 70

A 24-year-old dancer sustains the injury shown in Figure 28. Management should consist of

Explanation

DISCUSSION: The patient has a moderately displaced distal diaphyseal fracture of the fifth metatarsal, and the most appropriate treatment is brief immobilization and symptomatic management. Attempts at closed reduction are unlikely to appreciably alter the position of the fracture. Surgical techniques for either reduction of the fracture or fixation have not been shown to result in improved functional outcomes.
REFERENCES: O’Malley MJ, Hamilton WG, Munyak J: Fractures of the distal shaft of the fifth metatarsal: “Dancer’s Fracture.” Am J Sports Med 1996;24:240-243.
DeLee JC: Fractures and dislocations of the foot, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, CV Mosby, 1993, pp 1465-1703.
Hamilton WG: Foot and ankle injuries in dancers, in Yokum L (ed): Sports Clinics of North America. Philadelphia, PA, Williams and Wilkins, 1988.

Question 71

A previously healthy 29-year-old man reports a 2-day history of severe atraumatic lower back pain. He denies any bowel or bladder difficulties and no constitutional signs. Examination is consistent with mechanical back pain. No focal neurologic deficits or pathologic reflexes are noted. What is the most appropriate management?

Explanation

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 72

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 73

A 31-year-old male sustains an ipsilateral displaced transverse acetabular fracture, pubic rami fractures, and a sacroiliac joint dislocation. What structure should be reduced and stabilized first?

Explanation

DISCUSSION: In an ipsilateral unstable pelvic ring and acetabular fractures, the pelvic ring injury must be initially stabilized in order to reduce the acetabular fracture to a stable base.
The referenced article by Matta reviewed 259 patients with acetabular fractures treated within 21 days of injury and found that the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

Question 74

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Explanation

A patient with an injury at the level of: C4 injury needs puffer control; C5 can use hand controls; C6 can use a manual wheelchair and sliding board transfers; C7 allows independent transfers; and no cervical injury routinely allows ambulation with crutches and leg braces.

Question 75

A 22-year-old professional baseball pitcher has had pain in the axillary region of his dominant shoulder for the past several weeks. While throwing a pitch during a game, he notes a sharp pulling sensation with a “pop” in his shoulder. Examination the following day reveals tenderness along the posterior axillary fold and pain and weakness with resisted extension of the shoulder. What is the most likely cause of his symptoms?

Explanation

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.

Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 76

A 78-year-old woman underwent total hip arthroplasty 15 years ago. She reports a recent history of increasing thigh pain prior to a fall and is now unable to ambulate. Radiographs are shown in Figures 87a and 87b. What is the best treatment for this condition?

Explanation

DISCUSSION: Severe periprosthetic fractures after total hip arthroplasty with a loose implant and progressive bone loss are difficult problems for orthopaedic surgeons, with a high complication rate. Recent literature favors the use of long fluted tapered stems that have a long distal taper that may optimally engage the remaining femoral shaft isthmus. Plating options are problematic because the ability to use screws with the plate is limited by the intramedullary stem. Although not the only solution to this problem (such as allograft-prosthetic composites, impaction grafting, tumor prostheses), long distally fixed stems circumvent this problem by enhancing fracture healing and create a long-term prosthetic solution in these most difficult cases.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 475503.
Kwong LM, Miller AJ, Lubinus P: A modular distal fixation option for proximal bone loss in revision total hip
arthroplasty: A 2- to 6-year follow-up study. J Arthroplasty 2003;18:94-97.

Question 77

A 35-year-old man presents with mechanical knee pain after a fall. An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. Which of the following statement is true with respect to Technique B and C? Review Topic

Explanation

Microfracture (Technique B) heals with fibrocartilage, predominantly Type I collagen. Mosaicplasty/OAT (Technique C) transfers articular cartilage, containing predominantly Type II collagen.
The initial treatment for small articular cartilage defects is rest, NSAIDS and bracing. For larger defects (<2-4cm2), options include marrow stimulation procedures (abrasion chondroplasty, microfracture, osteochondral drilling) and autograft procedures (Mosaicplasty, a technique of osteochondral autograft transfer (OAT).
Alford et al. reviewed cartilage restoration. They defined a spectrum of treatment option ranging from (1) palliative (debridement/lavage), intended to reduce irritation
and inflammation, (2) reparative (marrow stimulation techniques), intended to recruit stem cells to proliferate fibrocartilage repair tissue, to (3) restorative (osteochondral grafting), designed to replace articular cartilage and subchondral bone as a single unit.
Magnussen et al. reviewed the treatment of cartilage defects in the knee. They compared autologous chondrocyte implantation (ACI), OATs, matrix-induced ACI, and microfracture. No one technique was superior to the rest. Outcomes for microfracture tended to be worse in larger lesions.
Figures A is an arthroscopic picture showing a grade IV chondral defect. Figure B shows microfracture. Figure C shows the multiple cylindrical plugs of mosaicplasty, a technique of osteochondral autograft transfer (OAT). Illustration A shows donor and recipient sites in mosaicplasty. Illustration B shows the spectrum of treatment options defined by Alford et al (MST = marrow stimulation; ACI = autologous chondrocyte implantation; OCG = osteochondral grafting with autograft/allograft).
Incorrect Answers:

Question 78

A 25-year-old patient undergoes the procedure seen in Figure A. Which of the following statements best describes the incorporation of the graft and biopsy results of the graft at one year? Review Topic

Explanation

The patient underwent an osteochondral autograft transfer (OAT) with multiple plugs (also known as mosaicplasty) for a full-thickness chondral defect of the medial femoral condyle. The chondrocytes in the graft remain viable, the transferred cartilage heals, and biopsy reveals articular cartilage composed primarily of type II collagen.
Articular cartilage defects can be treated by a variety of methods including debridement, fixation of unstable osteochondral fragments, marrow stimulation techniques (microfracture, abrasion chondroplasty), cartilage replacement techniques (osteochondral autograft and allograft) and cellular techniques (autologous chondrocyte implantation). Osteochondral autograft transfer is performed by harvesting normal articular cartilage with underlying bone from lesser weightbearing areas (e.g. intercondylar notch) and transferring the graft to a recipient socket at the site of the chondral defect. Graft incorporation occurs by integration of the bony graft into the subchondral bone and healing of the overlying cartilage layer.
Hangody et al. reviewed the outcomes of autologous osteochondral mosaicplasty in professional athletes. They found successful outcomes similar to that of less athletic patients, despite a higher rate of preoperative osteoarthritic changes in the athletic population. The authors noted that histological evaluation revealed good graft incorporation in all 11 cases.
Alford et al. authored a two part Current Concepts article on cartilage restoration. They constructed an algorithm (Illustration A) highlighting many factors that impact treatment choice, including patient activity level and defect characteristics such as location and size. This algorithm also illustrates comorbidities (malalignment, ligament insufficiency) that warrant correction prior to addressing the chondral defect.
Figure A shows a full-thickness chondral defect (left) and subsequent osteochondral autograft transfer (right). Illustration A is a treatment algorithm for the management of chondral defects, as discussed above. Illustration B shows a microfracture procedure, a marrow stimulation technique resulting in fibrocartilage filling of the chondral defect. Illustration C shows an osteochondral allograft transplant, a cartilage replacement technique useful for large defects in which donor graft is obtained from a cadaver hemicondyle and transferred to a recipient socket at the site of the chondral defect. Illustration D shows the autologous chondrocyte implantation technique, a two-stage procedure consisting of 1. Cartilage biopsy for growth of autologous
chondrocytes, and 2. Subsequent injection of autologous chondrocytes beneath a periosteal patch.
Incorrect

Question 79

A 23-year-old right-hand dominant professional baseball pitcher has right shoulder pain when releasing the ball. He has noticed his velocity has decreased over the past 2 months. Examination reveals supine abducted external rotation of 110 degrees compared to 100 degrees on the left side. His internal rotation is 30 degrees on the right compared to 70 degrees on the left side. Rotator cuff strength is normal. All other clinical tests are normal. MRI with contrast reveals no intra-articular lesions. What is the best course of treatment? Review Topic

Explanation

The examination reveals that the patient has posterior capsular tightness. Surgery should not be considered until the patient has failed to respond to nonsurgical management. The internal rotation contracture (GIRD - glenohumeral internal rotation deficit) should be addressed with appropriate posterior capsular stretching. This
should then be followed by appropriate rotator cuff and scapular stabilization exercises. Only if this management fails to relieve the patient's symptoms should surgery be considered. This patient clearly does not need external rotation stretching given the fact that he has normal external rotation.

Question 80

The essential lesion in recurrent or posterior instability following simple dislocation of the elbow typically involves which of the following structures?

Explanation

The lateral ulnar collateral ligament is the essential lesion in recurrent or persistent instability following simple dislocations of the elbow. Simple elbow dislocations are usually stable and may be managed by a short period of immobilization followed by early range of motion. Treatment of dislocations resulting in persistent instability frequently involves focusing on the lateral ulnar collateral ligament. The medial collateral ligament is repaired only if treatment of associated fractures and lateral collateral ligament injury does not restore stability.

Question 81

A patient has a large T11-T12 disk herniation that is causing substantial compression of the spinal cord. The patient reports walking imbalance over the past few weeks. Examination of the patient's reflexes is likely to show Review Topic

Explanation

The patient has a large thoracic disk herniation that is causing spinal cord compression. The history of gait imbalance suggests that the patient has thoracic level myelopathy. Assuming that the patient does not have lumbar stenosis, compression of the spinal cord at the T11-T12 level will cause upper motor neuron findings distal to it. Hyperreflexia of the upper extremities would suggest that the patient has cervical spinal cord compression. In this patient, the upper extremity reflexes should be normal. Most likely, the patient will exhibit hyperreflexia in the lower extremities, which is an upper motor tract sign.

Question 82

A 15-year-old boy has had pain in the right shoulder for the past 3 months. He denies any history of trauma and has no constitutional symptoms. Examination reveals a large firm mass in the proximal arm. A radiograph and MRI scan are shown in Figures 27a and 27b. Biopsy specimens are shown in Figures 27c and 27d. Management should consist of

Explanation

DISCUSSION: The patient has an aneurysmal bone cyst. The fluid-fluid levels seen on the MRI scan are typical for aneurysmal bone cyst, and the histology is consistent with a cystic lining. Vascular lakes, multinucleated giant cells, reactive bone, fibrovascular tissue, and an absence of atypical cells or numerous mitoses are seen histologically. Aneurysmal bone cysts will typically continue to grow and cause further bone destruction; therefore, observation is not recommended. Steroid injections are not effective. A thorough curettage of the cyst lining and bone grafting are required. Wide resection and chemotherapy are reserved for more aggressive tumors. There is no evidence of infection radiographically or histologically. Telangiectatic osteosarcoma should also be considered in the differential diagnosis; therefore, biopsy is an important part of the work-up.
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 232-233.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-196.

Question 83

A 25-year-old woman has had pain and stiffness in her knee following a motor vehicle accident 9 months ago. The radiograph, CT scan, MRI scan, and biopsy specimen are shown in Figures 53a through 53d. What is the most likely diagnosis?

Explanation

DISCUSSION: Heterotopic ossification may occur spontaneously or following trauma. The imaging studies and histology reveal mature fatty bone marrow and trabecular bone. Osteochondromas are cortically based with the medullary canal extending into the lesion. This is not evident in this patient. Also, no obvious cartilage cap is present. Parosteal osteosarcoma commonly occurs in the posterior distal femoral cortex but is ruled out by the lack of the typical fibrous stromal cells forming the low-grade malignant osteoid. The histology and clinical presentation eliminate osteomyelitis and osteoblastoma.
REFERENCES: Horne LT, Blue BA: Intra-articular heterotopic ossification in the knee following intramedullary nailing of the fractured femur using a retrograde method. J Orthop Trauma 1999;13:385-388.
Stannard JP, Wilson TC, Sheils TM, McGwin G Jr, Volgas DA, Alonso JE: Heterotopic ossification associated with knee dislocation. Arthroscopy 2002;18:835-839.
Mills WJ, Tejwani N: Heterotopic ossification after knee dislocation: The predictive value of the injury severity score. J Orthop Trauma 2003;17:338-345.

Question 84

Which sterilization method is expected to produce the most degradation of an allograft used for anterior cruciate ligament reconstruction?

Explanation

CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
Figures 43a and 43b are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable.

Question 85

Figure 28 is the radiograph of a 25-year-old soccer player who twisted her left ankle 1 week ago. She has pain and swelling over the anterolateral ankle and there is ecchymosis over the lateral ankle. She has these muscle group findings: anterior tibial tendon-right 5/5, left 5/5; posterior tibial tendon-right 5/5, left 5/5; peroneals-right 5/5, left 4/5; Achilles-right 5/5, left 5/5. What is the best next diagnostic or treatment step?

Explanation

DISCUSSION
Thousands of ankle sprains occur in the United States every day. Most affected patients do not have serious sequelae associated with their injury. In this case, a young athlete sprained her ankle. Her only area of tenderness is isolated to the anterior talofibular ligament. She also has associated weakness. The radiograph shows an os subfibulare; this is an entity that she likely was born with. There is no indication of bony pain, and it is too soon to test for instability; consequently, no further imaging is required. Considering the nature of the sprain and her weakness, physical therapy with proprioceptive training and peroneal strengthening would be most beneficial.
RECOMMENDED READINGS
Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997 Jan-Feb;25(1):130-7. PubMed PMID: 9006708. View Abstract at PubMed
McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006 Jul;34(7):1103-11. Epub 2006 Feb 13. PubMed PMID: 16476915. View Abstract at PubMed
Chun TH, Park YS, Sung KS. The effect of ossicle resection in the lateral ligament repair for treatment of chronic lateral ankle instability. Foot Ankle Int. 2013 Aug;34(8):1128-33. doi: 10.1177/1071100713481457. Epub 2013 Mar 7. PubMed PMID: 23471672.View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 29 THROUGH 33
Figures 29a and 29b are the weight-bearing radiographs of a 49-year-old woman who has had several months of increasing pain and deformity in her left foot. She points to her plantar medial arch as her area of greatest pain; however, she also has pain just distal to the tip of the distal fibula. Her pain worsens with walking or navigating stairs. Upon examination she has a flexible unilateral pes planus deformity with increased heel valgus and forefoot abduction. She is unable to perform a single heel raise.

29A

Question 86

When compared to traditional open repair through a posterior incision, percutaneous Achilles tendon repair clearly results in a reduction of what complication?

Explanation

DISCUSSION: Prospective studies, including randomized and randomized multicenter reports, have shown that percutaneous or mini-open acute Achilles tendon repair has comparable functional results when compared to traditional open techniques. Calder and Saxby reported one superficial infection out of 46 patients with a mini-open repair; Assal and associates and Cretnik and associates had no wound complications or infections. The other complications have not proved to be less likely with the mini-open or percutaneous technique.
REFERENCES: Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures:

A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84:161-170.
Calder JD, Saxby TS: Early, active rehabilitation following mini-open repair of Achilles tendon rupture: A prospective study. Br J Sports Med 2005;39:857-859.
Cretnik A, Kosanovic M, Smrkolj V: Percutaneus versus open repair of the ruptured Achilles tendon: A comparative study. Am J Sports Med 2005;33:1369-1379.

Question 87

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 13. The arrow is pointing to what muscle?

Explanation

DISCUSSION: The obturator internus muscle originates from the internal pelvic wall and passes laterally through the lesser sciatic foramen, banking around the ischium below the sacrospinous ligament before inserting on the medial aspect of the greater trochanter.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, Ogose A (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,

ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 88

A 22-year-old swimmer underwent thermal capsulorrhaphy treatment for recurrent anterior subluxation. Following 3 weeks in a sling, an accelerated rehabilitation program allowed him to return to swimming in 3 1/2 months. While practicing the butterfly stroke, he sustained an anterior dislocation. He now continues to have symptoms of anterior instability and has elected to have further surgery. Surgical findings may include a

Explanation

DISCUSSION: Complications of thermal capsule shrinkage or accelerated rehabilitation include capsule ablation. Since the original surgery did not include labral reattachment, findings of a Bankart lesion or a glenoid fracture from a nontraumatic injury are unlikely. Subscapularis detachment or biceps subluxation is a postoperative complication of open repairs. Failure of early postoperative instability treatment should not produce loose bodies.
REFERENCES: Abrams JS: Thermal capsulorrhaphy for instability of the shoulder: Concerns and applications of the heat probe. Instr Course Lect 2001;50:29-36.
Hecht P, Hayashi K, Lu Y, et al: Monopolar radiofrequency energy effects on joint capsular tissue: Potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model. Am J Sports Med 1999;27:761-771.

Question 89

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

Explanation

Question 90

Figure 72 is the MRI scan of a 61-year-old man who had left shoulder pain with a massive rotator cuff tear. Active forward elevation was 120 degrees. Arthroscopic examination revealed that the rotator cuff tear was irreparable. The articular surfaces of the glenohumeral joint have a normal appearance without significant degenerative changes. What is the most appropriate treatment option? Review Topic

Explanation

The MRI scan shows medial subluxation of the biceps tendon. Biceps tenotomy has been an effective treatment option for patients with large to massive rotator cuff tears when the tear is irreparable and pain is the main symptom. The MRI scan does not show a loose body. Patients with severe external rotation deficit and a deficient teres minor may experience a better functional result with latissimus dorsi transfer. Reverse total shoulder arthroplasty is an option in patients with cuff tear arthropathy and pseudoparalysis.

Question 91

Patients with rheumatoid arthritis may exhibit an increase in viral load for which of the following viruses?

Explanation

DISCUSSION: Rheumatoid arthritis (RA) is a complex multisystem disorder. It has been suggested that patients with RA have an impaired capacity to control infection with Epstein-Barr virus. Epstein-Barr virus has oncogenic potential and is implicated in the development of some lymphomas. Recent publications provide evidence for an altered Epstein-Barr virus-host balance in patients with RA who have a relatively high Epstein-Barr virus load. Large epidemiologic studies confirm that lymphoma is more likely to develop in patients with RA than in the general population. The overall risk of development of lymphoma has not risen with the increased use of methotrexate or biologic agents. Histologic analysis reveals that most lymphomas in patients with RA are diffuse large B cell lymphomas, a form of non-Hodgkin lymphoma. Epstein-Barr virus is detected in a proportion of these. Patients with RA do not have prevalence for infection with any of the other mentioned viruses.
REFERENCES: Callan MF: Epstein-Barr virus, arthritis, and the development of lymphoma in arthritis patients. Curr Opin Rheumatol 2004;16:399-405.
Baecklund E, Sundstrom C, Ekbom A, et al: Lymphoma subtypes in patients with rheumatoid arthritis: Increased proportion of diffuse large B cell lymphoma. Arthritis Rheum

2003;48:1543-1550.

Question 92

A 12-year-old girl has the painful foot deformity seen in Figure 79. You advise her that she has juvenile bunions. How do they differ from adult bunions?

Explanation

The hallmark of the juvenile bunion is metatarsus primus varus. Increased flexibility of the first metatarsal phalangeal joint leads to increased deformity. The hallux valgus
angle is less than the adult bunion. Bursal thickenings and prominence of the medial eminence are less in a juvenile bunion.

Question 93

When harvesting an iliac crest bone graft from the posterior approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?

Explanation

DISCUSSION: If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the first structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it difficult to obtain hemostasis. The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft.
REFERENCES: Banwart JC, Asher MA, Hassanein RS: Iliac crest bone graft harvest donor site morbidity: A statistical evaluation. Spine 1995;20:1055-1060.
Shin AY, Moran ME, Wenger DR: Superior gluteal artery injury secondary to posterior iliac crest bone graft harvesting: A surgical technique to control hemorrhage. Spine 1996;21:1371-1374.

Question 94

Figures 25a and 25b are the radiographs of a 63-year-old man who had right total hip arthroplasty (THA) 4 months ago. Progressive stiffness began 2 months after surgery, and he now reports pain only after prolonged physical activity. His examination reveals normal gait and painless range of motion with flexion of 70 degrees, extension of 0 degrees, internal rotation of 20 degrees, external rotation of 20 degrees, abduction of 10 degrees, and adduction of 10 degrees. His erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are within defined limits. Physical therapy has produced no benefit. What is the most appropriate next step?

Explanation

DISCUSSION
This patient presents with HO 4 months after undergoing THA. Symptomatic HO may complicate nearly 7% of primary THA cases. Improvement in pain is expected within 6 months, and most patients will not need surgical treatment. Surgical excision may be warranted for symptomatic patients after full maturation of the HO, usually 6 to 18 months after the surgery. Patients can be followed with repeated serum alkaline phosphatase levels, which are elevated initially and should return to normal upon maturation of HO. Alternatively, a bone scan can show decreased activity once the HO has matured. Twenty-five milligrams of indomethacin 3 times daily for 6 weeks or 1 dose of irradiation at 700 to 800 Gy is effective in the prevention of HO, not for the treatment of established HO.
RESPONSES FOR QUESTIONS 26 THROUGH 29
Minimum inhibitory concentration (MIC)
Minimum bactericidal concentration (MBC)
Antiobiotic susceptibility
Antibiograms
Antimicrobial resistance
Spectrum of coverage
Match the description below with the appropriate response above.

Question 95

A 17-year-old pitcher reports pain over the medial aspect of the elbow that occurs during the acceleration phase of throwing, and it prevents him from throwing at the velocity needed to be competitive. What structure is most likely injured in this patient?

Explanation

/
Figure 55a Question 55
A 22-year-old male basketball player has had knee pain for the past 3 months. He denies any history of trauma. He has symptoms of catching but no locking. He has rested for 2 weeks but symptoms returned when he resumed sporting activities. Tr and T2-weighted MRI scans are shown in Figures 55a and 55b. What is the most likely diagnosis?
Locked lateral meniscus tear
Anterior cruciate ligament tear
Ganglion cyst of the anterior cruciate ligament
Synovial osteochondromatosis
Pigmented villonodular synovitis PREFERRED RESPONSE: 3
DISCUSSION: The MRI scans show a cystic structure within the anterior cruciate ligament. It is fluid filled as seen on the T2 sequence. Ganglion cysts of the cruciate ligaments are rare. The most common presentation is pain with occasional loss of motion. Instability is not a chief complaint and often there is no evidence of laxity on examination. If nonsurgical management fails, arthroscopic debridement of the cyst is the accepted method of treatment.
REFERENCES: Liu SH, Osti L, Mirzayan R: Ganglion cysts of the anterior cruciate ligament: A case report and review of the literature. Arthroscopy 1994; 10:110-112.
Parish EN, Dixon P, Cross MJ: Ganglion cysts of the anterior cruciate ligament: A series of 15 cases. Arthroscopy 2005;21:445-447.

Question 96

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

Explanation

DISCUSSION
Although many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.
RECOMMENDED READINGS
Pareyson D, Marchesi C. Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol. 2009 Jul;8(7):654-67. Review. PubMed PMID: 19539237. View Abstract at PubMed
Wenz W, Dreher T. Charcot-Marie-Tooth disease and the cavovarus foot. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:291-306.
CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63
Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area. Upon examination the following arcs of motion are identified: ankle dorsiflexion-right, 5 degrees/left, 5 degrees; ankle plantar flexion-right, 30 degrees/left 30 degrees; foot inversion-right, 10 degrees/left, 5 degrees; foot eversion-right, 10 degrees/left 5 degrees.

Question 97

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Explanation

DISCUSSION: Rehabilitation of the quadriceps muscle following a partial tear of the PCL has been associated with a favorable outcome. The quadriceps acts an antagonist to the PCL because its contraction results in anterior tibial translation, which reduces the tensile stress on the injured ligament. Strengthening of the hamstring musculature increases posterior tibial translation and is contraindicated during the early rehabilitative phase following a PCL injury. Brace use has not been found to significantly alter the outcome following nonsurgical management of PCL tears.
REFERENCES: Parolie JM, Bergfeld JA: Long-term results of nonoperative treatment of isolated posterior cruciate ligament injuries in the athlete. Am J Sports Med 1986;14:35-38.
Griffin JR, Annunziata CC, Harner CD: Posterior cruciate ligament injuries in the adult, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2083-2106.

Question 98

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Explanation

DISCUSSION: Monteggia fractures in children must be recognized. Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation. In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation. Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion. Posterior Monteggia fractures are less common and may be managed in elbow extension. Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures. Annular ligament repair is rarely needed in the acute fracture.
REFERENCES: Wilkins KE: Changes in the management of Monteggia fractures. J Pediatr Orthop 2002;22:548-554.
Kay RM, Skaggs DL: The pediatric Monteggia fracture. Am J Orthop 1998;27:606-609.
Ring D, Jupiter JB, Waters PM: Monteggia fractures in children and adults. J Am Acad Orthop Surg 1998;6:215-224.

Question 99

A 33-year-old man had his foot run over by a forklift 1 hour ago. Examination reveals that the head of the fifth metatarsal is extruded through the plantar aspect of the foot. The foot is severely swollen and pale, there is no sensation in the toes, and the pulses are not palpable. Radiographs are shown in Figures 42a and 42b. Emergent management should consist of

Explanation

DISCUSSION: Following a severe crush injury, the patient has an acute compartment syndrome. Even though there is an open fracture, this is not sufficient to decompress the compartment syndrome. Therefore, splinting and observation are not appropriate. The surgical treatment of choice is fasciotomy with fixation of the multiple fractures. A primary amputation is not indicated because there is potential for salvage of this devastating injury.
REFERENCES: Fakhouri AJ, Manoli A II: Acute foot compartment syndromes. J Orthop Trauma 1992;6:223-228.
Myerson MS: Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248.
Ziv I, Mosheiff R, Zeligowski A, Liebergal M, Lowe J, Segal D: Crush injuries of the foot with compartment syndrome: Immediate one-stage management. Foot Ankle 1989;9:185-189.

Question 100

Reconstruction of the injured structure is performed. After surgery, the patient initially notes limitation in motion, and later develops recurrent instability of the knee. Which factor most likely contributed to the development of instability?

Explanation

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to 63 the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056. View Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068. View Abstract at PubMed

Full Question & Answer Text (for Search Engines)

Question 1:

- A 14-year-old girl has idiopathic scoliosis with a 52-degree right thoracic curve and a 36-degree left lumbar curve. The rotation of the apical vertebra appears greater in the thoracic curve. A sagittal view radiograph shows the spine to be virtually straight. The iliac apophyses are Risser 2. Treatment should consist of

Options:

Anterior fusion of the lumbar curve
Anterior and posterior fusion of the thoracic curve
Posterior fusion of the thoracic curve
Posterior fusion of the thoracic and lumbar curves
Application of a brace until the iliac apophyses are Risser 4 or 5, followed by surgical correction

Correct Answer: Posterior fusion of the thoracic curve

Explanation:

Question 2:

Options:

activity modification
arthroscopic evaluation of fragment stability.
transarticular drilling of the lesion with 0.045 Kirschner wire.
arthroscopic excision of the fragment and microfracture of underlying cancellous bone.
excision of the fragment and mosaicplasty.

Correct Answer: activity modification

Explanation:

This skeletally immature patient has a small OCD lesion that appears stable, and he has not undergone any treatment. Therefore, a trial of activity modification and limited weight bearing until pain resolves is the best initial choice.
Cessation of sport activities for 4 to 6 months may allow healing of the lesion. Surgical treatment of juvenile OCD lesions is reserved for unstable lesions, patients
who have not shown radiographic evidence of healing and are still symptomatic after
6 months of nonsurgical management, or patients who are approaching skeletal maturity. Good results with stable in situ lesions that have failed to respond to nonsurgical management have been reported with both transarticular and retroarticular drilling. Results after excision alone are poor at 5-year follow-up, and it is unclear if microfracture will improve the long-term outcome. Mosaicplasty may be the next best option for patients who remain or become symptomatic after excision of the fragment and microfracture.
Wall et al. reviewed juvenile OCD. They state that JOCD has better potential for healing than adult OCD, but several series have shown up to a 50% failure to heal with nonsurgical techniques. The presence of a loose body is an indication for surgical fixation, drilling or regenerative procedures, depending on the presence/extent of subchondral bone sclerosis and the surgeon's experience.
Figure A and B are coronal MRI images showing a stable appearing JOCD lesion of the medial femoral condyle.
Incorrect
in the first
(SBQ13PE.9) A 6-year-old boy complains of a 'clunking' sensation in his left knee. He has no associated pain and denies trauma. He can elicit the sensation when moving his knee from flexion into full extension. He is otherwise healthy, with no birth or developmental issues. On examination, there is a palpable clunk felt over the anterior knee through range of motion. There is no obvious instability or tenderness and he had normal patellar tracking. An AP radiograph of the knee is shown in Figure A. What would be the most likely diagnosis?
Review
Topic
Agenesis of the anterior cruciate ligament
Thickened medial plica
Grade IV chondral flap
Pigmented villonodular synovitis
Abnormal meniscal morphology
This child presents with an asymptomatic click in the knee. It is associated with widening of the lateral joint space of the knee on X-ray. These features are highly suggestive of a discoid lateral meniscus in this age category.
The principal diagnostic feature of a discoid meniscus is the complaint of snapping or clicking in the knee. Children are usually asymptomatic. Although, less frequently, children may present with pain that is largely secondary to an underlying meniscal tear. MRI scans of the knee have show to have the greatest sensitivity for identifying discoid menisci. The presence of a contiguous central meniscus on three consecutive slices is usually indicative of the diagnosis. Treatment is mostly focused on conservative modalities. Surgical intervention is reserved for symptomatic cases with recurrent locking, swelling or persistent pain is present in older children.
Kramer et al. looked at the presentation of pediatric knee pain. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the discoid meniscus.
Figure A shows an AP radiograph of a pediatric knee. There is an increased lateral joint space suggestive of a discoid meniscus.
Illustrations A-C show an MRI of the knee with 3 consecutive coronal cuts showing an abnormal appearing discoid meniscus.
Incorrect Answers:

Question 3:

A 56-year-old woman sustained the fracture shown in Figures 30a and 30b in a motor vehicle accident. What mechanism is most likely responsible for the injury?

Options:

Flexion distraction
Vertical shear
Extension distraction
Flexion compression
Axial load

Correct Answer: Axial load

Explanation:

DISCUSSION: The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.
REFERENCES: Theiss SM: Thoracolumbar and lumbar spine trauma, in Stannard JP, Schmidt AH, Kregor PJ (eds): Surgical Treatment of Orthopaedic Trauma. New York, NY, Thieme, 2007, pp 179-207.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 201-216.

Question 4:

Options:

Internal iliac
External iliac
Pudendal
Superior rectal
Superior gluteal

Correct Answer: Superior gluteal

Explanation:

Question 5:

Options:

CT scan with 3D reconstructions
Ultrasonography
MRI scan
Fluoroscopically-guided arthrogram

Correct Answer: CT scan with 3D reconstructions

Explanation:

Question 6:

Options:

Open treatment of the metatarsal malunion
Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis
Cast application and an external bone stimulator
Hallux valgus correction
Hallux metatarsophalangeal arthrodesis

Correct Answer: Open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis

Explanation:

Question 7:

Options:

Reamed intramedullary nail
Unreamed intramedullary nail
Percutaneous plate fixation
Skeletal traction
External fixation

Correct Answer: External fixation

Explanation:

Question 8:

Figures 15a through 15d

Options:

T-type fracture
Anterior column fracture
Anterior wall fracture
Posterior wall fracture
Posterior column and posterior wall fracture
Transverse with posterior wall fracture

Correct Answer: T-type fracture

Explanation:

DISCUSSION
Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis (anteroposterior [AP], iliac oblique, obturator oblique, inlet, and outlet views). These views will show fractures of the acetabulum and help to evaluate for pelvic fractures and hip joint integrity. The obturator oblique view is taken with the injured side rotated 45 degrees forward with the beam centered on the patient’s affected hip. This shows the anterior column and posterior wall and will reveal if any posterior subluxation of the hip is present. The iliac oblique view is taken with the injured side of the patient rolled 45 degrees forward with the beam centered on the affected hip. This shows the posterior column and the anterior wall. Inlet and outlet pelvic radiographs may depict pelvic injuries such as sacroiliac joint fracture or widening.
Judet and Letournel have a classification system for acetabular fractures. The system consists of 5 elementary fracture patterns: anterior wall, anterior column, posterior wall, and posterior column fractures of the acetabulum and a transverse pattern. There are also 5 associated fracture patterns: posterior column/posterior wall, transverse/posterior wall, T-type, anterior column with hemitransverse fracture of the posterior column, and both-column fractures.
Figure 12b shows a fracture of the posterior column on the Iliac oblique, and Figure 12c shows a fracture of the posterior wall in the obturator oblique.
In Question 13, the figures only reveal a fracture of the posterior wall, and this is best appreciated in Figure 13c, the obturator oblique view.
The T-type fracture is a transverse fracture with a secondary fracture line extending inferiorly. This causes the anterior and posterior columns to be separated. The iliac oblique view, Figure 14b, shows a fracture extending through the posterior column. In the obturator oblique view (Figure 14c), the yellow arrow shows a fracture extending through the anterior column, and the red arrow shows a fracture extending inferiorly through the ischium.
Fractures extending through the anterior and posterior columns are seen, which represent a transverse fracture, but there is no extension inferiorly, which eliminates T-type as a possible correct response. The anterior column fracture is best seen on the inlet view (Figure 15b), but it also can be seen in Figure 15d, the obturator oblique view. Figure 15c shows the fracture through the posterior column. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).
RECOMMENDED READINGS
Dickson KF, Dowling RM. Treatment of pelvic and acetabular fractures in elderly patients. Orthopaedic Knowledge Online Journal. Volume 11, Number 8 August 2013.
Tornetta P 3rd. Displaced acetabular fractures: indications for operative and nonoperative management. J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28. Review. PubMed PMID: 11174160.
View Abstract
at PubMed
Moed BR, Kregor PJ, Reilly MC, Stover MD, Vrahas MS. Current management of posterior wall fractures of the acetabulum. Instr Course Lect. 2015;64:139-59. Review. PubMed PMID: 25745901.
View Abstract at PubMed

Question 9:

Options:

Basilar invagination of less than 1 cm
Anterior atlanto-dens interval of 4 mm
Posterior atlanto-dens interval of greater than 14 mm
Rotatory subluxation of less than 10 degrees
Subaxial subluxation of less than 3.5 mm

Correct Answer: Posterior atlanto-dens interval of greater than 14 mm

Explanation:

DISCUSSION: Boden and associates’ article presents compelling evidence that patients with rheumatoid arthritis and neurologic deterioration in C1-2 instability are more likely to achieve some improvement if the posterior atlanto-dens interval is greater than 10 mm on preoperative studies. All the patients in their series who had neurologic deterioration and a preoperative posterior atlanto-dens interval of greater than 14 mm achieved complete motor recovery.
REFERENCES: Boden SD, Dodge LD, Bohlman HH, et al: Rheumatoid arthritis of the cervical spine: A long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg Am 1993;75:1282-1297.
Boden SD, Clark CR: Rheumatoid arthritis of the cervical spine, in Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott Raven, 1998, pp 755-764.
Monsey RD: Rheumatoid arthritis of the cervical spine. J Am Acad Orthop Surg 1997;5:240-248.

Question 10:

What is the best initial screening test for a patient with a limb-length discrepancy?

Options:

CT scanography
Orthoroentgenography (scanography)
Measurement from the anterior superior iliac spine to the malleolus with a tape measure
With the patient standing, placement of blocks under the short leg to level the pelvis, followed by measurement of the blocks
Galeazzi test

Correct Answer: With the patient standing, placement of blocks under the short leg to level the pelvis, followed by measurement of the blocks

Explanation:

Question 11:

Options:

Closed reduction and above-elbow cast immobilization in supination
Closed reduction and joint spanning external fixation
Closed reduction and percutaneous pinning followed by cast immobilization
Open reduction through a dorsal approach and fixation with an angular stable plate
Open reduction through a volar approach and stabilization with a buttress plate

Correct Answer: Open reduction through a volar approach and stabilization with a buttress plate

Explanation:

Question 12:

Options:

radiation therapy.
bisphosphonate therapy.
antitubercular therapy.
parathyroidectomy.
a diet low in phosphate.

Correct Answer: radiation therapy.

Explanation:

Question 13:

Figure 28 shows an arthroscopic view of a right shoulder in the lateral position through a posterior portal. What is the area between structure B (biceps) and SS (subscapularis tendon)? Review Topic

Options:

Inferior glenohumeral ligament
Superior glenohumeral ligament
Rotator cuff interval
Subscapularis recess
Interior recess

Correct Answer: Rotator cuff interval

Explanation:

Question 14:

Options:

fragmentation, realignment, and intramedullary nailing of the tibia.
resection of the dysplastic region of the tibia and insertion of a vascularized fibula.
supplemental vitamin D and phosphate.
a clamshell orthosis.
observation for spontaneous remodeling.

Correct Answer: a clamshell orthosis.

Explanation:

Question 15:

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

Options:

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

Correct Answer: acromioclavicular joint reduction and stabilization.

Explanation:

Question 16:

A coronal MRI scan through the shoulder joint is shown in Figure 26. The cyst indicated by the arrow will most likely cause compression of what nerve?

Options:

Subscapular
Suprascapular
Axillary
Musculocutaneous
Medial pectoral

Correct Answer: Suprascapular

Explanation:

Question 17:

Plate fixation without bone grafting

Options:

The majority of stress fractures are treated with rest and protected weight-bearing. When the patient rests, strain on the affected bone is reduced and formation exceeds resorption, leading to bone healing.
Electrical stimulation and ultrasound have not been shown to increase the rate of healing. For most stress fractures, surgery is not necessary.

Correct Answer: The majority of stress fractures are treated with rest and protected weight-bearing. When the patient rests, strain on the affected bone is reduced and formation exceeds resorption, leading to bone healing.

Explanation:

(3787) Q2-7569:
Which of the following stress fractures most often requires internal fixation:

Question 18:

A patient with a documented allergy to nickel requires a total knee arthroplasty. Which of the following prostheses is most likely to provide long-term success in this individual?

Options:

All-polyethylene tibial component and pure titanium femoral component
All-polyethylene tibial component and cobalt-chromium alloy femoral component
Cobalt-chromium alloy tibial component and cobalt-chromium alloy femoral component
Modular titanium tibial component and pure titanium femoral component
Modular titanium tibial component and oxidized zirconium femoral component

Correct Answer: Modular titanium tibial component and oxidized zirconium femoral component

Explanation:

DISCUSSION: Nickel allergy is not an infrequent preoperative finding. The ramifications of such allergies in arthroplasty patients are poorly understood at this time. Stainless steel and cobalt-chromium alloys contain relatively high concentrations of nickel. Titanium, oxidized zirconium, and polyethylene do not contain significant amounts of nickel. Titanium is not a good surface for the articulating portion of the femoral component because of its propensity for metallosis. Oxidized zirconium is the only suitable femoral component for patients allergic to nickel. A modular titanium tibial component or an all-polyethylene tibial component would be satisfactory for these patients.
REFERENCES: Laskin RS: An oxidized Zr ceramic surfaced femoral component for total knee arthroplasty. Clin Orthop 2003;416:191-196.
Nasser S, Campbell PA, Kilgus D, et al: Cementless total joint arthroplasty prostheses with titanium-alloy articular surfaces: A human retrieval analysis. Clin Orthop 1990;261:171-185.

Question 19:

Options:

Relatively young, active patient
Patient with an inflammatory systemic disorder
Elderly patient with a sedentary lifestyle
Patient with severe arthritis of the ipsilateral hip or knee
Patient with Parkinson’s disease

Correct Answer: Elderly patient with a sedentary lifestyle

Explanation:

DISCUSSION: Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.
REFERENCES: Chao W, Wapner KL, Lee TH, et al: Nonoperative management of posterior tibial tendon dysfunction. Foot Ankle Int 1996;17:736-741.
Noll KH: The use of orthotic devices in adult acquired flatfoot deformity. Foot Ankle Clin 2001;6:25-36.

Question 20:

Options:

Patellar clunk syndrome
Flexion gap instability
Polyethylene wear
Femoral component malrotation

Correct Answer: Patellar clunk syndrome

Explanation:

Question 21:

Options:

Closed reduction and percutaneous pinning
Open reduction and internal fixation
Rotator cuff repair with possible latissimus dorsi tendon transfer
Shoulder arthroplasty
Open bone grafting

Correct Answer: Closed reduction and percutaneous pinning

Explanation:

Question 22:

Options:

Axillary nerve dysesthesia
Axillary nerve motor partial paralysis
Suprascapular nerve neurapraxia
Musculocutaneous nerve neurapraxia
Radial nerve sensory dysesthesia

Correct Answer: Axillary nerve dysesthesia

Explanation:

Question 23:

Options:

oral antibiotics and a follow-up office appointment the next day.
incision and drainage of the distal fibular metaphysis.
indium-labeled WBC scan.
antituberculous medication for 6 months.
three-phase technetium Tc 99m bone scan.

Correct Answer: incision and drainage of the distal fibular metaphysis.

Explanation:

DISCUSSION: The initial signs and symptoms of acute hematogenous osteomyelitis vary widely but usually include fever, bone pain, and impaired use of the involved extremity. In lower extremity infections, the child may limp or refuse to walk. Examination often reveals bone tenderness. In more advanced cases, erythema, warmth, and swelling may be present. The WBC and neutrophil counts are not always elevated, but the erythocyte sedimentation rate will be abnormal in more than 90% of patients. When the infection is diagnosed early, before a subperiosteal abscess has formed, antibiotics alone may be adequate to treat the infection. This patient has a more advanced infection, however, with the MRI scan revealing a subperiosteal abscess that was confirmed by aspiration. When an abscess is present, surgical drainage is generally indicated to remove devitalized tissue and to enhance the efficacy of the antibiotics. Further studies, such as bone or indium scans, are not necessary and will delay
definitive treatment.
REFERENCES: Scott RJ, Christofersen MR, Robertson WW Jr, et al: Acute osteomyelitis in children: A review of 116 cases. J Pediatr Orthop 1990;10:649-652.
Vaughan PA, Newman NM, Rosman MA: Acute hematogenous osteomyelitis. J Pediatr Orthop 1987;7:652-655.

Question 24:

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

Options:

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

Correct Answer: Open reduction and internal fixation

Explanation:

Question 25:

What type of brace is shown in Figures 22a and 22b?

Options:

Charcot restraining orthotic walker (CROW)
University of California Biomechanics Laboratory (UCBL) orthosis
Double upright ankle-foot orthosis
Chopart’s prosthesis
Below-knee prosthesis

Correct Answer: Charcot restraining orthotic walker (CROW)

Explanation:

Question 26:

Which of the following is not a reported mode of failure for a constrained acetabular component?

Options:

Loosening of the acetabular component
Disengagement of the constraining ring (with or without redislocation)
Increased abrasive (polyethylene) wear
Dissociation of the femoral head from the neck
Dissociation of the polyethylene liner from the acetabular shell

Correct Answer: Increased abrasive (polyethylene) wear

Explanation:

Question 27:

Options:

Convert to skeletal leg traction
Radiograph/CT scan hip
MRI scan hip
Frog leg lateral hip radiograph
Oncology consultation

Correct Answer: Convert to skeletal leg traction

Explanation:

Question 28:

Options:

Technetium Tc 99m bone scan
Intravenous antibiotics
Oral antibiotics
CT of the hips
Aspiration of the left hip

Correct Answer: Technetium Tc 99m bone scan

Explanation:

Examination reveals an irritable hip, creating a differential diagnosis of transient synovitis versus pyogenic hip arthritis. Kocher and associates described four criteria to help predict the presence of infection: inability to bear weight, fever, ESR of more than 40 mm/h, and a peripheral WBC count of more than 12,000/mmP3P. This patient meets three of the four criteria, with a positive predictive value of 73% to 93% for joint infection. Therefore, aspiration of the hip is warranted, with a high likelihood that emergent hip arthrotomy will be indicated. Ideally, intravenous antibiotics should be administered after culture material has been obtained from needle aspiration of the hip. An urgent bone scan is better indicated as a screening test for sacroiliitis or diskitis. If the arthrocentesis proves negative, CT or MRI of the pelvis may be indicated to rule out a pelvic or psoas abscess.
(SBQ13PE.16) A 4-week-old infant who had been born with a dislocated hip has been treated in a Pavlik Harness since 1 week of age. Parents have been compliant with the prescribed bracing protocol, and no complications or neurologic abnormalities have been noted. The hip remains Ortolani positive. Figure A shows the ultrasound image obtained in the office. What is the next best step in management?
Review
Topic
No further treatment
Continue Pavlik Harness treatment
Convert to semi-rigid abduction brace
Perform a hip arthrogram with closed vs. open reduction under general anesthesia
Perform a pelvic osteotomy
This is a 4 week old infant with DDH who has failed Pavlik harness treatment for 3 weeks. Figure A is an ultrasound image demonstrating a dislocated hip.
Initial treatment for an infant with a dislocated, but reducible ("Ortolani positive") hip is bracing in a Pavlik Harness. The Pavlik harness is a dynamic brace that requires normal muscle function and tone to help keep the hip in a reduced position. If this treatment fails to hold the hip reduced after three weeks of treatment, the harness should be discontinued to prevent "Pavlik Harness Disease" which involves erosion of the posterior acetabulum as the femoral head is inappropriately being held against it.
After failure of Pavlik harness treatment, if the hip remains subluxated, the next step in treatment is to convert to a semi-rigid orthosis of another 2-3 weeks. If the semi-rigid brace likewise fails to keep the hip reduced, then hip arthrogram with closed vs. open reduction and spica-cast placement can be planned.
Swaroop and Mubarak present a study using a protocol of initial pavlik harness treatment with weekly ultrasound assessment for 3 weeks. If the hip remained unstable but reducible, then semi-rigid abduction bracing with continues weekly ultrasounds were done for an additional 2-3 weeks. This treatment protocol had a 93% success rate, which compared favorably to protocols not including the abduction
brace.
Hedequist et al. presented a review of 15 patients treated similarly with intial pavlik harness treatment for 3-4 weeks, and then abduction bracing if the remained unstable but reducible. They found that abduction bracing produced a stable hip within 1-2 months.
Illustration A shows a baby wearing a semi-rigid orthosis. Illustration B is the hip ultrasound image from Figure A with labels added. Illustration C is an ultrasound of a hip that is not dislocated.
Incorrect answers:

Question 29:

Options:

a hard-soled shoe for 4 to 6 weeks.
closed reduction and percutaneous pinning.
burning a hole in the nail for relief of the impending hematoma.
digital block and irrigation and debridement of the wound.
repair of the extensor hallucis longus tendon injury and use of a hard-soled shoe.

Correct Answer: digital block and irrigation and debridement of the wound.

Explanation:

DISCUSSION: Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of
the fracture.
REFERENCES: Noonan KJ, Saltzman CL, Dietz FR: Open physeal fractures of the distal phalanx of the great toe: A case report. J Bone Joint Surg Am 1994;76:122-125.
Banks AS, Cain TD, Ruch JA: Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.

Question 30:

Options:

Immediate MRI of the lumbar spine and possible acute surgical intervention
General reassurance, anti-inflammatory medications, and an early home exercise program
Radiographs of the lumbar spine and pain medications with 2 days of bed rest
Caudal epidural steroid injection with follow-up in 1 week
Outpatient MRI of the lumbar spine with follow-up in 1 week

Correct Answer: Immediate MRI of the lumbar spine and possible acute surgical intervention

Explanation:

Question 31:

A 39-year-old man presents with back pain radiating to the left lower extremity for the past 6 weeks. Magnetic resonance images of the pathology are

Options:

Pain/parasthesias near the medial malleolus due to impingement of L4 nerve root
Pain/parasthesias near the medial malleolus due to impingement of L3 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L4 nerve root
Pain/parasthesias near the medial epicondyle of femur due to impingement of L3 nerve root
Intermittent claudication due to impingement on segmental vessel

Correct Answer: Intermittent claudication due to impingement on segmental vessel

Explanation:

Question 32:

Options:

Renal osteodystrophy
Pyogenic osteomyelitis
Osteoarthritis
Osteonecrosis
Tuberculosis osteomyelitis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: The photomicrograph demonstrates a wedge-shaped infarct with femoral head collapse; therefore, the diagnosis is osteonecrosis of the femoral head. Perthes disease and osteoarthritis do not involve a wedge-shaped defect. Tuberculosis of the hip joint results in greater destruction of the articular cartilage.
REFERENCES: Basset LW, Mirra JM, Cracchiolo A III: Ischemic necrosis of the femoral head: Correlation between magnetic resonance imaging and histologic sections. Clin Orthop 1987;223:181-187.
Sugano N: Osteonecrosis, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopedics. St Louis, MO, Mosby, 2002, pp 878-887.

Question 33:

Options:

Moist dressings and continued observation
Debridement of the necrotic tissue
Amputation at the metatarsophalangeal level with open wound management
Closed forefoot amputation
Guillotine transtibial amputation

Correct Answer: Moist dressings and continued observation

Explanation:

DISCUSSION: The patient has no clinical or observed signs of sepsis. The skin just proximal to the gangrenous tissue appears somewhat hyperemic and is clearly viable. These wounds should be managed much like burn wounds. Moist dressings should be used until the tissue clearly demarcates. Much of the insult may simply be superficial and only require late debridement.
REFERENCES: McAdams TR, Swenson DR, Miller RA: Frostbite: An orthopedic perspective.
Am J Orthop 1999;28:21-26.
Taylor MS: Cold weather injuries during peacetime military training. Milit Med 1992;157:602-604.

Question 34:

What is the primary mechanism of degradation of calcium phosphate cement?

Options:

- Macrophage-mediated degradation
- Osteoclast-mediated degradation
- Giant-cell-mediated degradation
- Dissolution by interstitial fluid

Correct Answer: - Osteoclast-mediated degradation

Explanation:

Question 35:

Options:

Gender
Age
Sport
Bone loss DISCUSSION… Nonsurgical treatment for a first-time traumatic dislocation may not be effective in a young, athletic patient; moreover, a Bankart lesion may be present in 70% of all traumatic subluxations. A period of immobilization in external rotation may decrease the risk for recurrence, but only if the patient is placed in a brace immediately and complies with the treatment. Return to play may be possible after 2 weeks of immobilization, provided the patient undergoes appropriate range of motion, cuff strengthening, and scapular stabilization exercises. Among athletes in 1 study, 80% were able to finish the season, but 40% experienced episodes of subluxation or recurrent dislocation prior to the end of the season. The rate of recurrence after arthroscopic stabilization should be lower than 10% and may be equivalent to open repair for most patients. Bone loss remains the primary indication for open procedures, as coracoid transfers or other bone-grafting operations may be needed to reconstruct the glenoid if more than 20% of its surface area is missing. Furthermore, collision athletes may fare better with open surgery than arthroscopic options. Bone loss remains the most significant factor for recurrence across many studies. Glenoid bone loss may be present in 20% of primary dislocations and 70% of recurrent dislocations. Age younger than 30 has a high correlation with recurrence. Although men may be almost twice as likely as women to have a recurrent dislocation, age seems to be the most reliable patient-related risk factor for recurrence. Thermal capsulorrhaphy has not proven to be effective and carries a high risk for complication. More recent studies have found equal recurrence rates between open and arthroscopic Bankart repair, with a greater loss of motion in patients who underwent open repair. Longitudinal studies have demonstrated that 40% to 50% are likely to develop arthritis after a shoulder dislocation; however, recurrent dislocation seems to be the most important factor for early development of arthritis, while age younger than 25 may be protective. Postcapsulorrhaphy arthropathy may be more associated with open repairs or those that severely limit external rotation.

Correct Answer: Age

Question 36:

A 55-year-old man sustained an elbow dislocation in a fall. Postreduction radiographs are shown in Figures 40a and 40b. What is the best course of management?

Options:

Closed reduction and casting for 4 weeks
Closed reduction and bracing with immediate range of motion
Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head
Open reduction, radial head silastic arthroplasty, and lateral collateral ligament repair
Open reduction, lateral collateral ligament repair, and radial head excision

Correct Answer: Open reduction, lateral collateral ligament repair, and open reduction and internal fixation or metallic replacement of the radial head

Explanation:

DISCUSSION: The radiographs show an elbow dislocation associated with a comminuted radial head fracture. In the setting of comminution and instability, factures of the radial head are best managed with an arthroplasty rather than open reduction and internal fixation. Resection of the radial head will worsen the instability and is not recommended. Silastic radial head replacements are contraindicated.
REFERENCES: Hildebrand KA, Patterson SD, King GJ: Acute elbow dislocations: Simple and complex. Orthop Clin North Am 1999;30:63-79.
O’Driscoll SW, Jupiter JB, King GJ, et al: The unstable elbow. Instr Course Lect
2001;50:89-102.

Question 37:

Options:

Completion of the surgical procedure with continued monitoring
Reversal of the corrective maneuver and consideration of a wake-up test
Administration of high dose corticosteroids intraoperatively
Removal of all instrumentation
Discontinue monitoring

Correct Answer: Reversal of the corrective maneuver and consideration of a wake-up test

Explanation:

Question 38:

Options:

recruitment in the extensor pollicis longus, abductor pollicis longus, extensor digitorum communis, and extensor carpi ulnaris muscles. Which nerve is most likely compressed?
Median
Radial
Anterior interosseous
Posterior interosseous
Lateral antebrachial cutaneous

Correct Answer: Anterior interosseous

Question 39:

Options:

Observation
Application of Pavlik harness
Closed reduction and hip spica casting
Open hip capsulorrhaphy +/- femoral osteotomy +/- pelvic osteotomy
Open hip capsulorrhaphy, adductor and hamstring tenotomy, gastrocnemius recession +/- pelvic osteotomy

Correct Answer: Application of Pavlik harness

Explanation:

Question 40:

What is the most common complication associated with scalene regional anesthesia for shoulder procedures?

Options:

Cardiovascular collapse
Block failure
Seizure secondary to intravascular injection
Phrenic nerve injury
Laryngeal nerve injury

Correct Answer: Block failure

Explanation:

Question 41:

Options:

Risser 0
Risser I
Risser II
Risser III
Risser IV

Correct Answer: Risser 0

Explanation:

Question 42:

Figure 11 shows the radiograph of an otherwise healthy 22-year-old man who sustained a midfoot injury in a motor vehicle accident 9 days ago. Treatment should consist of

Options:

open reduction and internal fixation.
a short leg weight-bearing cast.
a short leg non-weight-bearing cast.
first tarsometatarsal fusion.
functional brace application and early range of motion.

Correct Answer: open reduction and internal fixation.

Explanation:

DISCUSSION: The dislocation is between the medial and middle cuneiform. Although the first and second tarsometatarsal joints are aligned, there is a gap between the cuneiforms. The radiograph shows a Lisfranc dislocation variant. In a healthy active individual, open reduction and internal fixation yields the best results. The reestablishment of the normal arch and medial column support with anatomic reduction is critical to obtaining the best possible outcome from these injuries.
REFERENCES: Teng AL, Pinzur MS, Lomasney L, et al: Functional outcome following anatomic restoration of the tarsal-metatarsal fracture dislocation. Foot Ankle Int
2002;23:922-926.
Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am 2000;82:1609-1618.

Question 43:

Options:

MRI scan
Diagnostic arthroscopy
Surgical repair of a ruptured quadriceps tendon
Knee immobilizer for 6 weeks, followed by a sport brace
Limited weight bearing for 3 weeks, followed by physical therapy

Correct Answer: Surgical repair of a ruptured quadriceps tendon

Explanation:

Question 44:

Options:

Inlet view helps best guide superior-inferior orientation
AP pelvis best guides anterior-posterior screw orientation
AP pelvis best guides superior-inferior screw orientation
Outlet view best guides anterior-posterior screw orientation
Outlet view best guides superior-inferior screw orientation

Correct Answer: Inlet view helps best guide superior-inferior orientation

Explanation:

Question 45:

Options:

IV antibiotics
Oral antibiotics
Ibuprofen
Observation and repeat evaluation in 2 weeks
Aspiration of the right hip

Correct Answer: Aspiration of the right hip

Explanation:

Question 46:

Which of the following best describes the recommended treatment for a 13-year-old pitcher with a painful chronic stress injury to the proximal humeral physis as confirmed on an MRI scan? Review Topic

Options:

Brief shoulder immobilization followed by avoidance of pitching and throwing for the remainder of the season
Brief shoulder immobilization followed by avoidance of pitching and throwing until skeletal maturity
In situ screw fixation of the proximal humeral growth plate
Arthroscopic shoulder debridement
Arthroscopic repair of the Bankart lesion

Correct Answer: Brief shoulder immobilization followed by avoidance of pitching and throwing for the remainder of the season

Explanation:

Question 47:

Figure 1 is the ultrasound of a 23-year-old patient who has had a volar radial 1.5-cm tender and painful wrist mass for 6 months. The additional workup prior to surgery should consist of

Options:

serum and urine protein electrophoresis.
a chest CT scan.
MRI with intravenous contrast.
age-appropriate presurgical laboratory studies.

Correct Answer: age-appropriate presurgical laboratory studies.

Explanation:

Question 48:

Which of the following mechanisms of inhibition has been linked to cigarette smoking and lumbar spinal fusion?

Options:

Diminished revascularization of cancellous bone graft
Increased activity of osteoblasts
Increased activity of osteocytes
Antibody-induced necrosis
Inhibition of prostaglandins

Correct Answer: Diminished revascularization of cancellous bone graft

Explanation:

DISCUSSION: Cigarette smoking has been directly linked to pseudarthrosis in spinal fusions. The direct mechanism of action is diminished revascularization of cancellous bone graft. Additionally, a smaller area of revascularization is seen in these grafts, as well as an increased area of necrosis. Increased activity of osteoblasts would result in more bone production. Increased activity of osteocytes would not affect the fusion because osteocytes are mature bone cells.
REFERENCE: Daftari TK, Whitesides TE Jr, Heller JG, et al: Nicotine on the revascularization of bone graft: An experimental study in rabbits. Spine 1994;19:904-911.

Question 49:

Options:

neutral rotation.
full pronation.
full supination.
full extension.
full flexion.

Correct Answer: full supination.

Explanation:

Question 50:

Options:

Metastatic renal cell carcinoma
Metastatic adenocarcinoma
Chordoma
Osteoblastoma
Chondrosarcoma

Correct Answer: Chordoma

Explanation:

Question 51:

Options:

Ceramic-on-ceramic
Ceramic-on-highly cross-linked polyethylene (HXPE)
Metal-on-HXPE
Metal-on-metal

Correct Answer: Metal-on-metal

Explanation:

Question 52:

- The primary effect of deep freezing on musculoskeletal allografts is a reduction of

Options:

Strength
Stiffness
Shelf life
Antigenicity
Risk of HIV transmission

Correct Answer: Antigenicity

Explanation:

Question 53:

Options:

Transoral, transmucosal direct anterior approach to C2-3
Left-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided posterior retropharyngeal approach to C2-3 (Whitesides)
Right-sided anterior approach to C2-3 (Smith-Robinson)
Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Correct Answer: Right-sided anterior retropharyngeal approach with extended vertical incision (superior extension Smith-Robinson)

Explanation:

Question 54:

Options:

tendon repair, and thenar flap coverage.
full-thickness skin graft.
reversed cross-finger flap from the ring finger.
cross-finger flap coverage from the ring finger.

Correct Answer: reversed cross-finger flap from the ring finger.

Explanation:

Question 55:

Options:

The posterior bundle demonstrates the greatest change in tension from flexion to extension.
The posterior bundle is isometric.
The anterior bundle becomes tight in flexion and lax in extension.
The anterior and posterior bundles are isometric.

Correct Answer: The posterior bundle demonstrates the greatest change in tension from flexion to extension.

Explanation:

Question 56:

Options:

O'Brien's test
Speed's test
Jerk test
Neer impingement test
Apprehension test

Correct Answer: Jerk test

Explanation:

Question 57:

Options:

Achilles rupture
Gastrocnemius strain
Calcaneal apophysitis
Os trigonum syndrome DISCUSSION-Calcaneal apophysitis (Sever disease) is a common cause of heel pain in adolescent athletes who participate in running or jumping sports. The condition occurs primarily before or during peak growth and is characterized by a tight Achilles tendon, a positive squeeze test, and tenderness over the calcaneal apophysis. Pain is localized to the heel and exacerbated by running. Os trigonum syndrome involves posterior ankle impingement and is commonly associated with ballet dancers. Gastrocnemius strain typically causes pain more proximally at the myotendinous junction. The Thompson test is performed with the patient lying prone on the examination table. Absence of ankle plantar flexion when the examiner squeezes the calf constitutes a positive test and is indicative of Achilles rupture.

Correct Answer: Calcaneal apophysitis

Explanation:

CLINICAL SITUATION FOR QUESTIONS 60 AND 61
A 15-year-old boy has had shoulder pain for 4 weeks during the middle of baseball season. The patient says his pain is “all over my shoulder.” Examination reveals tenderness to palpation over the anterolateral aspect of the shoulder. Internal and external rotation range of motion is restricted.
Radiographs show metaphyseal sclerosis.

Question 58:

Options:

Irrigation and debridement of the cystic lesion and 6 weeks of IV antibiotics
Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics
Complete resection of the infected portion of bone, placement of an external fixator to stabilize the tibia, and 6 weeks of IV antibiotics
Amputation
Local debridement of bone and the overlying skin and soft tissues, 6 weeks of IV antibiotics, and free-flap wound coverage

Correct Answer: Curettage, debridement of nonviable bone, and placement of absorbable antibiotic beads, followed by a course of IV antibiotics from 1 to 4 weeks and a 6-week course of oral antibiotics

Explanation:

Question 59:

Options:

Loose body
Discoid lateral meniscus
Transverse meniscal ligament
Displaced lateral meniscus tear
Displaced medial meniscus tear

Correct Answer: Discoid lateral meniscus

Explanation:

Question 60:

Which of the following infectious organisms may be associated with underlying malignancy?

Options:

Acinetobacter species
Clostridium septicum
Peptostreptococcus
Proteus mirabilis
Pseudomonas mendocina

Correct Answer: Clostridium septicum

Explanation:

Question 61:

Options:

Subacromial corticosteroid injection
Use of a sling until the pain resolves
Posterior capsular stretching
Arthroscopic SLAP repair
Arthroscopic anterior-inferior capsulolabral plication with posterior capsular release

Correct Answer: Posterior capsular stretching

Explanation:

Question 62:

An eversion mechanism of injury is associated with which of the following ankle conditions?

Options:

Peroneal tendon splits
Osteochondral talar dome fracture
Superficial peroneal nerve palsy
Anterolateral soft-tissue impingement
Fracture of the anterior colliculus

Correct Answer: Fracture of the anterior colliculus

Explanation:

Question 63:

Options:

Continued observation
Cervical epidural injections
Nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy
Cervical facet blocks
Cervical MRI

Correct Answer: Nonsteroidal anti-inflammatory drugs (NSAIDs), activity modification, and physical therapy

Explanation:

Question 64:

Options:

Subacromial corticosteroid injection
Aspiration of the subacromial and glenohumeral joint spaces
Nonsteroidal anti-inflammatory drugs
Extensive surgical debridement
Diagnostic arthroscopy

Correct Answer: Aspiration of the subacromial and glenohumeral joint spaces

Explanation:

Question 65:

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 66:

Options:

Humeral head erosion
Glenoid erosion
Rotator cuff integrity
Status of the coracoacromial ligament
Acromioclavicular arthritis

Correct Answer: Rotator cuff integrity

Explanation:

Question 67:

Options:

Distal femoral pin and 90-90 traction for 3 weeks, followed by a spica cast
Closed reduction and stabilization with an external fixator
Closed reduction and stabilization with an interlocking nail
Closed reduction and stabilization with multiple flexible intramedullary nails
Open reduction and stabilization with a plate and screws

Correct Answer: Closed reduction and stabilization with multiple flexible intramedullary nails

Explanation:

Question 68:

Which of the following statements best describes the process of articular cartilage degeneration in osteoarthritis?

Options:

In the second stage there is decreased catabolic activity with less matrix breakdown.
In the second stage there is less chondrocyte proliferation and decreased matrix production.
Matrix degradation includes increased proteoglycan production, more proteoglycan
production, and longer glycosaminoglycan chains.
Cartilage degeneration may be initiated by inflammation, overload, or decreased matrix production.
Chondrocyte repair responses improve with aging.

Correct Answer: production, and longer glycosaminoglycan chains.

Explanation:

Question 69:

As reflected by the SF-36 scores, patients with which of the following conditions demonstrate the most disability in physical function?

Options:

AIDS
Polytrauma
Pelvic fracture
Pilon fracture
Acute myocardial infarction (AMI)

Correct Answer: Pilon fracture

Explanation:

DISCUSSION: Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health).
REFERENCE: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Question 70:

A 24-year-old dancer sustains the injury shown in Figure 28. Management should consist of

Options:

closed reduction and application of a well-molded cast.
open reduction and percutaneous pin fixation.
open reduction and internal fixation with a mini fragment plate and screws.
intramedullary screw fixation.
brief immobilization and symptomatic treatment.

Correct Answer: brief immobilization and symptomatic treatment.

Explanation:

Question 71:

Options:

Radiographs, including anterior, lateral, and oblique views
MRI of the lumbar spine and follow-up at the clinic in 1 week
Caudal epidural steroid injection
Reassurance, limited analgesics, and early range of motion as tolerated
Immediate MRI of the lumbar spine and possible urgent surgical decompression

Correct Answer: Reassurance, limited analgesics, and early range of motion as tolerated

Explanation:

DISCUSSION: In general, a previously healthy patient with an acute onset of nontraumatic lower back pain does not need diagnostic imaging before proceeding with therapeutic treatment. In the absence of any “red flags” during the history and physical examination, such as trauma or constitutional symptoms (ie, fevers, chills, weight loss), the appropriate treatment for acute onset lower back pain is purely symptomatic treatment including limited analgesics and early range of motion. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful and symptoms are prolonged. Miller and associates suggested that the use of radiographs can lead to better patient satisfaction but not necessarily better outcomes.
REFERENCES: Miller P, Kendrick D, Bentley E, et al: Cost effectiveness of lumbar spine radiographs in primary care patients with low back pain. Spine 2002;27:2291-2297.
Wong DA, Transfeldt E: Macnab’s Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins 2007, pp 298-338.

Question 72:

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 73:

A 31-year-old male sustains an ipsilateral displaced transverse acetabular fracture, pubic rami fractures, and a sacroiliac joint dislocation. What structure should be reduced and stabilized first?

Options:

Pubic rami
Posterior column
Anterior column
Sacroiliac joint
Quadrilateral plate

Correct Answer: Pubic rami

Explanation:

Question 74:

A patient has a C6 spinal cord injury. Following stabilization of the spine, the patient should be advised that their expected maximum level of function

Options:

An electric wheelchair with puffer control
An electric wheelchair with hand controls
A manual wheelchair and sliding board transfers
A manual wheelchair and independent transfers
Crutches with long leg braces for short distance ambulation

Correct Answer: A manual wheelchair and sliding board transfers

Explanation:

Question 75:

Options:

Type 2 tear of the superior labrum anterior and posterior
Tear of the anterior labrum
Tear of the subscapularis tendon
Tear of the latissimus dorsi tendon
Tear of the supraspinatus tendon

Correct Answer: Tear of the latissimus dorsi tendon

Explanation:

DISCUSSION: Injury to the latissimus dorsi tendon recently has been reported as a cause of pain in the thrower’s shoulder. The etiology of this injury is felt to be eccentric overload during the follow-through of the throwing motion. Recommended management for this unusual injury consists of a short period of rest, followed by physical therapy to restore shoulder motion and strength. Throwing is allowed when the athlete demonstrates full, pain-free motion and good strength and balance of the rotator cuff and scapular rotator muscles. Currently there are no defined indications for surgical repair.
REFERENCES: Schickendantz MS, Ho CP, Keppler L, et al: MR imaging of the thrower’s shoulder: Internal impingement, latissimus dorsi/subscapularis strains and related injuries.
Magn Reson Imaging Clin N Am 1999;7:39-49.
Livesey JP, Brownson P, Wallace WA: Traumatic latissimus dorsi: Tendon rupture. J Shoulder Elbow Surg 2002;11:642-644.

Question 76:

Options:

Surgical traction for 6 weeks followed by application of a cast brace
Application of a femoral cable plate
Femoral revision with a cemented long stem prosthesis
Application of cerclage wired double allograft femoral struts
Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Correct Answer: Femoral revision with a cementless long taper fluted modular stem and proximal allograft strut supplementation

Explanation:

Question 77:

Options:

A diminished immune response to transplanted chondrocytes is seen in Technique C because the dense cartilage matrix acts as a barrier that limits antigen exposure.
In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch.
Grafts in Technique C are transferred to an antibiotic solution to kill microorganisms and stored at 4°C until use.
A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C.
Technique C is a 2-stage procedure. Technique B is a single-stage procedure.

Correct Answer: In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch.

Explanation:

Question 78:

Options:

The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type I collagen.
The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type II collagen.
The transplanted chondrocytes are nonviable and cartilage is used as a scaffold for growth of new articular cartilage. Biopsy shows type II collagen.
The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows type I collagen.
The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Biopsy shows mixture of type I and II collagen.

Correct Answer: The transplanted chondrocytes are viable and articular cartilage heals. Biopsy shows type I collagen.

Explanation:

Question 79:

Options:

Arthroscopic capsular plication
Arthroscopic thermal shift
Arthroscopic subacromial decompression
Posterior capsular stretching
Selective external rotation stretching

Correct Answer: Posterior capsular stretching

Explanation:

Question 80:

The essential lesion in recurrent or posterior instability following simple dislocation of the elbow typically involves which of the following structures?

Options:

Medial collateral ligament
Lateral ulnar collateral ligament
Coracohumeral ligament
Anterior joint capsule
Posterior joint capsule

Correct Answer: Lateral ulnar collateral ligament

Explanation:

Question 81:

Options:

normal reflexes in the upper extremities and hyperreflexia in the lower extremities.
hyperreflexia in the upper extremities and normal reflexes in the lower extremities.
hyperreflexia in the upper extremities and hyporeflexia in the lower extremities.
hyperreflexia in the upper and lower extremities.
hyporeflexia in the upper and lower extremities.

Correct Answer: normal reflexes in the upper extremities and hyperreflexia in the lower extremities.

Explanation:

Question 82:

Options:

observation.
steroid injection.
curettage and bone grafting.
wide resection with neoadjuvant chemotherapy.
debridement, irrigation, and intravenous antibiotics.

Correct Answer: curettage and bone grafting.

Explanation:

Question 83:

Options:

Osteochondroma
Osteoblastoma
Osteomyelitis
Heterotopic ossification
Parosteal osteosarcoma

Correct Answer: Heterotopic ossification

Explanation:

Question 84:

Which sterilization method is expected to produce the most degradation of an allograft used for anterior cruciate ligament reconstruction?

Options:

Deep freezing
Supercritical CO2 treatment
Gamma irradiation with 1.2 Mrad
Chlorhexidine gluconate 4% cleansing

Correct Answer: Supercritical CO2 treatment

Explanation:

DISCUSSION
A biomechanical study compared unprocessed, irradiated (2.0 Mrad-2.8 Mrad), and supercritical CO2-treated soft-tissue allografts and demonstrated a 27% to 36% decrease in stiffness of the supercritical CO2-treated grafts. No significant difference was found between the irradiated and untreated soft-tissue allografts. Low-dose (1.0 Mrad-1.2 Mrad) gamma irradiation of bone-patellar-tendon-allograft has been shown to produce a 20% decrease in graft stiffness. Deep freezing or cleansing with 4% chlorhexidine gluconate does not appear to adversely affect the biomechanical properties of the allograft tissue.
CLINICAL SITUATION FOR QUESTIONS 43 THROUGH 46
Figures 43a and 43b are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable.

Question 85:

Options:

Stress radiographs
Surgical resection of the fragment with lateral ligament reconstruction
Physical therapy for peroneal strengthening and proprioceptive training
Ankle arthroscopy for debridement

Correct Answer: Physical therapy for peroneal strengthening and proprioceptive training

Explanation:

DISCUSSION
Thousands of ankle sprains occur in the United States every day. Most affected patients do not have serious sequelae associated with their injury. In this case, a young athlete sprained her ankle. Her only area of tenderness is isolated to the anterior talofibular ligament. She also has associated weakness. The radiograph shows an os subfibulare; this is an entity that she likely was born with. There is no indication of bony pain, and it is too soon to test for instability; consequently, no further imaging is required. Considering the nature of the sprain and her weakness, physical therapy with proprioceptive training and peroneal strengthening would be most beneficial.
RECOMMENDED READINGS
Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997 Jan-Feb;25(1):130-7. PubMed PMID: 9006708.
View Abstract at PubMed
McGuine TA, Keene JS. The effect of a balance training program on the risk of ankle sprains in high school athletes. Am J Sports Med. 2006 Jul;34(7):1103-11. Epub 2006 Feb 13. PubMed PMID: 16476915.
View Abstract at PubMed
Chun TH, Park YS, Sung KS. The effect of ossicle resection in the lateral ligament repair for treatment of chronic lateral ankle instability. Foot Ankle Int. 2013 Aug;34(8):1128-33. doi: 10.1177/1071100713481457. Epub 2013 Mar 7. PubMed PMID: 23471672.
View Abstract at
PubMed
CLINICAL SITUATION FOR QUESTIONS 29 THROUGH 33
Figures 29a and 29b are the weight-bearing radiographs of a 49-year-old woman who has had several months of increasing pain and deformity in her left foot. She points to her plantar medial arch as her area of greatest pain; however, she also has pain just distal to the tip of the distal fibula. Her pain worsens with walking or navigating stairs. Upon examination she has a flexible unilateral pes planus deformity with increased heel valgus and forefoot abduction. She is unable to perform a single heel raise.
29A
B

Question 86:

When compared to traditional open repair through a posterior incision, percutaneous Achilles tendon repair clearly results in a reduction of what complication?

Options:

Wound infection
Sural nerve injury
Achilles tendon re-rupture
Weakness
Deep venous thrombosis

Correct Answer: Wound infection

Explanation:

DISCUSSION: Prospective studies, including randomized and randomized multicenter reports, have shown that percutaneous or mini-open acute Achilles tendon repair has comparable functional results when compared to traditional open techniques. Calder and Saxby reported one superficial infection out of 46 patients with a mini-open repair; Assal and associates and Cretnik and associates had no wound complications or infections. The other complications have not proved to be less likely with the mini-open or percutaneous technique.
REFERENCES: Assal M, Jung M, Stern R, et al: Limited open repair of Achilles tendon ruptures:
A technique with a new instrument and findings of a prospective multicenter study. J Bone Joint Surg Am 2002;84:161-170.
Calder JD, Saxby TS: Early, active rehabilitation following mini-open repair of Achilles tendon rupture: A prospective study. Br J Sports Med 2005;39:857-859.
Cretnik A, Kosanovic M, Smrkolj V: Percutaneus versus open repair of the ruptured Achilles tendon: A comparative study. Am J Sports Med 2005;33:1369-1379.

Question 87:

An axial T 1 -weighted MRI scan of the pelvis is shown in Figure 13. The arrow is pointing to what muscle?

Options:

Adductor magnus
Pectineus
Obturator externus
Obturator internus
Levator ani

Correct Answer: Obturator internus

Explanation:

DISCUSSION: The obturator internus muscle originates from the internal pelvic wall and passes laterally through the lesser sciatic foramen, banking around the ischium below the sacrospinous ligament before inserting on the medial aspect of the greater trochanter.
REFERENCES: Higuchi T: Normal anatomy and magnetic resonance appearance of the pelvis, in Takahashi HE, Morita T, Hotta T, Ogose A (eds): Operative Treatment of Pelvic Tumors. Tokyo, Japan, Springer-Verlag, 2003, pp 4-21.
Berquist TH: Pelvis, hips and thigh, in Berquist TH (ed): MRI of the Musculoskeletal System,
ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2001, pp 210-238.

Question 88:

Options:

biceps subluxation.
glenoid rim fracture.
subscapularis detachment.
loose body.
deficient anterior capsule.

Correct Answer: deficient anterior capsule.

Explanation:

Question 89:

.A patient is unable to actively externally rotate the shoulder when the arm is placed into 90 degrees of abduction and neutral rotation. This finding is most consistent with a tear of the

Options:

biceps tendon.
isolated subscapularis.
isolated supraspinatus.
superior and anterior labrum.
infraspinatus and teres minor.

Correct Answer: infraspinatus and teres minor.

Question 90:

Options:

Biceps tenotomy
Loose body removal
Latissimus dorsi transfer
Reverse total shoulder arthroplasty

Correct Answer: Biceps tenotomy

Explanation:

Question 91:

Patients with rheumatoid arthritis may exhibit an increase in viral load for which of the following viruses?

Options:

Human immunodeficiency virus (HIV)
Papilloma virus
Epstein-Barr virus (EBV)
Hepatitis C virus (HCV)
Hepatitis B virus( HBV)

Correct Answer: Epstein-Barr virus (EBV)

Explanation:

Question 92:

A 12-year-old girl has the painful foot deformity seen in Figure 79. You advise her that she has juvenile bunions. How do they differ from adult bunions?

Options:

Metatarsus primus varus
Large exostosis
Rigidity of the metatarsal phalangeal joint
Greater hallux valgus angle than in adult bunions
Prominent bursal thickening over the medial eminence

Correct Answer: Metatarsus primus varus

Explanation:

Question 93:

When harvesting an iliac crest bone graft from the posterior approach, what anatomic structure is at greatest risk for injury if a Cobb elevator is directed too caudal?

Options:

Sciatic nerve
Cluneal nerves
Inferior gluteal artery
Superior gluteal artery
Sacroiliac joint

Correct Answer: Superior gluteal artery

Explanation:

DISCUSSION: If a Cobb elevator is directed caudally while stripping the periosteum over the iliac wing, it will encounter the sciatic notch. Although this puts the sciatic nerve at risk, the first structure encountered is the superior gluteal artery. Because it is tethered at the superior edge of the notch, it is very vulnerable to injury and can then retract inside the pelvis, making it difficult to obtain hemostasis. The inferior gluteal artery exits the sciatic notch below the piriformis and is more protected. The cluneal nerves are at risk only if the incision extends too anteriorly, and the sacroiliac joint can be entered while harvesting the graft.
REFERENCES: Banwart JC, Asher MA, Hassanein RS: Iliac crest bone graft harvest donor site morbidity: A statistical evaluation. Spine 1995;20:1055-1060.
Shin AY, Moran ME, Wenger DR: Superior gluteal artery injury secondary to posterior iliac crest bone graft harvesting: A surgical technique to control hemorrhage. Spine 1996;21:1371-1374.

Question 94:

Options:

25 mg of indomethacin 3 times daily for 6 weeks
1 dose of irradiation at 800 Gy
Surgical excision of heterotypic ossification (HO)
Reevaluation in 6 months

Correct Answer: Reevaluation in 6 months

Explanation:

Question 95:

Options:

Radial collateral ligament
Posterior bundle of the ulnar collateral ligament
Anterior bundle of the ulnar collateral ligament
Flexor carpi ulnaris
Pronation teres

Correct Answer: Anterior bundle of the ulnar collateral ligament

Explanation:

DISCUSSION: The anterior bundle of the ulnar collateral ligament of the elbow is the primary constraint to valgus force of the elbow. In pitchers and in overhead athletes, injury to this portion of the ligament results in valgus instability. Reconstruction of the anterior band of the ulnar collateral ligament is necessary in many elite athletic throwers to allow them to return to this competitive activity.
REFERENCES: Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28:16-23.
Cain EL, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 2003;31:621-635.
Rettig AC, Sherrill C, Snead DS, et al: Nonoperative treatment of ulnar collateral ligament injuries in
throwing athletes. Am J Sports Med 2001 ;29:15-17.
/
Figure 55a Question 55
A 22-year-old male basketball player has had knee pain for the past 3 months. He denies any history of trauma. He has symptoms of catching but no locking. He has rested for 2 weeks but symptoms returned when he resumed sporting activities. T
r
and T
2
-weighted MRI scans are shown in Figures 55a and 55b. What is the most likely diagnosis?
Locked lateral meniscus tear
Anterior cruciate ligament tear
Ganglion cyst of the anterior cruciate ligament
Synovial osteochondromatosis
Pigmented villonodular synovitis PREFERRED RESPONSE: 3
DISCUSSION: The MRI scans show a cystic structure within the anterior cruciate ligament. It is fluid filled as seen on the T
2
sequence. Ganglion cysts of the cruciate ligaments are rare. The most common presentation is pain with occasional loss of motion. Instability is not a chief complaint and often there is no evidence of laxity on examination. If nonsurgical management fails, arthroscopic debridement of the cyst is the accepted method of treatment.
REFERENCES: Liu SH, Osti L, Mirzayan R: Ganglion cysts of the anterior cruciate ligament: A case report and review of the literature. Arthroscopy 1994; 10:110-112.
Parish EN, Dixon P, Cross MJ: Ganglion cysts of the anterior cruciate ligament: A series of 15 cases. Arthroscopy 2005;21:445-447.

Question 96:

Which lower extremity muscle is first weakened in Charcot-Marie-Tooth (CMT) disease?

Options:

Peroneus brevis
Peroneus longus
Foot intrinsics
Tibialis anterior

Correct Answer: Foot intrinsics

Explanation:

DISCUSSION
Although many of the lower extremity muscles may be affected in CMT, those innervated by the longest axons have been shown to be affected first. In the lower extremity the muscles innervated by the longest axons are the intrinsic foot muscles. The tibialis anterior and the peroneus brevis may be severely affected but not before the foot intrinsics. The peroneus longus typically is spared, resulting in the cavus.
RECOMMENDED READINGS
Pareyson D, Marchesi C. Diagnosis, natural history, and management of Charcot-Marie-Tooth disease. Lancet Neurol. 2009 Jul;8(7):654-67. Review. PubMed PMID: 19539237.
View
Abstract at PubMed
Wenz W, Dreher T. Charcot-Marie-Tooth disease and the cavovarus foot. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:291-306.
CLINICAL SITUATION FOR QUESTIONS 60 THROUGH 63
Figure 60 is the standing radiograph of a 27-year-old man who played football throughout his teen years. During those years, he noted that he had less mobility of his left foot and ankle. He twisted his left foot and ankle 8 months ago and has tried over-the-counter nonsteroidal anti-inflammatory drugs and a brace. He now has pain and edema in the left sinus tarsi area. Upon examination the following arcs of motion are identified: ankle dorsiflexion-right, 5 degrees/left, 5 degrees; ankle plantar flexion-right, 30 degrees/left 30 degrees; foot inversion-right, 10 degrees/left, 5 degrees; foot eversion-right, 10 degrees/left 5 degrees.

Question 97:

A favorable outcome following nonsurgical management of a partial tear of the posterior cruciate ligament (PCL) is best associated with

Options:

hamstring strength.
quadriceps strength.
a body mass index of less than 30.
anterior cruciate ligament stability.
compliance with brace use.

Correct Answer: quadriceps strength.

Explanation:

Question 98:

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

Options:

closed reduction of the ulna and transcapitellar pinning of the radial head.
closed reduction of the ulna and radial head dislocation.
closed reduction of the ulna and annular ligament repair.
open reduction of the radius and plating of the ulna.
open reduction of the ulna and immobilization in an extension cast.

Correct Answer: closed reduction of the ulna and radial head dislocation.

Explanation:

Question 99:

Options:

immediate transmetatarsal amputation.
immediate below-knee amputation.
application of a splint and observation.
fasciotomy and fracture fixation.
fasciotomy without fracture fixation.

Correct Answer: fasciotomy and fracture fixation.

Explanation:

Question 100:

Options:

Inadequate graft strength
Failure to restore graft length
Malposition of the femoral tunnel
Malposition of the tibial tunnel

Correct Answer: Malposition of the femoral tunnel

Explanation:

DISCUSSION
The anteromedial bundle originates on the anterior and proximal aspect of the lateral femoral condyle and inserts on the anteromedial aspect of the anterior cruciate ligament (ACL) footprint on the proximal tibia. The posterolateral bundle originates posterior and distal to
63
the anteromedial bundle and inserts on the posterolateral aspect of the tibial footprint. The fibers are parallel when the knee is in an extended position. As the knee moves into flexion,
the fibers of the anteromedial bundle rotate externally with respect to the posterolateral bundle. The anteromedial bundle is tensioned in both flexion and extension. The posteromedial bundle is tensioned in extension, but relaxes as the knee moves into flexion.
The lateral meniscus is more commonly injured with an acute injury to the ACL. The medial meniscus is injured more commonly when the ACL is chronically unstable.
The ACL is an intra-articular and intrasynovial structure. It is innervated by posterior articular branches from the tibial nerve. Innervation of the ACL involves several types of mechanoreceptors (Ruffini, Pacini, Golgi tendon, and free-nerve endings) that may contribute to proprioceptive function of the knee and modulation of quadriceps function.
Injury to the ACL is predominantly associated with instability to anterior translation of the tibia in extension. The ACL plays a secondary role to limit internal rotation of the tibia, and a loss of ACL stability is confirmed by the reduction of the tibia from a position of anterior translation and internal rotation (pivot shift). The radiographs demonstrate anterior placement of the femoral tunnel. The convex shape of the lateral femoral condyle can make it more difficult to visualize the anatomic femoral origin of the ACL. Failure to identify the
anatomic footprint can result in anterior placement of the femoral tunnel. Anterior ACL graft placement can result in its impingement against the posterior cruciate ligament and early limitation of knee flexion. Over time, impingement on the graft may result in stretching of the graft and recurrent knee instability symptoms.
RECOMMENDED READINGS
Duthon VB, Barea C, Abrassart S, Fasel JH, Fritschy D, Ménétrey J. Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2006 Mar;14(3):204-13. Epub 2005 Oct 19. Review. PubMed PMID: 16235056.
View
Abstract at PubMed
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. Review. PubMed PMID: 16897068.
View Abstract at PubMed

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

Orthopedic Board Review MCQs: Spine, Trauma, Shoulder & Knee | Part 162

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 162

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index