OITE & ABOS Orthopedic Board Prep: Trauma & Elbow MCQs

About This Board Review Set

This is Part 166 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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Two distinct learning modes are available:

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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 166

This module focuses heavily on: Ankle, Elbow, Foot, Fracture, Tendon, Trauma.

Sample Questions from This Set

Sample Question 1: A patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the si...

Sample Question 2: Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?...

Sample Question 3: A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of...

Sample Question 4: A 14-year-old boy reports pain in the distal thigh. He denies any history of trauma. Examination reveals tenderness and swelling of the distal thigh without effusion. A radiograph and CT scan are shown in Figures 10a and 10b. A biopsy speci...

Sample Question 5: Communication breakdown is the leading cause of which of the following?...

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 patient underwent an open reduction and internal fixation of a calcaneus fracture 6 months ago via an extensile lateral approach. He now reports burning pain on the lateral side of his ankle and foot. A local cortisone injection at the site of the tenderness, about 7 cm above the lateral heel, provided temporary relief of the pain. What is the recommended course of management for the persistent burning pain?

Explanation

The patient has a sural nerve neuroma, which is a known complication of the extensile lateral approach. Of the available choices, excision and burial of the sural nerve in muscle or vein is the best choice because it gives better pain relief due to the better blood supply in muscle than bone. Recent authors advocate burying the nerve in vein as the best option. Neuroplasty is a possibility (but not of the superficial peroneal nerve), but the sural nerve is usually very sensitive and often pain relief with a release is incomplete. Additionally, implant removal is not indicated because of the patient's complaints; also, the implants should not be removed at 6 months. A subtalar fusion is the choice for posttraumatic arthritis from the calcaneus fracture. Electromyography/nerve conduction velocity studies are reasonable choices if there was an indication the pain could be coming from the back or there was no clear evidence of a sural nerve neuroma.

Question 2

Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?

Explanation

DISCUSSION: The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.
REFERENCE: Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Question 3

A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of

Explanation

DISCUSSION: Open reduction and internal fixation of distal humeral fractures in elderly patients often fails. These fractures characteristically have a very small distal segment and poor bone quality, resulting in failure of fixation and nonunion. Nonunion is often painful and functionally debilitating. Total elbow arthroplasty provides good results when used for distal humeral fractures in elderly patients with osteopenic bone and fracture patterns thought to be irreconstructable. Long arm casting may result in union, but the resulting stiffness is unacceptable for an active patient. Elbow arthrodesis has few indications. A sling and range-of-motion exercises will often result in a painful and debilitating nonunion at the fracture site.
REFERENCES: Frankle MA, Herscovici D Jr, DiPasquale TG, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intra-articular distal humerus fractures in women older than 65. J Orthop Trauma 2003;17:473-480.
Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humerus fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832.
Obremskey WT, Bhandari M, Dirschl DR, et al: Internal fixation versus arthroplasty of comminuted fractures of the distal humerus. J Orthop Trauma 2003;17:463-465.

Question 4

A 14-year-old boy reports pain in the distal thigh. He denies any history of trauma. Examination reveals tenderness and swelling of the distal thigh without effusion. A radiograph and CT scan are shown in Figures 10a and 10b. A biopsy specimen is shown in Figure 10c. Management should consist of

Explanation

DISCUSSION: Based on these findings, the patient has an aneurysmal bone cyst. Frequently, fluid-fluid levels can be detected on MRI or CT images. The histologic results show a lesion that consists of cavernous spaces filled with blood. The lining of the cavity contains spindle cells, multinucleated giant cells, and reactive bone. Curettage and bone grafting is the preferred treatment method. Without treatment, these lesions can become quite large and destructive. Radiation therapy is not recommended for resectable lesions. Chemotherapy is not required for these benign lesions.
REFERENCES: Simon MA, Springfield DS, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 194-200.
Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, p 232.

Question 5

Communication breakdown is the leading cause of which of the following?

Explanation

Communication failures are the leading cause of wrong side surgeries, medication errors and diagnostic delays.
Poor communication sets up environments in which medical errors can take place. Per the Joint Commission, medical errors may be the among the top 10 causes of death in the United States. Establishing open lines of communication is critical to reduce the risk of error and enhance patient safety.
Gandhi et al. designed a framework to study missed or delayed diagnoses and their causes. The most significant factors contributing to errors were poor handoffs, failures in judgment, failures in memory and failures in knowledge.
O’Daniel et al. review the importance of professional communication and collaborative team efforts. They note that patient safety is at risk when poor communication is in place. The leading cause for medication errors, treatment delays and wrong-site surgeries is communication failure.
Illustration A shows the leading causes of death in the United States. This includes “preventable errors” as a cause.
Incorrect Answers:

Question 6

A 40-year-old man who is an avid weight lifter has had chronic pain in the proximal anterior shoulder for the past year. He denies any history of trauma. Examination reveals tenderness at the intertubercular groove, a positive speed test, and a positive Neer impingement sign. Nonsurgical management has failed to provide relief, and he is now considering surgery. Arthroscopic findings in the glenohumeral joint are shown in Figure 31. Based on these findings, treatment should consist of

Explanation

DISCUSSION: The arthroscopic image shows a tear through more than 50% of the biceps tendon; therefore, treatment should consist of tenodesis or tenotomy of the tendon. However, because this patient is relatively young and active, the treatment of choice is tenodesis of the biceps tendon.
REFERENCES: Sethi N, Wright R, Yamaguchi K: Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8:644-654.
Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-310.
Burkhead WZ, Arcand MA, Zeman C, et al: The biceps tendon, in Rockwood CA, Matsen FA, Wirth MA, et al (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1996.

Question 7

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 8

Figure 53 shows a thoracolumbar specimen as viewed from posterior to anterior following removal of all posterior elements. Which of the following structures does the red string pass under?

Explanation

DISCUSSION: The string passes under the ligamentum flavum as it runs from the posterior aspect of the vertebra above to the inferior aspect of the vertebra below in the sagittal midline. This is an important structure in diskectomy and in posterior approaches to the thoracolumbar spine and neural elements. It is rarely visualized in its entirety because typical exposures provide only a limited view.
REFERENCE: Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, vol 2, p 1465.

Question 9

A 19-year-old football player who sustained three traumatic anterior shoulder dislocations underwent surgery to repair a Bankart lesion. Nine months after surgery, examination reveals stability, elevation to 150 degrees, external rotation to 0 degrees with the elbow at his side and to 50 degrees at 90 degrees of abduction, and internal rotation to T12. If his range of motion does not improve, he is at most risk for

Explanation

DISCUSSION: Loss of external rotation can lead to degenerative joint disease following an anterior stabilization procedure. A tight anterior capsule will prevent internal impingement. Risk of thoracic outlet syndrome should not be increased. Subscapularis detachment is a risk following open anterior repair; however, a gain in external rotation would be noted. In time, this patient’s shoulder may show increased posterior glenohumeral wear but should not have symptoms of recurrent subluxation unless multidirectional instability is present.
REFERENCES: Hawkins RJ, Angelo RL: Glenohumeral osteoarthrosis: A late complication of the Putti-Platt repair. J Bone Joint Surg Am 1990;72:1193-1197.
Norns TR: Complications following anterior instability repairs, in Bigliani LU (ed): Complication of Shoulder Surgery. Baltimore, MD, Williams and Wilkins, 1993, pp 98-116.

Question 10

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

Explanation

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

Question 11

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Explanation

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 12

A 16-year-old boy falls while playing soccer. He reports that his knee buckled when he planted his leg to kick a ball. He noticed an obvious deformity of his knee, which spontaneously resolved with a “clunk.” He could not finish the game but was able to bear weight with a limp. He has had two similar episodes but has never sought medical attention. An initial examination demonstrated an effusion, tenderness at the proximal medial collateral region and medial patellofemoral retinaculum, decreased range of motion, and patella apprehension. A lateral patellar glide performed at 30° of flexion was 3+. He was otherwise ligamentously stable, and there were no other noteworthy findings.Figures 3 and 4 are this patient's proton density fat-saturated MR images. His tibial tubercle-trochlear groove (TT-TG) distance is 12 mm, and he has normal limb-alignment film findings. Treatment at this stage should include

Explanation

This patient’s examination and history indicate recurrent patellar dislocations. Radiographs show an osseous or osteochondral loose fragment. There is no evidence of an obvious nondisplaced fracture or physeal changes. In the setting of suspected patella dislocation or subluxation with loose fragment seen on radiograph, an MRI is indicated. Lateral release alone is seldom indicated in a knee that is normal before injury. The examination and MRI do not indicate a need for medial collateral ligament repair.
Treatment should consist of arthroscopy or arthrotomy and attempted internal fixation of this fragment. If fixation is not possible, the loose body can be removed. Normal TT-TG values, an increased lateral patellar glide, and a history of recurrent patellar dislocations after trauma suggest MPFL incompetence and the need for reconstruction.

Question 13

A 63-year-old male, with history of myocardial infarction, presents with buttock and leg pain. He states the pain is worse when climbing stairs, and is absent when walking down a hill. He reports when walking on a flat surface the pain begins after roughly 50 meters, but if he stops walking and remains standing upright, the pain resolves after a few minutes. He denies any leg pain when sitting and driving a car. These symptoms are most consistent with: Review Topic

Explanation

This clinical presentation is most consistent with vascular claudication.
Vascular claudication refers to the pain, aching or fatigue of the muscles of the buttocks, thigh and/or calf that occurs with exertion, and is related to a failure to meet muscular oxygen requirements, usually caused by peripheral vascular disease impeding blood flow to the peripheral muscles.
Neurogenic claudication is the classic symptom caused by lumbar spinal stenosis. Neurogenic claudication classically presents with bilateral buttock pain with upright activities, but seems to improve by postural changes that flex the lumbar spine. These posture changes are thought to increase the cross sectional area of the central canal, which relieves pressure on the affected area.
Issack et al. reviewed degenerative lumbar spinal stenosis. They state that patients with vascular claudication will have similar symptoms of leg cramping, whether ambulating or riding a stationary bicycle. In comparison, patients with neurogenic
claudication have diminished symptoms of claudication while positioned seated.
Young et al. reviewed the use of lumbar epidural/transforaminal steroids for managing spinal disease. They report that two thirds of acute low back pain episodes resolve within 7 weeks, so the utility and practice patterns regarding the timing and number of epidural/transforaminal steroid injections is usually based on expert opinion, rather than high level research evidence.
Illustration A shows an angiogram of a patients with normal (left) vs abnormal (right) arterial vasculature. Illustration B shows the typical MRI of a patient with spinal stenosis.
Incorrect

Question 14

A 12-year-old boy has had left thigh pain for the past 4 months. Examination shows lack of internal rotation and abduction, and external rotation with hip flexion. A radiograph is shown in Figure 87. What is the most appropriate treatment? Review Topic

Explanation

The patient has a stable slipped capital femoral epiphysis (SCFE). Preferred treatment of stable SCFE is in situ pinning. In situ fixation of stable SCFE has an extremely low rate of osteonecrosis. Gentle postural reduction with hip capsulotomy or surgical dislocation of the hip with reduction has been advocated for unstable SCFE.

Question 15

Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.

Explanation

DISCUSSION
Figure 26 shows lucent areas of both femoral condyles. This may represent a variation of ossification, in which case this boy’s knee pain is coincidental. Another possibility is atypical osteochondritis dissecans. An MRI will distinguish between the 2 entities and will guide treatment.
Figures 27a and 27b show healing rib and distal tibia fractures. These fractures likely are attributable to child abuse. A plain radiographic skeletal survey is sufficient for orthopaedic needs.
A triplane fracture of the distal tibia is revealed in Figure 28. A CT scan will quantify displacement and identify fracture fragments for planning of screw trajectories if open reduction and internal fixation is indicated (displacement > 2 mm).
In Figure 29, the linear lucency of the capitellum indicates an early osteochondritis dissecans. An MRI will allow staging of the lesion.
Figure 30 shows that the left radius and ulna do not align with the humerus; this is the likely result of a transphyseal fracture of the distal humerus. An arthrogram will outline the unossified distal humerus and allow for reduction. For an unstable neonate, this likely can be performed in the NICU.
Figures 31a and 31b reveal a widely displaced lateral condyle fracture for which open reduction and internal fixation is required. No advanced imaging is necessary.

Question 16

Which of the following complications may occur subsequent to resurfacing hip arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?

Explanation

DISCUSSION: Advocates of resurfacing hip arthroplasty cite preservation of the proximal femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture of the retained femoral neck has been reported following resurfacing arthroplasty. The exact etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure, may result in femoral neck fracture.
REFERENCES: Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head osteonecrosis. J Arthroplasty 2003;18:96-99.
Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am 2004;86:1874-1877.

Question 17

Which of the following methods of treatment of a displaced Lisfranc fracture-dislocation will most reliably lead to good functional results?

Explanation

It is recommended that If ligament injury is documented in the presence or absence of fracture, open reduction and internal fixation should be performed. According to gossans and De Stoop, who studied 20 patients with Lisfranc injuries, 5 of 7 had a poor outcome with plaster immobilization, 1 out of 2 had a poor outcome with reduction and plaster, and 7 out of I 1 had a good result with ORIF. 2 of these had a poor result, and 2 had injuries severe enough to result in amputation due to Clostridium infection secondary to open fractures.

Question 18

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

Explanation

DISCUSSION: The patient is at risk for a pelvic vascular injury and major hemorrhage. This type of complication of pelvic trauma is highest in motorcyclists. Once it is recognized that the pelvic ring has opened, it is important to close that ring to tamponade any venous bleeding with a pelvic binder and to add a skeletal traction pin to the limb on the involved side. This will correct any translational displacement. The noninvasive pelvic binders or sheets are easy to apply and are very effective. They do not compromise future care and allow the surgeons access to the abdomen. External fixation or pelvic resuscitation clamps require a certain amount of skill to apply and are not always available. If the pelvic stabilization does not improve the hemodynamic parameters in 10 to 15 minutes, angiography is necessary.
REFERENCE: Mayo K, Kellam JK: Pelvic ring disruptions, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1052-1108.

Question 19

A patient who underwent open reduction and internal fixation of an olecranon fracture 2 months ago now reports painless limitation of motion. Examination reveals a well-healed incision and a flexion-extension arc from 40 degrees to 80 degrees. The patient has been performing home exercises. Radiographs are shown in Figures 26a and 26b. What is the most appropriate treatment?

Explanation

DISCUSSION: The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern.
REFERENCES: Morrey BF: The posttraumatic stiff elbow. Clin Orthop Relat Res

2005;431:26-35.
King GJ, Faber KJ: Posttraumatic elbow stiffness. Orthop Clin North Am 2000;31:129-143.

Question 20

Surgical treatment for this patient should include

Explanation

DISCUSSION

Video 22 for reference
This patient has an unstable cruciate-retaining TKA. The tibial cut appears to be substantial, necessitating a very thick polyethylene liner. In addition, the femoral component may be slightly more proximally located. Tests for flexion-extension gap balancing would indicate flexion instability. However, the possibility of infection remains, so screening blood tests are appropriate. The surgical treatment for this unstable knee is revision TKA to a more constrained implant, ensuring flexion-extension gap balancing. No evidence indicates that the knee is infected. A thicker polyethylene insert will not adequately balance the knee.

Question 21

A 65-year-old woman with type II diabetes mellitus (most recent Hgb A1C was 8.2) has had 3 days of left knee pain. Physical examination of the left knee reveals erythema, warmth and a large effusion. Range of motion is painful and limited to 30 degrees of flexion. She is found to be hypotensive and not responding to volume resuscitation. She requires phenylephrine to maintain Mean Arterial Pressure (MAP) of 70. ESR and CRP are elevated and Lactate is 3.1 mmol/L. What is the next best intervention for this patient’s treatment?

Explanation

Discussion: The patient is demonstrating signs of septic shock. Administration of antibiotics should not be delayed. Aspirating the knee joint and obtaining blood cultures can be rapidly accomplished to obtain accurate specimens. This should be followed immediately by administration of broad spectrum IV antibiotics. Patients with septic shock can be identified with a clinical construct of sepsis with persisting hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥ 65 mmHg and having a serum lactate level > 2mmol/L (18 mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%.

Question 22

Figures 38a and 38b show the AP and lateral radiographs of a 12-year-old baseball pitcher who has pain in his right dominant elbow. Management should consist of

Explanation

DISCUSSION: The patient has a stress fracture of the olecranon; therefore, the most appropriate management is modification of activities below the threshold of symptoms to allow for healing. Ultrasound provides no benefit, and immobilization is not necessary. MRI is not necessary because there is no associated ligamentous injury. Arthroscopy is not indicated.
REFERENCES: Cabanela ME, Morrey BF: Fractures of the olecranon, in Morrey BF (ed): The Elbow and Its Disorders. Philadelphia, PA, WB Saunders, 2000, pp 365-379.
Nuber GW, Diment MT: Olecranon stress fractures in throwers: A report of two cases and a review of the literature. Clin Orthop 1992;278:58-61.

Question 23

Following a fall from a height of 5 feet, a patient reports pain along the lateral border of the foot. The CT scan shown in Figure 54 indicates what pathology?

Explanation

DISCUSSION: The CT scan reveals an avulsion of the dorsal beak of the anterior process of the calcaneus. This common fracture is an avulsion of the origin of the bifurcate ligament, which runs from the anterior calcaneal process to both the cuboid and the lateral aspect of the navicular. An inversion mechanism is common, and the fracture is often missed in evaluation for a suspected ankle sprain. MRI may be useful in the diagnosis of these occult injuries, and suspicion should be present when tenderness exists over the superior portion of the anterior process of the calcaneus.
REFERENCE: Robbins MI, Wilson MG, Sella EJ: MR imaging of anterosuperior calcaneal process fractures. Am J Roentgenol 1999;172:475-479.

Question 24

A 51-year-old woman has had progressively increasing right knee pain for the past 6 months. She has a history of metastatic renal cell carcinoma to the lung and the skeletal system. Radiographs are seen in Figures 18a and 18b. The next step in management of the right distal femur lesion should consist of

Explanation

DISCUSSION: In a patient with known metastatic disease, the surgeon must rule out additional lesions throughout the femur prior to surgical management. Lesions located in the diaphysis or in the peritrochanteric region may influence the surgical procedure.
REFERENCES: Frassica FJ, Gitelis S, Sim FH: Metastatic bone disease: General principles, pathophysiology, evaluation, and biopsy. Instr Course Lect 1992;41:293-300.
Sim FH: Metastatic bone disease of the pelvis and femur. Instr Course Lect 1992;41:317-327.

Question 25

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Explanation

DISCUSSION: Most lesions of eosinophilic granuloma are simply observed, but larger aggressive lesions may require curettage and bone grafting. Frequently, biopsy is required to rule out a malignant diagnosis. The differential diagnosis of eosinophilic granuloma is osteomyelitis, Ewing’s sarcoma of bone, or osteogenic sarcoma. The biopsy alone can be followed by spontaneous resolution. In some patients, low-dose radiation therapy is used. Chemotherapy or amputation is not indicated for these benign lesions.
REFERENCE: Simon M, Springfield D, et al: Common Benign Bone Tumors: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 200.

Question 26

Which characteristic of complex regional pain syndrome (CRPS) type 2 differentiates it from CRPS 1?

Explanation

EXPLANATION:
CRPS 2 develops after nerve injury, whereas CRPS 1 occurs without nerve injury. The diagnostic criteria are otherwise the same for the 2 conditions. A 3-phase bone scan can be helpful; a pattern of increased uptake in all 3 phases, and particularly diffuse periarticular uptake in and around the joints of the affected extremity during the delayed phase, is considered typical of CRPS, especially during the first 6 months; however, it is not specific enough to be used as a diagnostic criteria. Unfortunately, the pathophysiological mechanisms underlying CRPS remain unclear, and, as such, no standard diagnostic test for CRPS exists. There are 3 major sets of diagnostic criteria for CRPS: the International Association for the Study of Pain (IASP) criteria, the Budapest Research Criteria, and the Veldman criteria. According to IASP, CRPS type
1 involves an initiating noxious event or a cause of immobilization; continuing pain/allodynia/hyperalgesia for which the pain is disproportionate to any known inciting event; evidence of edema, changes in skin blood flow, or abnormal pseudomotor activity in the region of pain; and exclusion of the diagnosis by the existence of other conditions that would otherwise account for the degree of pain and dysfunction. CRPS type 2 is a syndrome that develops after nerve injury, contends IASP. Spontaneous pain or allodynia/hyperalgesia occurs and is not necessarily limited to the territory of the injured nerve; there is or has been evidence of edema, a skin blood flow abnormality, or abnormal sudomotor activity in the region of pain since the inciting event; and the diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.

Question 27

What is the most common donor site complication following a free vascularized fibular graft for osteonecrosis of the femoral head?

Explanation

DISCUSSION: Urbaniak and Harvey reported donor site morbidity following free vascularized fibular graft in 198 consecutive patients. At a 5-year follow-up, they reported overall complications in 24% of the patients. The most common complication was a sensory deficit (11.8%), followed by motor weakness (2.7%), flexor hallucis longus contracture (2%), and deep venous thrombosis (less than 1%).
REFERENCE: Urbaniak J, Harvey E: Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 1998;6:44-54.

Question 28

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Explanation

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.
McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 29

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

Explanation

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

Question 30

Figure 33 shows the radiograph of a 28-year-old avid golfer who has chronic right wrist pain. Management should consist of

Explanation

DISCUSSION: The patient’s chronic symptoms are associated with a fracture of the base of the hook of the hamate; therefore, the treatment of choice is simple excision of the fracture fragment, with reasonable expectations of functional return. Acute fractures may be difficult to treat because of the high incidence of nonunion, but once nonunion is discovered, nonsurgical management usually is unsuccessful. Bone grafting may be a surgical alternative, but successful outcomes with percutaneous fixation or trephination of the fibrous union have not been reported.
REFERENCES: Geissler WB: Carpal fractures in athletes. Clin Sports Med 2001;20:167-188.
Rettig ME, Dassa GL, Raskin KB, Melone CP Jr: Wrist fractures in the athlete: Distal radius and carpal fractures. Clin Sports Med 1988;17:469-489.

Question 31

A 15-year-old male jumps off a 6 foot ramp and lands awkwardly. His knee swells up immediately and he is taken to the emergency room. Figures A is a sagittal CT scan image. In the next 3 hours, he complains of increasing leg pain. This is likely because of injury to which of the following structures? Review Topic

Explanation

This child has a tibial tuberosity avulsion fracture with intraarticular extension. There is a risk for anterior compartment syndrome of the leg because of rupture of the anterior tibial recurrent artery located around the lateral border of the tibial tubercle. The vessels retract under the fascia, leading to bleeding into the anterior compartment.
Tibial tubercle fractures usually occur during aggressive quadriceps contraction during sports. The Ogden classification classifies this by site of fracture (Type I, through the tubercle; Type II, at the level of the tibial physis; Type III, extending through the anterior tibial epiphysis). Other complications include extensive soft tissue damage, periosteal stripping, vascular compromise and intra-articular damage.
Pandya et al. reviewed 41 tibial tubercle fractures. They found compartment syndrome or vascular compromise in nearly 10%. They found that the degree of injury was underestimated 50% of the time when classified using lateral radiographs alone. They recommend CT scan or MRI as an adjunct. If intra-articular involvement is seen, arthroscopy or open arthrotomy should be performed.
Pape et al. describe 2 case reports of anterior compartment syndrome after tibial tubercle fracture. The compartment syndrome occurs as a result of proximity of the tibial tubercle physis to the anterior tibial recurrent artery.
Figure A shows the sagittal reconstruction CT image showing intraarticular involvement. Illustrations A and B are axial and coronal CT images in the subchondral region showing the fracture line traversing the zone between fused and unfused physis (see Illustration C for physeal closure pattern). Illustration C shows the direction of closure of the proximal tibial physis. In the sagittal plane, the proximal tibial physis closes from posterior to anterior, then to the tubercle apophysis which closes from proximal to distal also. In the coronal plane, the physis closes from medial to lateral. In the axial plane, the physis closes from posteromedial to anterolateral. Illustration D shows the anterior tibial recurrent artery.
Incorrect Answers:

Question 32

Figure 41a shows the AP radiograph of a 15-year-old boy who reports lateral knee pain. Figures 41b and 41c show a radiograph of the distal femur that was obtained 5 years ago and a current CT scan. The indication for surgery in this patient would be

Explanation

DISCUSSION: In a young person with solitary osteochondroma, the best surgical indication is symptoms that limit activity. A growth deformity is unlikely to occur at this age. Malignant degeneration is exceptionally rare and noted most commonly in adults. Growth is expected until skeletal maturity.
REFERENCES: Mirra JM: Bone Tumors: Clinical, Radiologic, and Pathologic Correlations. Philadelphia, PA, Lea and Febiger, 1989, pp 1626-1659.
Simon MA, Springfield DS, et al: Common Benign Bone Tumors and Usual Treatment: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, pp 181-205.

Question 33

below show the radiographs obtained from a year-old woman who has been experiencing increasing tibial pain 10 years after undergoing revision total knee arthroplasty. No evidence of infection is seen. What is the most appropriate treatment?

Explanation

DISCUSSION:
Stems are available for cemented and press-fit implantation. To be effective, press-fit stems should engage the diaphysis, as shown in Figures 3 and 4. They also assist in obtaining correct limb alignment. Short metaphyseal-engaging stems are associated with failure rates that range between 16% and 29%. Cemented stems may be shorter than press-fit stems, because they do not have to engage the diaphysis. Short, fully cemented stems offer the advantage of metaphyseal fixation. Hybrid stem fixation makes use of the metaphysis for cement fixation with metaphyseal cones or sleeves and diaphyseal-engaging press-fit stems.

Question 34

A 21-year-old female college athlete sustained a stress fracture of the fifth metatarsal 1 year ago which was treated successfully with surgical stabilization and she returned to normal activities. She now has a tension-sided femoral neck fracture. Along with surgical fixation of the fracture, what is the next step in management? Review Topic

Explanation

Stress fractures can be seen in female athletes who develop the female athletic triad including amenorrhea, osteoporosis, and eating disorders. Any female athlete with a history of stress fractures should undergo a workup for this disorder. Workup should include obtaining a menstrual history, obtaining a nutritional consultation, and obtaining a bone density. When properly counseled, these athletes may return to high endurance sports activities. Although these athletes may require a change in training intensity or psychiatric consultation, it would not be the next step in management. Psychiatric consultation may not be necessary unless an eating disorder has been diagnosed. Serum calcium levels are normal in these patients. Tension-sided stress fractures of the femoral neck require surgical stabilization with internal fixation as opposed to compression-sided stress fractures that can be treated with rest and nonsurgical management.

Question 35

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Explanation

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462. View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381. View Abstract t PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303. View Abstract at PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803. View Abstract at PubMed Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228. View Abstract at PubMed

Question 36

What is the most frequent location of entrapment of the deep peroneal nerve?

Explanation

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 37

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

Explanation

DISCUSSION: Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature.
REFERENCES: Bibbo C, Anderson RB, Davis WH, et al: The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: Analysis of 725 procedures in 104 patients. Foot Ankle Int 2003;24:40-44.
Bibbo C, Goldberg JW: Infections and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int

2004;25:331-335.
Sorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg 2003;238:1-5.

Question 38

An elderly woman with radiographic evidence of spinal stenosis reports difficulty walking and calf pain that is relieved by rest and a change of position. The most likely cause of pain is ischemia of the

Explanation

Pain and numbness in the buttock, thigh and legs during walking or prolonged standing in the upright posture-that is relieved by various postures-is caused by spinal stenosis. Neurogenic claudication may result from nerve root ischemia secondary to increased epidural pressure, intermittent compression of nerve roots and venous congestion.

Question 39

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

Explanation

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

Question 40

A 27-year-old man has recurrent anterior shoulder instability following an arthroscopic Bankart repair 4 years ago. Current CT scans are shown in Figures 19a and 19b. Deficiency of what mechanism is most likely to contribute to the current joint instability? Review Topic

Explanation

Loss of the anterior glenoid rim can commonly occur as a result of acute fracture or progressive wear following multiple dislocations. This decreases the effective depth of the glenoid. The ability of the rotator cuff to stabilize the joint through production of a joint reactive force is markedly decreased. Synovial fluid adhesion-cohesion and negative intra-articular pressure are maintained in the closed capsular space. The Hill-Sachs lesion in this case is not large enough to be a significant factor in failed Bankart repair. Poor scapulothoracic rhythm can increase the risk of instability but is not typically the primary factor.

Question 41

A 60-year-old right hand-dominant women fell on her outstretched arm and sustained an anterior shoulder dislocation. The shoulder is reduced in the emergency department and she is seen for follow-up 1 week later wearing a sling. Examination reveals that she has significant difficulty raising her arm in forward elevation and has excessive external rotation compared to the contralateral shoulder. What is the next most appropriate step in management?

Explanation

DISCUSSION: In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography.
REFERENCES: Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.
Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-1311.

Question 42

Figure 94 is an arthroscopic view of the intercondylar notch of a right knee from an anterolateral portal. After injury to the structure as indicated by the asterisks, which examination test most likely will demonstrate an abnormal finding?

Explanation

DISCUSSION
The structure shown is the PL bundle of the anterior cruciate ligament (ACL), which is tight near terminal knee extension. Biomechanical analysis suggests the PL bundle provides a greater degree of rotational stability than the anteromedial bundle. The pivot-shift test evaluates for rotational instability of the ACL, while the Lachman test assesses anterior-posterior stability. The posterior drawer and PL drawer test findings are positive after a posterior cruciate ligament tear and PL corner injury, respectively.
RESPONSES FOR QUESTIONS 95 THROUGH 98
Axillary nerve injury
Musculocutaneous nerve injury
Radial nerve injury
Glenoid fracture
Loss of reduction
Deltoid detachment
Chondrolysis
Recurrent instability
Propionibacterium acnes (P. acnes) infection
Staphylococcus epidermidis
Staphylococcus aureus
Select the complication listed above that is most commonly associated with the shoulder arthroscopy scenarios described below.

Question 43

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. What is the most appropriate treatment?

Explanation

A 20-year-old division 1 collegiate football player presents with an acute left ankle injury. He states that as he was carrying the football, his left foot became trapped under another player while his body was rotated inward, causing a hyperexternal rotation moment to his ankle. He was unable to return to the game secondary to pain and inability to bear weight. Radiographs did not show any fracture. An external rotation stress radiograph is shown in Figure 1. In comparison to screw fixation, suture button fixation of this injury has demonstrated what clinical
outcomes? 16
A. Decreased American Orthopaedic Foot and Ankle Society (AOFAS) scores at 2- year follow-up
B. Slower return to work
C. Increased rate of hardware removal
D. Decreased rate of syndesmotic malreduction
The clinical vignette demonstrates an unstable left ankle syndesmotic injury, also known as a “high ankle sprain”. The distal tibiofibular syndesmosis comprises five structures: the anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, the interosseous membrane, the interosseous ligament, and the inferior transverse ligament.
This injury commonly occurs secondary to a forced external rotation motion of the foot. Stable grade 1 strains without diastasis on stress radiographs can be treated with a period of non-weight bearing followed by physical therapy. Unstable injuries, grade 2 and 3, which demonstrate diastasis on external rotation stress radiographs, are commonly treated operatively. Fixation constructs commonly include screw fixation, suture button fixation, or a hybrid combination technique. Naqvi and associates demonstrated more accurate syndesmotic reduction with suture button fixation versus screw fixation. Syndesmotic malreduction has been shown to be an important independent predictor of decreased clinical outcomes. Andersen and associates demonstrated higher AOFAS scores and diminished syndesmotic widening at radiographic follow-up at 2 years with suture button fixation. In a systematic review, Zhang and associates demonstrated higher AOFAS scores, diminished need for implant removal (3.7% vs 40.2%), diminished implant failure, and lower rates of malreduction (1% vs 12%). Thornes and associates demonstrated a faster return to work following suture button fixation versus screw fixation.
21- A 26-year-old weightlifter has increasing pain in his left shoulder for 4 months. Nonsurgical treatment consisting of anti-inflammatory medication, corticosteroid injections, and rest fails to alleviate his symptoms. He undergoes an arthroscopic distal clavicle resection with excision of the distal 8 mm of clavicle (Mumford procedure). Three months after surgery, he reports mild pain and popping by his clavicle. His clavicle demonstrates mild posterior instability on examination without any obvious deformity on his radiographs. What structures were
compromised during his excision? 17
A. Anterior and superior acromioclavicular joint ligaments
B. Posterior and superior acromioclavicular joint ligaments
C. Conoid ligament
D. Trapezoid ligament
The posterior and superior acromioclavicular ligaments provide the most restraint to posterior translation of the acromioclavicular joint and must be preserved during a Mumford procedure. Anterior and superior acromioclavicular joint ligaments are the opposite of the preferred response and prevent anterior translation of the clavicle. Injuries to the conoid and trapezoid ligaments are more pronounced with grade III or higher acromioclavicular separations, with superior migration of the clavicle relative to the acromion.
22- Figures 1 and 2 are the T2-weighted MRI scans of a 54-year-old woman with medial knee pain and catching of 6 months’ duration. What treatment option is most likely to be associated with a favorable outcome?
A. Physical therapy
B. Meniscal repair
C. Meniscectomy
D. Reconstruction
The MRI scans reveal a posterior horn root tear of the medial meniscus. LaPrade and associates found that outcomes after posterior meniscal root 18
repair significantly improved postoperatively and patient satisfaction was high, regardless of age or meniscal laterality. Patients aged <50 years had outcomes similar to those of patients ≥50 years, as did patients who underwent medial versus lateral root repair. In patients undergoing pullout fixation for posterior medial meniscus root tear, Chung and associates (in “Pullout Fixation of Posterior Medial Meniscus Root Tears”) found that patients with decreased meniscus extrusion at postoperative 1 year have more favorable clinical scores and radiographic findings at midterm follow-up than those with increased extrusion at 1 year. Krych and associates found that nonoperative treatment of medial meniscus posterior horn root tears is associated with poor clinical outcome, worsening arthritis, and a relatively high rate of arthroplasty at 5-year follow-up. Reconstruction would have no role in the setting of a reparable meniscal root tear.
22- A 24-year-old semiprofessional baseball player has noted increasing medial elbow pain for the past 2 months. This has been associated with a concomitant loss in velocity and control. He denies pain, numbness, or tingling in the hand or digits. Examination demonstrates medial elbow tenderness and swelling. Elbow range of motion is full. There is pain with milking maneuver and valgus stress test. Tinel’s sign is negative over the cubital tunnel, and there is no ulnar nerve subluxation. His MRI scan is shown in Figure 1. After thorough discussion, the player elects to undergo surgical intervention. What surgical variable has been associated with inferior outcomes?
A. Use of palmaris autograft
B. Ulnar nerve transposition
C. Muscle-splitting approach
D. Use of a docking technique
The information and image provided describe a throwing athlete with a complete tear of his ulnar collateral ligament (UCL) of the elbow. Numerous techniques have been described for UCL reconstruction, and at this time, optimal graft choice and fixation methods have not been established. Most studies show no.
major differences in outcome between gracilis autograft palmaris autograft, and allograft. Similarly, no clear advantage has been established when comparing use of bone tunnels with interference screws, tunnels with a docking technique, modified docking techniques, and combination

Question 44

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

Explanation

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

Question 45

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Explanation

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.

J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 46

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Explanation

DISCUSSION: The radiographic findings show 30 degrees of talar tilt (severe) and 10 mm of anterior translation that typically involves laxity of both of the major lateral ligaments of the ankle (anterior talofibular and calcaneofibular). There is no evidence of deltoid laxity.
REFERENCES: Harper MC: Stress radiographs in the diagnosis of lateral instability of the ankle and hindfoot. Foot Ankle 1992;13:435-438.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 39-54.

Question 47

An otherwise healthy 25-year-old man sustained a wound with a 1-cm by 1.5-cm soft-tissue loss over the volar aspect of the middle phalanx of his middle finger. After appropriate debridement and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a

Explanation

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger

flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 48

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?

Explanation

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 49

A 35-year-old man sustained a 10% compression fracture of the C5 vertebra in a diving accident. Radiographs show good alignment, and examination reveals no neurologic compromise. An MRI scan reveals no significant soft-tissue disruption posteriorly. Management should consist of

Explanation

DISCUSSION: The patient has a stable flexion-compression injury of the cervical spine. The fracture occurs as a result of compression failure of the vertebral body. If the force continues, a tension failure of the posterior structures occurs, leading to potential dislocation. Immobilization in a rigid cervical orthosis will allow this fracture to heal.
REFERENCES: Clark CR (ed): The Cervical Spine, ed 3. Philadelphia, PA, Lippincott-Raven, 1998, pp 457-464.
Allen GL, Ferguson RL, Lehmann TR, O’Brien RP: A mechanistic classification of closed, indirect fractures and dislocations of the lower cervical spine. Spine 1982;7:1-27.

Question 50

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Explanation

DISCUSSION: This question is a simple review of anatomy and nerve innervation. The L5 root is at risk with an "in-out-in" screw, as described in the question, as the nerve root is just anterior to the sacral ala as it enters the true pelvis. L5 is primarily evaluated by extensor hallucis longus function. L4 is tested with tibialis anterior function and S1 by gastroc-soleus function (ankle plantarflexion).

Question 51

The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?

Explanation

DISCUSSION: The patient has a rim avulsion fracture that is the result of a forceful twisting injury as the superior peroneal retinaculum is avulsed from its fibular attachment along with a small rim of bone. Injuries to the anterior talofibular ligament or calcaneal fibular ligament would show cortical avulsions more anteriorly or distally at the fibular tip. Deltoid ligament injuries would reveal medial radiographic changes. In a true injury to the syndesmosis, if osseous structures do show avulsion, it would be more directly posterior or anterior on the distal fibula or would occur on the tibial surface.
REFERENCES: Murr S: Dislocation of the peroneal tendons with marginal fracture of the lateral malleolus. J Bone Joint Surg Br 1961;43:563-565.
Clanton TO: Athletic injuries to the soft tissues of the foot and ankle, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 1090-1209.

Question 52

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Explanation

DISCUSSION:
Some authors have reported the incidence of lateral femoral cutaneous nerve neuropraxia following hip arthroplasty with the direct anterior approach to be near 80%, but resolution of the sensory deficits has been observed in most patients over time. Femoral nerve palsy has been reported to occur in .64% to 2.3% direct lateral (Hardinge) and anterolateral (Watson-Jones) approaches, and the superior gluteal nerve may be injured with proximal extension of the abductor muscular dissection. The posterior approach has been reported to be associated with sciatic nerve injury, especially in cases of dysplasia. Pudendal nerve injury has not been reported with the anterior, anterolateral, direct lateral, or posterior approaches to hip
arthroplasty. It has been reported following hip arthroscopy and the use of a traction table, however.

Question 53

A 16-year-old girl sustains the closed injury shown in Figure 1. On physical examination, she is found to have a complete radial nerve palsy. Her fracture is treated nonsurgically, and her nerve palsy is followed clinically for improvement. What muscle is most likely to improve last as her nerve recovers?

Explanation

A 35-year-old man reports ulnar sided wrist pain. Radiographs show ulnar positive variance with cystic changes in the ulnar head and lunate. His body mass index (BMI) is 22, and he has had a 1.5-pack-per-day smoking history for the past 10 years. He undergoes an oblique ulnar shortening osteotomy with volar placement of the plate. Nine months after surgery, he reports continued pain, and radiographs reveal a nonunion. Of the factors cited for this patient, which has been shown to most likely increase the risk of nonunion?

Question 54

A surgeon prepares a medial gastrocnemius rotational flap to cover a medial proximal tibia defect at the time of revision knee replacement surgery. To optimize coverage, the surgeon must optimally mobilize which artery?

Explanation

DISCUSSION:
The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. These arteries arise from the popliteal artery. If this artery is not adequately mobilized, a gastrocnemius soleus flap can be devascularized.

Question 55

A 69-year-old man sustains a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in Figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changes in the emergency department. Clinical pictures taken in the office are shown in Figures 27c through 27e. What is the most appropriate management of this soft-tissue wound?

Explanation

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 56

Figures below demonstrate the radiographs obtained from a 56-year-old man with a 3-year history of right groin pain. A comprehensive nonsurgical program has failed, and the patient would like to proceed with total hip arthroplasty. He is seen by a pain management specialist and is currently taking 40 mg of sustained-release morphine twice daily with oxycodone 10 mg 2 to 3 times a day for severe pain. What is the recommended course of action regarding his chronic narcotic use?

Explanation

DISCUSSION:
Chronic opioid consumption prior to total joint arthroplasty has been associated with increased pain after surgery, increased opioid requirements, a slower recovery and longer hospital stay, and higher 90-day postoperative complications compared with patients not on chronic opioids preoperatively. Based on this information, Nguyen and associates performed a study in three patient groups that included 1) chronic opioid users who underwent no preoperative intervention, 2) chronic opioid users who were weaned down to 50% of their prior opioid regimen, and 3) patients who were not chronic opioid users. The authors found that the reduction of preoperative opioid use improved postoperative function, pain, and recovery and that the weaned group performed more like the opioid naive group than the chronic opioid user
group. Increasing opioid use prior to surgery in this patient would make it more difficult to control pain after surgery. Stopping all of his opioids just prior to surgery would place the patient at substantial risk for opioid withdrawal and is not recommended. Avoiding the use of all narcotics and using only acetaminophen postoperatively is very unlikely to provide appropriate pain relief in a chronic opioid user. The recommendation based on the provided literature is to decrease the patient's narcotic use prior to
surgery.

Question 57

Figures 43a and 43b show the T 1 - and T 2 -weighted MRI scans of a 78-year-old woman who reports the sudden atraumatic onset of well-localized medial knee pain. Pain is worse at night and also occurs with weight-bearing activity. What is the most likely diagnosis?

Explanation

DISCUSSION: Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone of the medial tibial plateau. The diagnosis is more easily established with a bone scan where increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic involvement of the medial compartment, uptake is over both the medial femoral condyle and the medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing accompanying the weight-bearing pain.
REFERENCES: Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-424.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am 1995;77:596-601.

Question 58

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data? Review Topic

Explanation

Patient positioning that results in local nerve compression, plexus traction, or improper neck alignment is the most common nonanesthetic-related cause of changes in intraoperative neurophysiologic monitoring data during spinal surgery.

Question 59

A 40-year-old man has a palpable mass over the dorsum of the ankle. He reports no history of direct trauma but notes that he sustained a laceration to the middle of his leg 6 weeks ago. Examination reveals a 4-cm x 1-cm mass. T 1 - and T 2 -weighted MRI scans are shown in Figures 12a and 12b. An intraoperative photograph and biopsy specimen are shown in Figures 12c and 12d. What is the most likely diagnosis?

Explanation

DISCUSSION: The findings are most consistent with a rupture of the anterior tibial tendon. The damaged area of tendon should be resected, followed by tendon reconstruction or tenodesis. The histology is not consistent with giant cell tumor of the tendon sheath, gout, or synovial sarcoma. Fibromatosis is characterized by a large number of spindle cells within the collagen background.
REFERENCES: Otte S, Klinger HM, Loreaz F, Haerer T: Operative treatment in case of closed rupture of the anterior tibial tendon. Arch Orthop Traum Surg 2002;122:188-190.
Kausch T, Rutt J: Subcutaneous rupture of the tibialis anterior tendon: Review of the literature and case report. Arch Orthop Traum Surg 1998;117:290-293.

Question 60

Figure 40 shows the radiograph of a 30-year-old woman who has a painful elbow. Examination reveals a deformed skull, multiple cafe-au-lait spots, and bone deformities. What is the most likely diagnosis?

Explanation

DISCUSSION: Findings in patients with McCune-Albright syndrome include polyostotic fibrous dysplasia, multiple cafe-au-lait spots, and precocious puberty. The bone changes in NF-1 resemble nonossifying fibromas, not fibrous dysplasia. NF-2 has little bony change with typical ocular abnormalities. Paget’s disease occurs in older individuals and does not present with cafe-au-lait spots. Ollier’s disease (multiple enchondromatosis) may show bone changes but not the other findings.
REFERENCES: Albright F, Butler AM, Hampton AO, et al: Syndrome characterized by osteitis fibrosa disseminata, areas of pigmentation and endocrine dysfunction with precocious puberty in females. N Engl J Med 1937;216:727-746.
Danon M, Robboy SJ, Kim S, Scully R, Crawford JD: Cushing syndrome, sexual precocity, and polyostotic fibrous dysplasia (Albright syndrome) in infancy. J Pediatr 1975;87:917-921.
Grabias SL, Campbell CJ: Fibrous dysplasia. Orthop Clin North Am 1977;8:771-783.

Question 61

Figure 6a shows the radiograph of a 50-year-old man who sustained an anterior dislocation of the shoulder. He undergoes closed reduction, and the postreduction radiograph is shown in Figure 6b. Management should now consist of

Explanation

DISCUSSION: Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement.
REFERENCES: Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103.
Flatow EL, Cuomo F, Maday MG, et al: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-1218.

Question 62

Revision of failed hip resurfacing arthroplasty should involve

Explanation

DISCUSSION
Hip resurfacing offers several potential advantages over conventional total hip arthroplasty, particularly for patients younger than 75 years of age. This intervention can be
relatively bone conserving and is appropriate in settings involving proximal femoral deformity, precluding the use of a traditional femoral component. The use of hip resurfacing in osteonecrosis has been controversial, however. Although there are several reports of successful use of these implants to address osteonecrosis, concerns remain about extensive femoral head involvement (exceeding 40%) and ability to support the femoral head cap. Consequently, hip resurfacing is not recommended for patients with large femoral head lesions.
Evaluation of painful hip resurfacings requires a systematic approach. Radiographs can help surgeons assess implant position, loosening, or fractures. Serological studies including ESR, CRP, and serum cobalt and chromium levels can give clues as to whether infection, metallosis, or both are the underlying cause(s) of failure. Hip aspiration in the setting of metal-on-metal bearings necessitates a manual cell count and differential to avoid falsely elevated automated cell counts.
Revision of failed hip resurfacings should involve revisions of both the femoral and acetabular components. Although successful retention of the acetabular shell has been described, concerns remain regarding cup circumference mismatch, which can lead to suboptimal clearance between the new bearing surfaces.

Question 63

-Postsurgically, the patient recovers well and is fully rehabilitated. He demonstrates full motion with no instability or pain and is cleared to return to play 12 months after the surgery. He asks for your advice regarding use of a functional brace for playing basketball following his reconstruction. What is the most appropriate recommendation?

Explanation

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 64

A 35-year-old construction worker continues to have weakness with lifting overhead 2 years after he was treated with physical therapy for a "chest muscle" tear. An obvious deformity noted in his axilla worsens with resisted extension and adduction. A clinical photograph and MRI scan are shown in Figures 119a and 119b. What is the most appropriate treatment? Review Topic

Explanation

This scenario describes a chronic, symptomatic pectoralis major tendon rupture in a young laborer. Direct repair is difficult at this time; therefore, allograft reconstruction is a good alternative to recover strength. Tendon transfers, electrical stimulation, shoulder arthrodesis, and arthroscopy are not indicated in this patient. They will not offer proper reconstruction of the lost muscle tendon unit and/or cosmetic repair.

Question 65

A 60-year-old patient had the procedure shown in Figure 7 performed 5 years ago. When converting this patient to a total knee arthroplasty (TKA), what patellar problem is commonly encountered intraoperatively?

Explanation

DISCUSSION: Patella baja is commonly encountered when converting a high tibial osteotomy (HTO) to a TKA. Patella baja most likely occurs because of scarring. Meding and associates’ study did not show an increased rate of lateral release when converting a knee that had undergone a previous HTO.
REFERENCES: Yoshino N, Shinro T: Total knee arthroplasty after failed high tibial osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA,

JB Lippincott, 2003, vol 2, pp 1265-1271.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy:

A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 66

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 67

Following spinal cord injury (SCI), methylprednisolone (a bolus of 30 mg/kg plus 5.4 mg/kg per hour over 24 hours) initiated within 8 hours of injury has been associated with which of the following MRI findings? Review Topic

Explanation

MRI findings following SCI treated with high dose steroids have demonstrated that the steroids are associated with a lower extent of cord hemorrhage. No difference in cord edema was found. The decreased cord hemorrhage seen with use of high dose steroid adminstration in this setting has not correlated with improved clinical outcomes.

Question 68

A healthy 27 year-old-male is brought into the emergency department after a fall from height. He has a suspected left C8-T1 nerve injury. Which of the following findings would most suggest a root avulsion injury rather than a brachial plexus injury at this level?

Explanation

Drooping of the left eyelid is a presenting feature of Horner's syndrome. Horner's syndrome represents a disruption of the sympathetic chain via C8 and/or T1 root avulsion after trauma.
Brachial plexus injuries are often classified as preganglionic vs. postganglionic injuries. Preganglionic injuries are typically avulsion injuries proximal to the dorsal root ganglion. Clinical features suggestive of lower root avulsion injury include a person falling from height clutching on object to save himself, Horner’s syndrome (drooping of the eyelid (ptosis), pupillary constriction (miosis) and anhidrosis), absence of a Tinel sign or tenderness to percussion in the neck, and a normal histamine test (C8-T1 sympathetic ganglion - intact triple response (redness, wheal, flare)).
Caporrino et al. reviewed 102 patients to assess the best modality (e.g. physical examination, MRI and nerve conduction studies [NCSs]) for diagnosing and localizing brachial plexus injuries. They found the best diagnostic performance with physical examination (sensitivity = 97.8%; specificity = 30.8%) and NCSs (sensitivity
= 98.9%; specificity = 23.1%). MRI had inferior performance for all measurements. They conclude that NCSs exhibited superior performance to MRI, and should be considered a more reliable supporting tool after detailed physical examination.
Incorrect Answers:

Question 69

Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Explanation

PHASE V: the crescent sign and articular collapse. The supporting bony architecture may become sufficiently weakened by continued resorption of trabecular bone and subchondral bone plate along the reactive interface that the stress of weight-bearing can result in subchondral bone plate fracture with focal articular cartilage buckling and eventual collapse. This is best seen in the frog-lateral radiograph.

Question 70

The load versus deformation curve of the functional spinal unit (FSU) is made up of the neutral zone, the elastic zone, and the plastic zone. What is the plastic zone of the curve believed to represent?

Explanation

DISCUSSION: Plastic deformation of viscoelastic tissues represents deformation of the soft tissues to the point of failure. The lining up of collagen fibers would be in the “toe region” of the curve, which, in the case of the FSU, would be mainly in the neutral zone. Elastin is a minor contributor to the composition of the ligaments and would be protected by the stiffer collagen fibers. The transition between flexion and extension occurs in the neutral zone, and reversible elongation occurs in the elastic zone.
REFERENCES: Fardon DF, Garfin SR, Abitbol J, et al (eds): Orthopaedic Knowledge Update: Spine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 15-23.
Panjabi MM, White AA: Physical properties and functional biomechanics of the spine, in White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, JB Lippincott, 1990, pp 1-83.

Question 71

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Explanation

DISCUSSION:
Obesity, a prior history of venous thromboembolism, and metabolic syndrome have all been associated with an increased risk of thromboembolism. A recent meta-analysis showed that diabetes had no significant relationship with venous thromboembolism following hip or knee arthroplasty. Tranexamic acid is an antifibrinolytic agent that has been shown to reduce blood loss substantially following hip and knee arthroplasty. It has also been shown to be safe in patients with severe medial comorbidities and a prior history of venous thromboembolism.

Question 72

Which of the following lesions most closely resembles Ewing’s sarcoma histologically?

Explanation

DISCUSSION: Ewing’s sarcoma is characterized by small round blue cells. Lesions with a similar appearance include lymphoma, primitive neuroectodermal tumor, rhabdomyosarcoma, small cell lung tumor, and metastatic neuroblastoma. Karyotyping, immunohistochemistry, and electron microscopy can help differentiate these lesions.
REFERENCE: Wold LE, McLeod RA, Sim FH, Unni KK: Atlas of Orthop Pathology. Philadelphia, PA, WB Saunders, 1990.

Question 73

A 79-year-old woman reports a history of left leg pain with walking. Her pain is exacerbated with walking and stair climbing, and her symptoms are improved by standing after she stops walking. Lumbar flexion does not provide any significant improvement of the symptoms and sitting does not significantly change symptoms. Her leg pain is worse at night and she obtains relief by hanging her leg over the side of the bed. The neurologic examination is essentially normal. Examination of the lower extremities demonstrates mild early trophic changes, and her pulses distally are palpable but are diminished bilaterally. Radiographs are shown in Figures 15a and 15b. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,

pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 74

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

Explanation

DISCUSSION: Acute posterior dislocations occur rarely, accounting for less than 5% of acute dislocations. They are most often the result of falls on an outstretched hand. Reduction can be accomplished with flexion of the arm to 90 degrees and adduction to disimpact the humeral head from the glenoid rim. The arm is then externally rotated until the head has cleared the glenoid rim. Following brace immobilization in neutral to 5 to 10 degrees of external rotation and slight abduction, it is critical to avoid internal rotation for 4 to 6 weeks.
REFERENCES: Burkhead WZ Jr, Rockwood CA Jr: Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am 1986;68:724-731.
Pollock RG, Bigliani LU: Recurrent posterior shoulder instability: Diagnosis and treatment.

Clin Orthop 1993;291:85-96.

Question 75

-Figures 55a and 55b are the radiograph and CT scan of a 61-year-old woman who has had neck pain after being involved in a high-speed motor vehicle collision. Examination reveals normal strength and sensation in both upper and lower extremities, normal rectal tone, and no other injuries. The C1-C2 lateral mass overhang measures 8.5 mm. What is the most appropriate treatment option?

Explanation

Question 76

Recent randomized controlled trials comparing early passive range of motion to 6 weeks of immobilization after successful arthroscopic rotator cuff repair concluded that, compared to immobilization, early passive range of motion resulted in: Review Topic

Explanation

A series of high-quality RCTs have demonstrated that early passive range of motion has equivalent functional outcomes when compared to 6 weeks of immobilization after arthroscopic rotator cuff surgery.
Traditionally, most surgeons recommended early post-operative range of motion exercises for their patients in order to prevent adhesions and ultimately stiffness. However, recent evidence has found that there is no difference in the healing rate, range of motion or functional outcome between patients who undergo early versus delayed (i.e. initial 6 weeks of immobilization) passive range of motion exercises after arthroscopic rotator cuff repair.
Kim et al. conducted a randomized controlled trial comparing early passive range of motion vs. immobilization in 106 patients who underwent arthroscopic repair for full-thickness rotator cuff tears. They found that there was no clinically or statistically significant difference between the two groups in pain, healing or function.
Keener et al. also conducted a randomized controlled trial of 124 patients who were undergoing arthroscopic repair of a full-thickness rotator cuff tear and found no difference between early and delayed range of motion in healing and functional outcome.
Cuff & Pupello also compared early vs. delayed range of motion during the postoperative rehabilitation phase in a randomized controlled trial of 68 individuals undergoing arthroscopic rotator cuff repair and found no significant difference in range of motion or healing.
Incorrect Answers:

Question 77

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

Explanation

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

Question 78

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

Explanation

Question 79

A 16-year-old boy with osteochondritis dissecans of the capitellum has intermittent symptoms of catching and locking. Examination is unremarkable. Radiographs reveal a loose body anteriorly with a diameter of 10 mm. To remove the loose body, elbow arthroscopy is being considered. Which of the following procedures would minimize the risk of neurovascular complication during the procedure?

Explanation

DISCUSSION: Complications of elbow arthroscopy are usually minor or temporary. However, serious complications include nerve injuries. The deep radial nerve is the closest to any of the portals, resting as close as 1 mm away from the scope inserted in the anterolateral portal. The capsule can be displaced anteriorly by distending the joint with about 25 mL of saline solution, thus moving the deep radial nerve approximately 1 cm anteriorly and decreasing the risk of injuring it while establishing the anterolateral portal. Keeping plastic cannulae in the portals may help to diminish fluid extravasation and swelling, which is more of an impediment than a serious complication. The image intensifier has no documented role in guiding loose body removal. While the proximal anteromedial portal is probably the safest anterior portal to establish, it is actually easier to remove a large loose body from this portal while viewing it from an anterolateral position. There is less tendon and muscle bulk to pass through at the site of the proximal anteromedial portal than at the anterolateral portal, making it less likely for the loose body to get stuck in the soft tissues. Techniques have been developed to permit removal of loose bodies as large as 2 cm in diameter without breaking them up into pieces. If it is possible to remove a large loose body intact, doing so greatly simplifies and shortens the procedure.
REFERENCES: Lynch GJ, Meyers JF, Whipple TL, Caspari RB: Neurovascular anatomy and elbow arthroscopy: Inherent risks. Arthroscopy 1986;2:190-197.
O’Driscoll S: Loose bodies and synovial conditions, in Green D, Hotchkiss R, Pederson W (eds): Green’s Operative Hand Surgery. New York, NY, Churchill Livingstone, 1999, pp 235-249.

Question 80

What vessel is marked with an asterisk in Figure 44?

Explanation

DISCUSSION: The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column.
REFERENCES: Agur AM, Dalley AF (eds): Grant’s Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.
Uflacker R: Atlas of Vascular Anatomy: An Angiographic Approach, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006.

Question 81

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Explanation

DISCUSSION: Unlike malignant bone tumors, malignant soft-tissue tumors usually are asymptomatic and present with the presence of a mass. Malignant soft-tissue tumors enlarge by centrifugal growth, creating a mass while compressing surrounding tissue. Symptoms may develop as the result of direct compression on neurovascular structures as the tumor enlarges. This is especially true in the pelvis where the tumor can enlarge appreciably without being noticed. However, in the extremities, the tumor is most often apparent before neurologic symptoms develop. An asymptomatic mass is not necessarily benign; therefore, biopsy should not be delayed. It is uncommon for a malignant soft-tissue mass to be discovered incidentally. Soft-tissue tumors are not typically apparent on radiographs; they are best identified with MRI.
REFERENCES: Brouns F, Stas M, De Wever I: Delay in diagnosis of soft tissue sarcomas. Eur J Surg Oncol 2003;29:440-445.
Rougraff B: The diagnosis and management of soft tissue sarcomas of the extremities in the adult. Curr Probl Cancer 1999;23:1-50.
Sim FH, Frassica FJ, Frassica DA: Soft-tissue tumors: Diagnosis, evaluation, and management. J Am Acad Orthop Surg 1994;2:202-211.

Question 82

A 45-year-old man reports a history of a popping sensation and pain in the right shoulder while lifting boxes 6 months ago. The pain has persisted with loss of motion of the shoulder. Radiographs and MRI scans are shown in Figures 47a through 47d. Which of the following studies is likely to produce a significant positive result? Review Topic

Explanation

The patient has a neuropathic joint secondary to syringomyelia that can be seen on a cervical MRI scan. The patient sustained minimal trauma that lead to a chronic anterior glenohumeral dislocation. He did not seek treatment for several months and has a massive rotator cuff tear and hygroma on MRI in addition to the chronic dislocation. Rheumatoid arthritis does not present with a neuropathic picture, except theoretically as the result of numerous intra-articular cortisone injections. This Charcot picture is inconsistent with ankylosing spondylitis or gout. Cannabis use is not typically associated with seizures that could produce anterior as well as posterior shoulder dislocations.

Question 83

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Explanation

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17. http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 84

A 10-year-old boy twisted his ankle while skateboarding and has pain and swelling around the lateral ankle just distal to the fibula. Radiographs are obtained and a lesion is identified in the distal tibia as seen in Figures 273a and 273b. Two weeks later he has no pain to palpation in the region and denies antecedent pain. What is the most appropriate treatment for this lesion?

Explanation

Question.2 .Figures 16a and 16b are the radiographs of a 38-year-old carpenter with progressively worsening ankle pain; 14 years ago, he was involved in an all-terrain vehicle collision. Anti-inflammatory medication,corticosteroid injections, and bracing no longer effectively control his pain. The pain now interferes with his work and family responsibilities. Examination reveals an antalgic limp, varus deformity, limited ankle motion, limited eversion, and normal strength. Treatment should now consist of

ankle arthrodesis.
total ankle arthroplasty.
distal tibia osteotomy.
lateral ligament repair.
deltoid ligament release.
Question. 3 .A 48-year-old woman had total knee arthroplasty. She is unable to “lift her toes or ankle to her nose.”After 2 months of physical therapy, she has a slapping gait. What is the best next treatment step?
Ankle fusion
Ankle-foot orthosis
Sural nerve graft
Medial heel post
Laminectomy of L4/5
Question. 4 .Figures 46a through 46c are the CT scans of an 18-year-old who sustained an injury 3 weeks ago and now has ankle pain. Examination reveals an ankle effusion and painful range of motion. Recommended treatment should consist of

transtalar drilling.
fixation of the fragment.
osteochondral autograft.
weight bearing in a boot with early range of motion.
cast immobilization and nonweight-bearing activity for 6 weeks.
Question. 5 .A 47-year-old woman has a closed, displaced, Weber C bimalleolar ankle fracture. Past medical history includes diabetes mellitus for 7 years controlled with diet and an oral hypoglycemic agent. Semmes-Weinstein sensory testing reveals absence of sensation to the 5.07/10-gm monofilament on the plantar aspect of both feet. The skin is intact with 2+ pedal pulses. Treatment should include
open reduction with limited internal fixation.
closed reduction and application of an external fixator.
closed reduction and total contact cast immobilization.
retrograde intramedullary rod fixation with ankle fusion.
internal fixation and an extended period of immobilization.

Question. 6 .Figures 68a and 68b are the clinical photographs of a 55-year-old woman who had a right hindfoot fusion 3 years ago for a pes planovalgus deformity. Since the surgery, she has had lateral hindfoot pain and places most of the weight-bearing load on the lateral border of her foot when walking. What is the most likely cause of her symptoms?

Deltoid insufficiency
Excessive forefoot abduction
Residual heel valgus
Residual Achilles tendon contracture
Malposition of the transverse tarsal joint

Question 85

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Explanation

Induction coupling stimulates bone growth by increasing expression of BMP7, BMP2, TGF-beta1, and by increasing osteoblasts proliferation. Induction coupling has not been shown to have the effect of decreasing osteoclast differentiation.
In basic science studies, electrical stimulation (i.e. induction coupling), has been shown to promote bone healing via release of growth factors that induce osteoblast differentiation/proliferation. Electrical current can be placed around bone in various ways, creating a current to stimulate growth factor release and subsequent osteoblast proliferation.
Aaron et al. summarized, in a systematic review, the effects of various types of electrical stimulation on bone and bone healing. Regardless of type (i.e. inductive coupling, capacitive coupling, direct current), they report electricity and/or electromagnetic fields promote gene expression of growth factors that promote an osteogenic environment.
Illustration A depicts a cathode placed directly to allograft with a subcutaneously placed electrical stimulator. Illustration B depicts cathodes placed anteriorly and posteriorly around the hip, connected to an outside power source to create the necessary current. Illustration C depicts an inductive coil placed laterally on the skin in order to create an electrical current.
Incorrect answers:

Question 86

A teenager is undergoing a correction of deformity and lengthening of the femur. Distractions are proceeding as expected; however, during his 6-week follow-up examination, the patient reports that the distraction motors have become harder to turn over for the past 2 to 3 days. Figures 37a and 37b show current radiographs. What is the most likely complication being encountered?

Explanation

DISCUSSION: Premature consolidation is a complication that is unique to gradual bone lengthening after corticotomy. Causes include excessive latency period, inadequate distraction rate, exuberant bone formation, patient compliance problems, and mechanical failure of the distraction apparatus. The femur and fibula are most commonly involved. This patient did not have an incomplete corticotomy, as initial distraction occurred before the distraction device was noted to seize up. The radiographs show bowing of the Ilizarov wires and mature regenerate bone, both suggestive of premature consolidation. No wire breakage or joint subluxation is seen on the radiographs. Treatment for premature consolidation includes continuing distraction until the consolidation bridge ruptures, or additional surgery may include closed rotational osteoclasis or repeat corticotomy.
REFERENCES: Paley D: Problems, obstacles and complications of limb lengthening, in Maiocchi AB, Aronson J (eds): Operative Principles of Ilizarov. Baltimore, MD, Williams & Wilkins, 1991, p 360.
Herring JA: Limb length discrepancy, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics,

ed 3. Philadelphia, PA, WB Saunders, 2002, p 1088.

Question 87

An obtunded 80-year-old man was found alone in his apartment after an apparent fall. A CT scan performed in the emergency department shows that he has an extensile injury of an ankylosed cervical spine. The fracture extends across the ossified C5-C6 disk space and into the lamina of C5. There is 1.5 cm of widening between the C5 and C6 vertebrae anteriorly. The patient's family asks you about the long-term impact of the fracture on his functional capacity and survival. You advise them that patients with fractures of the cervical spine with ankylosing conditions have

Explanation

DISCUSSION
Several studies have found that rates of neurologic deficit and mortality are higher for patients with ankylosing spondylitis and a spinal fracture than for age-matched controls. The 2011 work of Schoenfeld and associates, which directly compared patients with cervical fractures in ankylosed spines to age-and sex-matched controls who also had cervical fractures but no ankylosing condition, demonstrated that those with ankylosing spondylitis were at elevated risk for mortality for up to 2 years after sustaining a fracture. In a study by Westerveld and associates, the rate of neurologic deficit among patients with ankylosing spondylitis and a spinal fracture was 57.1% compared to 12.6% among controls.
RECOMMENDED READINGS
Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J. 2014 May 1;14(5):729-40. doi: 10.1016/j.spinee.2013.06.038. Epub 2013 Aug 27. PubMed PMID: 23992936. View Abstract at PubMed
Schoenfeld AJ, Harris MB, McGuire KJ, Warholic N, Wood KB, Bono CM. Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study. Spine J. 2011 Apr;11(4):257-64. doi: 10.1016/j.spinee.2011.01.018. Epub 2011 Mar 5. PubMed PMID: 21377938. View Abstract at PubMed

Question 88

Figures 25a and 25b show the radiographs of a 66-year-old man who has had a long history of bilateral painful flatfoot deformities. Examination reveals that his foot is partially correctable passively, albeit with discomfort, and he has an Achilles tendon contracture. An ankle-foot orthosis has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,

pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 89

A 53-year-old woman reports a 4-month history of gradual onset diffuse shoulder pain and limited function. She has had no prior treatment, and her medical history is unremarkable. Examination reveals globally painful active range of motion to 120 degrees forward elevation, 25 degrees external rotation with the arm at the side, and internal rotation to the sacrum. Passive range of motion is also limited in comparison with the contralateral shoulder. Radiographs are shown in Figures 31a through 31c. What is the most appropriate management? Review Topic

Explanation

The patient has stage II adhesive capsulitis. Patients most commonly affected are women between the ages of 40 and 60, and most cases are considered idiopathic. The preferred method of treatment is an intra-articular corticosteroid injection to decrease inflammation in the joint and allow for a gentle stretching therapy program. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. Aggressive capsular stretching in the early stages of the disease is often counterproductive, unless pain can be adequately controlled with medication or injections. Manipulation under anesthesia and arthroscopic surgical treatment are used when symptoms remain refractory despite initial nonsurgical management.

Question 90

Which of the following is a recognized predictor of mortality after hip fracture?

Explanation

DISCUSSION: The ASA classification (detailed in Illustration A) was initially developed in 1963 and has been shown to be predictive of post-surgical mortality in hip fracture patients. Basic categories are as follows: 1= normal, healthy; 2= mild systemic disease; 3= severe systemic disease, not incapacitating; 4= severe incapacitating systemic condition, constant threat to life; 5= moribund patient; 6 = brain dead, organs being donated.
The study by Richmond et al looked at 836 patients treated for a hip fracture and found that this injury is not associated with significant excess mortality amongst patients older than age 85. However, in younger patients, those with ASA classifications of 3 or 4 have significant excess mortality following hip fracture that persists up to 2 years after injury.

Question 91

A 53-year-old woman has severe neck and left shoulder pain after a rollover motor vehicle accident. Radiographs and a CT scan of the cervical spine are shown in Figures 34a through 34c. Management should consist of

Explanation

DISCUSSION: The plain radiographs show a horizontal orientation of the C5 facet joint. The CT scan through C5 reveals an ipsilateral pedicle and lamina fracture (floating facet). This injury involves two adjacent motion segments and is extremely unstable. Lateral mass plates, with or without the purchase of the “floating facet,” provide the best means of stabilization and should include the facet above (C4) and below (C6) the level of injury. Orthotic immobilization is insufficient for this particular injury. Halo vest treatment does not control the subaxial spine well and is of limited value. While simple midline (Rogers) wiring provides some tension band restoration, it is not optimal for rotational control. The use of lateral mass plates provides rotational stability. Another option would be anterior fusion and plating, which would save cervical segments.
REFERENCES: Levine AM, Mazel C, Roy-Camille R: Management of fracture separations of the articular mass using posterior cervical plating. Spine 1992;17:S447-S454.
Levine AM: Facet fractures and dislocations, in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 360-362.
Whitehill R, Richman JA, Glaser JA: Failure of immobilization of the cervical spine by the halo vest: A report of five cases. J Bone Joint Surg Am 1986;68:326-332.
Garvey TA, Eismont FJ, Roberti LJ: Anterior decompression, structural bone grafting, and Caspar plate stabilization for unstable cervical spine fractures and/or dislocations. Spine 1992;17:S431-S435.

Question 92

A 42-year-old man sustained a burst fracture at L2 in a motor vehicle accident. Examination reveals that he is neurologically intact. Figure 18 shows a cross-sectional CT scan through the fracture. If the fracture is managed nonsurgically for the next 2 years, the retained fragments can be expected to

Explanation

DISCUSSION: Numerous articles have reported that both surgical and nonsurgical management of burst fractures are associated with resolution of impingement at long-term follow-up. If the patient is neurologically intact and appropriately treated at the time of injury, neurologic deterioration is not expected nor is there a risk of injury to the dural sac. The retained fragments can be expected to gradually resorb and widen the spinal canal.
REFERENCES: Mumford J, Weinstein JN, Spratt KF, et al: Thoracolumbar burst fractures: The clinical efficacy and outcome of nonoperative management. Spine 1993;18:955-970.
Wood KB, Butterman G, Mehbod A, et al: Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurologic deficit: A prospective, randomized study. J Bone Joint Surg Am 2003;85:773-781.

Question 93

The posterior horn of the medial meniscus receives its primary blood supply from what artery?

Explanation

DISCUSSION: The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.
REFERENCES: Insall J, Scott WN: Anatomy, in Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, pp 64-70.
Scapinelli R: Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10:151-162.

Question 94

What tendon is closest to an appropriately placed anterolateral portal for ankle arthroscopy?

Explanation

DISCUSSION: The appropriate placement of the anterolateral portal provides access to the lateral gutter of the joint while avoiding the superficial peroneal nerve. The safest location for the portal is approximately 4 mm lateral to the peroneus tertius tendon, the closest of the tendons listed to the anterolateral portal. Because the superficial peroneal nerve location is variable, attempts to visualize, palpate, or transilluminate the nerve are mandatory.
REFERENCE: Ogut T, Akgun I, Kesmezacar H, et al: Navigation for ankle arthroscopy: Anatomical study of the anterolateral portal with reference to the superficial peroneal nerve. Surg Radiol Anat 2004;26:268-274.

Question 95

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

Explanation

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

Question 96

Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision?

Explanation

DISCUSSION: Arthroscopic versus open distal clavicle excision has the advantage of allowing evaluation of the glenohumeral joint arthroscopically prior to moving into the subclavicular and subacromial space to perform the distal clavicle excision. This can be of value in both confirming the diagnosis as well as avoiding diagnostic errors. Berg and Ciullo showed that
in 20 patients who underwent open distal clavicle excision that resulted in failure, 15 of those patients had a superior labral anterior posterior (SLAP) lesion. Of these 15 patients who had the lesion treated surgically, 9 went on to a good to excellent result after the surgery was performed arthroscopically. Fewer complications, lower infection rate, and decreased surgical time have not been documented in the literature. Arthroscopic technique sacrifices the inferior acromioclavicular ligament and preserves the superior acromioclavicular ligament.
REFERENCES: Berg EE, Ciullo JV: The SLAP lesion: A cause of failure after distal clavicle resection. Arthroscopy 1997;13:85-89.
Lemos MJ, Tolo ET: Complications of the treatment of acromioclavicular and sternoclavicular joint injuries, including instability. Clin Sports Med 2003;22:371-385.

Question 97

MRI results are shown in Figure 1 for a 22-year-old, right-hand dominant collegiate athlete who reports a 6-month history of progressive weakness in his right arm. He denies any specific traumatic event. He has altered his weight-lifting activities and tried over-the-counter ibuprofen without benefit. No appreciable deformity or atrophy is found on examination of the upper extremities. He demonstrates full active shoulder range of motion, and there is no weakness with abduction in the plane of the scapula. Belly press test findings are normal, but weakness is seen in external rotation with the arm in adduction. He does not demonstrate anterior apprehension, and there is no instability with load and shift testing. Radiographs are unremarkable. What is the best surgical option?

Explanation

A 45-year-old woman diagnosed with lateral epicondylitis undergoes an open debridement of the extensor carpi radialis brevis. During surgery, resection extends posterior to the equator of the radiocapitellar joint. Postoperatively, she complains of persistent pain, despite appropriate rehabilitation. What other physical examination finding is she likely to have?
A. Pain with elbow extension in forearm pronation
B. Mechanical symptoms when rising from a chair
C. Valgus instability
D. Tenderness over the medial collateral ligament (MCL)
Excessive resection of the common extensor origin posterior to the equator of the radiocapitellar joint may lead to iatrogenic lateral collateral ligament (LCL) injury, causing posterior lateral rotatory instability (PLRI). Patients may present with lateral elbow pain, a positive lateral pivot shift test, or mechanical symptoms/subjective instability when pushing up from a chair (positive chair rise test). PLRI is often provoked with combined elbow extension and forearm supination, as the posterior support for the radiocapitellar joint has been lost. Therefore, placing the forearm in pronation during elbow extension places the radiocapitellar joint in a more stable position and is less likely to induce pain or mechanical symptoms. Valgus instability and MCL tenderness would be associated with an MCL injury.
56- A 75-year-old man presents with complaints of shoulder pain, bruising, and weakness following a fall onto his outstretched hand. He underwent an uncomplicated anatomic total shoulder arthroplasty 5 years prior with good range of motion and strength. His current radiographs are shown in Figures 1 and 2. What is the most appropriate next step to restore this patient’s function?

Question 98

A 38-year-old woman has a lesion on her left foot that has increased in size over the past 6 months. The clinical photograph is shown in Figure 17a, and a photomicrograph of the biopsy specimen is shown in Figure 17b. What is the most likely diagnosis?

Explanation

DISCUSSION: Melanoma comprises 25% of lower extremity lesions and is the most common malignant tumor of the foot. The preferred treatment is wide resection.
REFERENCES: Hughes LE, Horgan K, Taylor BA, Laidler P: Malignant melanoma of the hand and foot: Diagnosis and management. Br J Surg 1985;72:811-815.
Fortin PT, Freiberg AA: Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995;77:1396-1403.

Question 99

-are the radiographs of a 7-year-old girl who was evaluated for a visible elbow deformity by a foster parent. She thought the child fell, but her history was vague. On physical examination, a large prominence was seen over the posterolateral elbow, and the girl lacks the terminal 20 degrees of elbow extension. She has 75 degrees of elbow pronation and supination. She was nontender on examination. What is the most appropriate next treatment step?

Explanation

Question 100

A 38-year-old man reports a 6-week history of shoulder pain and stiffness after falling on the stairs and landing onto the affected side. Radiographs are shown in Figures 54a and 54b. What is the most appropriate treatment? Review Topic

Explanation

The patient has a chronic posterior shoulder dislocation of 6-weeks duration. A CT scan will provide preoperative information regarding the size of the McLaughlin or reverse Hill-Sachs lesion. Open glenohumeral reduction with transfer of the lesser tuberosity and attached subscapularis has been shown to be successful in stabilizing a posterior dislocation. Closed reduction is highly unlikely to achieve a reduction and may cause displacement of an unrecognized humeral surgical neck fracture. Hemiarthroplasty would be considered for lesions involving more than 50% of the humeral head or when the joint has been dislocated for several months and late collapse of the head postreduction is likely. Rotator cuff tears are not commonly associated with posterior shoulder dislocation.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Subtalar fusion
Neuroplasty of the superficial peroneal nerve
Neuroplasty of the sural nerve and implant removal
Excision and burial of the sural nerve in deep muscle or vein
Electromyography/nerve conduction velocity studies to evaluate local nerve entrapment versus radiculopathy

Correct Answer: Excision and burial of the sural nerve in deep muscle or vein

Explanation:

Question 2:

Which of the following muscle tendons inserts just lateral to the long head of biceps tendon on the proximal humerus?

Options:

Teres major
Latissimus dorsi
Short head of the biceps
Pectoralis major
Subscapularis

Correct Answer: Pectoralis major

Explanation:

DISCUSSION: The pectoralis major insertion is just lateral to the long head of the biceps tendon. Medial to the biceps is the insertion for the teres major and latissimus dorsi. The short head of the biceps originates on the coracoid process. The subscapularis inserts on the lesser tuberosity just medial to the biceps.
REFERENCE: Bal GK, Basamania CJ: Pectoralis major tendon ruptures: Diagnosis and treatment. Tech Shoulder Elbow Surg 2005;6:128-134.

Question 3:

A healthy, active, independent 74-year-old woman fell and sustained the elbow injury shown in Figures 41a and 41b. Management should consist of

Options:

a sling and early elbow range-of-motion exercises.
a long arm cast for 6 weeks.
open reduction and internal fixation.
total elbow arthroplasty.
elbow arthrodesis.

Correct Answer: total elbow arthroplasty.

Explanation:

Question 4:

Options:

wide excision with neoadjuvant chemotherapy.
radiation therapy.
curettage and bone grafting.
observation.
chemotherapy followed by radiation therapy.

Correct Answer: curettage and bone grafting.

Explanation:

Question 5:

Communication breakdown is the leading cause of which of the following?

Options:

Delayed diagnoses
Medication errors
Surgical site infections
1 and 2
All of the above

Correct Answer: Delayed diagnoses

Explanation:

Question 6:

Options:

debridement of the biceps tendon.
debridement of the rotator cuff tear.
repair of the biceps pulley system.
repair of the rotator cuff tear.
tenodesis of the biceps tendon.

Correct Answer: tenodesis of the biceps tendon.

Explanation:

Question 7:

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 8:

Figure 53 shows a thoracolumbar specimen as viewed from posterior to anterior following removal of all posterior elements. Which of the following structures does the red string pass under?

Options:

Diskovertebral ligament
Posterior longitudinal ligament
Cauda equina
Batson’s plexus
Ligamentum flavum

Correct Answer: Ligamentum flavum

Explanation:

Question 9:

Options:

glenohumeral osteoarthritis.
recurrent posterior subluxation.
internal impingement syndrome.
thoracic outlet syndrome.
subscapularis tendon detachment.

Correct Answer: glenohumeral osteoarthritis.

Explanation:

Question 10:

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

Options:

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

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

Explanation:

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

Question 11:

Which of the following findings is most prognostic for the ability of a young child with cerebral palsy to walk?

Options:

Ability to sit independently by age 2 years
Ability to creep by age 2 years
Ability to roll by age 2 years
Pattern of cerebral palsy (quadriplegia, diplegia, hemiplegia)
Type of motor dysfunction (spastic, ataxic, dyskinetic, hypotonic)

Correct Answer: Ability to sit independently by age 2 years

Explanation:

DISCUSSION: Several studies have shown that sitting ability by age 2 years is highly prognostic of walking. Molnar and Gordon reported that children not sitting independently by age 2 years had a poor prognosis for walking. Wu and associates reported that children sitting without support by age 2 years had an odds ratio of 26:1 of walking compared with those unable to sit. This was far higher than the odds ratios for cerebral palsy location, motor dysfunction, crawling, creeping, scooting, or rolling.
REFERENCES: Molnar GE, Gordon SU: Cerebral palsy: Predictive value of selected clinical signs for early prognostication of motor function. Arch Phys Med Rehabil 1976;57:153-158.
Wu YW, Day SM, Strauss DJ, et al: Prognosis for ambulation in cerebral palsy: A population-based study. Pediatrics 2004;114:1264-1271.

Question 12:

Options:

hinged knee bracing, protected weight bearing, and physical therapy.
anteromedialization of the tibial tubercle.
internal fixation and medial patellofemoral ligament (MPFL) reconstruction.
arthroscopic lateral retinacular release.

Correct Answer: internal fixation and medial patellofemoral ligament (MPFL) reconstruction.

Explanation:

Question 13:

Options:

Neurogenic claudication
Vascular claudication
Lumbar radiculopathy
Cervical myelopathy
Central cord syndrome

Correct Answer: Neurogenic claudication

Explanation:

Question 14:

Options:

Physical therapy
In situ pinning
Reduction and percutaneous pinning
Surgical dislocation of the hip with reduction under direct vision
Spica casting

Correct Answer: In situ pinning

Explanation:

Question 15:

Figures 31a and 31b are the radiographs of a 5-year-old boy with an elbow injury.

Options:

Plain radiographs
CT scan
MRI
Arthrogram

Correct Answer: Plain radiographs

Explanation:

Question 16:

Which of the following complications may occur subsequent to resurfacing hip arthroplasty for osteonecrosis of the hip but not after total hip arthroplasty?

Options:

Aseptic loosening of the acetabular component
Fracture of the femoral neck
Fracture of the acetabulum
Infection
Groin pain

Correct Answer: Fracture of the femoral neck

Explanation:

DISCUSSION: Advocates of resurfacing hip arthroplasty cite preservation of the proximal femoral bone stock as the main advantage of this procedure over total hip arthroplasty. Fracture of the retained femoral neck has been reported following resurfacing arthroplasty. The exact etiology of the latter is unknown. Technical errors, such as notching of the femoral neck or possibly disruption of the blood supply to the femoral head during extensive soft-tissue exposure, may result in femoral neck fracture.
REFERENCES: Gabriel JL, Trousdale RT: Stem fracture after hemiresurfacing for femoral head osteonecrosis. J Arthroplasty 2003;18:96-99.
Amstutz HC, Campbell PA, Le Duff MJ: Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am 2004;86:1874-1877.

Question 17:

- Which of the following methods of treatment of a displaced Lisfranc fracture-dislocation will most reliably lead to good functional results?

Options:

Weightbearing short leg cast
Nonweightbearing short leg cast
Removable splint and early motion
Open reduction and internal fixation
Elastic compression bandage with full weightbearing

Correct Answer: Open reduction and internal fixation

Explanation:

Question 18:

Options:

Continued resuscitation with fluids and blood
Ongoing resuscitation and pelvic angiography
Application of an external fixator in the emergency department
A pelvic binder and continued resuscitation
A pelvic binder, skeletal traction, and continued resuscitation

Correct Answer: A pelvic binder, skeletal traction, and continued resuscitation

Explanation:

Question 19:

Options:

Continued observation and home therapy
Radiation therapy, followed by aggressive range-of-motion exercises
Formal physical therapy and static progressive splinting
Revision open reduction and internal fixation and capsular release
Manipulation under anesthesia

Correct Answer: Formal physical therapy and static progressive splinting

Explanation:

DISCUSSION: The radiographs do not show an articular malunion. Treatment is directed at the soft-tissue contracture and should begin with formal physical therapy and static progressive splinting. Radiation therapy is effective in the perioperative period and is indicated when ectopic bone formation is a concern.
REFERENCES: Morrey BF: The posttraumatic stiff elbow. Clin Orthop Relat Res
2005;431:26-35.
King GJ, Faber KJ: Posttraumatic elbow stiffness. Orthop Clin North Am 2000;31:129-143.

Question 20:

Surgical treatment for this patient should include

Options:

excision arthroplasty with placement of an articulating antibiotic cement spacer.
excision arthroplasty with placement of a static antibiotic cement spacer.
revision to a more constrained prosthesis, with reestablishment of the flexion and extension gap balance.
a thicker polyethylene insert.

Correct Answer: revision to a more constrained prosthesis, with reestablishment of the flexion and extension gap balance.

Explanation:

DISCUSSION
Video 22 for reference
This patient has an unstable cruciate-retaining TKA. The tibial cut appears to be substantial, necessitating a very thick polyethylene liner. In addition, the femoral component may be slightly more proximally located. Tests for flexion-extension gap balancing would indicate flexion instability. However, the possibility of infection remains, so screening blood tests are appropriate. The surgical treatment for this unstable knee is revision TKA to a more constrained implant, ensuring flexion-extension gap balancing. No evidence indicates that the knee is infected. A thicker polyethylene insert will not adequately balance the knee.

Question 21:

Options:

Administration of broad spectrum IV antibiotics
Irrigation and debridement in OR followed by broad spectrum IV antibiotics
NSAIDS and observation with repeat ESR and CRP in 24 hours
Joint aspiration and blood cultures

Correct Answer: Joint aspiration and blood cultures

Explanation:

Question 22:

Figures 38a and 38b show the AP and lateral radiographs of a 12-year-old baseball pitcher who has pain in his right dominant elbow. Management should consist of

Options:

gentle range of motion and ultrasound.
cast immobilization and a bone stimulator.
elimination of offending activities and cross-training.
arthroscopy with excision of the pathologic portion.
MRI for assessment of accompanying ligamentous instability.

Correct Answer: elimination of offending activities and cross-training.

Explanation:

Question 23:

Following a fall from a height of 5 feet, a patient reports pain along the lateral border of the foot. The CT scan shown in Figure 54 indicates what pathology?

Options:

Impaction injury of the cuboid
Retracted os peroneum
Fifth metatarsal avulsion fracture
Avulsion injury of the bifurcate (Y) ligament
Lisfranc injury

Correct Answer: Avulsion injury of the bifurcate (Y) ligament

Explanation:

DISCUSSION: The CT scan reveals an avulsion of the dorsal beak of the anterior process of the calcaneus. This common fracture is an avulsion of the origin of the bifurcate ligament, which runs from the anterior calcaneal process to both the cuboid and the lateral aspect of the navicular. An inversion mechanism is common, and the fracture is often missed in evaluation for a suspected ankle sprain. MRI may be useful in the diagnosis of these occult injuries, and suspicion should be present when tenderness exists over the superior portion of the anterior process of the calcaneus.
REFERENCE: Robbins MI, Wilson MG, Sella EJ: MR imaging of anterosuperior calcaneal process fractures. Am J Roentgenol 1999;172:475-479.

Question 24:

Options:

angiography.
curettage and cementation.
resection and modular distal femoral knee replacement.
radiation therapy.
a technetium Tc 99m bone scan and AP and lateral radiographs of the entire right femur.

Correct Answer: a technetium Tc 99m bone scan and AP and lateral radiographs of the entire right femur.

Explanation:

Question 25:

Eosinophilic granuloma frequently occurs as a solitary lesion in the tubular long bones. After biopsy, what is the best course of action?

Options:

Neoadjuvant chemotherapy
En bloc resection
Observation
Amputation
Chemotherapy followed by radiation therapy

Correct Answer: Observation

Explanation:

Question 26:

Which characteristic of complex regional pain syndrome (CRPS) type 2 differentiates it from CRPS 1?

Options:

Positive bone scan result
Identified nerve injury
Pseudomotor changes
No identified nerve injury

Correct Answer: Identified nerve injury

Explanation:

Question 27:

What is the most common donor site complication following a free vascularized fibular graft for osteonecrosis of the femoral head?

Options:

Sensory deficit
Motor deficit
Flexor hallucis longus contracture
Deep venous thrombosis
Fibular fracture

Correct Answer: Sensory deficit

Explanation:

Question 28:

A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement?

Options:

Hip is internally rotated, passively flexed to 90 degrees, and adducted
Hip is internally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed to 90 degrees, and adducted
Hip is externally rotated, passively flexed to 90 degrees, and abducted
Hip is externally rotated, maximally flexed, and abducted

Correct Answer: Hip is internally rotated, passively flexed to 90 degrees, and adducted

Explanation:

DISCUSSION: Patients with dysplasia often have a hypertrophic labrum. Abnormal contact between the femoral neck and the acetabular rim leads to labral injury, especially in the anterior-superior acetabular zone. Typically, young patients with the condition report pain with activity or long periods of sitting or driving. The hips often have limited motion, in particular in internal rotation and flexion. Forceful adduction with the maneuver causes pain.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 411-424.
Beck M, Leunig M, Parvizi J, et al: Anterior femoroacetabular impingement: Part II. Midterm results of surgical treatment. Clin Orthop 2004;418:67-73.
McCarthy JC, Noble PC, Schuck MR, et al: The role of labral lesions to development of early degenerative hip disease. Clin Orthop 2001;393:25-37.

Question 29:

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

Options:

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

Correct Answer: Rib overlap of the apical vertebra

Explanation:

Question 30:

Figure 33 shows the radiograph of a 28-year-old avid golfer who has chronic right wrist pain. Management should consist of

Options:

cast immobilization.
splinting with a bone stimulator.
excision of the fracture fragment.
arthroscopically assisted percutaneous fixation.
trephination of the fibrous union.

Correct Answer: excision of the fracture fragment.

Explanation:

Question 31:

Options:

Lateral femoral cutaneous nerve
Medial inferior genicular artery
Infrapatellar branch of the saphenous nerve
Anterior tibial recurrent artery
Lateral inferior genicular artery

Correct Answer: Lateral femoral cutaneous nerve

Explanation:

Question 32:

Options:

activity limitations because of localized pain.
the likelihood of development of malignant degeneration in adulthood.
the likelihood of development of a growth deformity.
ambiguity regarding the diagnosis based on the imaging studies.
obvious progression over the past 5 years, raising suspicion of malignant degeneration.

Correct Answer: activity limitations because of localized pain.

Explanation:

Question 33:

Options:

Retain the components, and implant a tibial strut allograft.
Revise the tibial component with a metaphyseal cone and metaphyseal uncemented stem.
Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.
Revise the tibial component with a long cemented diaphyseal-engaging stem.

Correct Answer: Revise the tibial component with a metaphyseal cone and a press-fit diaphyseal-engaging stem.

Explanation:

Question 34:

Options:

Obtain a menstrual history.
Advise the athlete never to compete in high level endurance sports again.
Obtain serum calcium levels.
Obtain a psychiatric consultation.
Recommend changes in training intensity.

Correct Answer: Obtain a menstrual history.

Explanation:

Question 35:

A 72-year-old man with diabetic neuropathy and 5 degrees of valgus talar tilt; he has pursued nonsurgical treatment for 30 years and now has unrelenting pain

Options:

Ankle replacement
Ankle fusion
Tibiotalocalcaneal fusion
Total contact cast
Intra-articular steroid injection

Correct Answer: Ankle fusion

Explanation:

DISCUSSION
Arthritis of the ankle and hindfoot can pose challenges. Depending upon patient age, comorbidities, and alignment, a variety of surgical interventions may be offered. A total ankle replacement may be considered for patients older than 60 years of age who have minimal misalignment and low-demand lifestyles. In all other cases, ankle fusion must be considered. The nonsurgical care of ankle arthritis includes anti-inflammatory medication, intra-articular steroid injections, bracing with customized products such as the Arizona brace, or a molded foot and ankle orthosis.
Patients with diabetes and Charcot arthropathy may be treated nonsurgically with total-contact casting during acute and active or "hot" phases and accommodative shoes during consolidation and stable or "cool" phases. When the patient has recurrent ulcers or major anatomy changes, surgical intervention must be considered. Tibiotalocalcaneal fusion helps to realign the foot and ankle and make it more braceable in the setting of ankle and hindfoot Charcot disease.
RECOMMENDED READINGS
Queen RM, Adams SB Jr, Viens NA, Friend JK, Easley ME, Deorio JK, Nunley JA. Differences in outcomes following total ankle replacement in patients with neutral alignment compared with tibiotalar joint malalignment. J Bone Joint Surg Am. 2013 Nov 6;95(21):1927-34. doi: 10.2106/JBJS.L.00404. PubMed PMID: 24196462.
View Abstract at PubMed
Nunley JA, Caputo AM, Easley ME, Cook C. Intermediate to long-term outcomes of the STAR Total Ankle Replacement: the patient perspective. J Bone Joint Surg Am. 2012 Jan 4;94(1):43-8. doi: 10.2106/JBJS.J.01613. PubMed PMID: 22218381.
View Abstract t
PubMed
Saltzman CL, Mann RA, Ahrens JE, Amendola A, Anderson RB, Berlet GC, Brodsky JW, Chou LB, Clanton TO, Deland JT, Deorio JK, Horton GA, Lee TH, Mann JA, Nunley JA, Thordarson DB, Walling AK, Wapner KL, Coughlin MJ. Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results. Foot Ankle Int. 2009 Jul;30(7):579-96. doi: 10.3113/FAI.2009.0579. PubMed PMID: 19589303.
View Abstract at
PubMed
Faraj AA, Loveday DT. Functional outcome following an ankle or subtalar arthrodesis in adults. Acta Orthop Belg. 2014 Jun;80(2):276-9. PubMed PMID: 25090803.
View Abstract at PubMed
Grear BJ, Rabinovich A, Brodsky JW. Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis. Foot Ankle Int. 2013 Nov;34(11):1541-7. doi: 10.1177/1071100713500490. Epub 2013 Jul 30. PubMed PMID: 23900228.
View Abstract at
PubMed

Question 36:

What is the most frequent location of entrapment of the deep peroneal nerve?

Options:

Tendon of the extensor hallucis brevis
Inferior extensor retinaculum
Osteophytes of the talonavicular joint
Os intermetatarseum
Base of the fifth metatarsal

Correct Answer: Inferior extensor retinaculum

Explanation:

DISCUSSION: The most frequently described entrapment of the deep peroneal nerve is the anterior tarsal tunnel syndrome. This syndrome refers to entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Entrapment can also occur as the nerve passes under the tendon of the extensor hallucis brevis. Compression by underlying dorsal osteophytes of the talonavicular joint and an os intermetatarseum (between the bases of the first and second metatarsals) have previously been described in runners.
REFERENCES: Kopell HP, Thompson WA: Peripheral entrapment neuropathies of the lower extremity. N Engl J Med 1960;262:56-60.
Schon LC, Mann RA: Diseases of the nerves, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 1, pp 675-677.

Question 37:

Which of the following have been found to affect the rate of perioperative infections or wound complication rates in foot and ankle surgery?

Options:

Methotrexate
Gold
Hydroxychloroquine
TNF-a inhibitors
Smoking

Correct Answer: Smoking

Explanation:

DISCUSSION: Clinical studies have shown that smoking cessation for 4 weeks reduces the risk of infection to the level of nonsmokers. Adverse effects on wound healing caused by chemotherapy used to treat rheumatoid arthritis has not been borne out in the literature.
REFERENCES: Bibbo C, Anderson RB, Davis WH, et al: The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: Analysis of 725 procedures in 104 patients. Foot Ankle Int 2003;24:40-44.
Bibbo C, Goldberg JW: Infections and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int
2004;25:331-335.
Sorensen LT, Karlsmark T, Gottrup F: Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg 2003;238:1-5.

Question 38:

Options:

Nerve roots
Spinal cord
Sciatic nerve
Peroneal nerve
Conus medullaris

Correct Answer: Nerve roots

Explanation:

Question 39:

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

Options:

pulselessness
palor
paresthesia
paralysis
increasing analgesia requirement

Correct Answer: pulselessness

Explanation:

Question 40:

Options:

Synovial fluid adhesion-cohesion
Negative intra-articular pressure
Concavity-compression of the humeral head in the glenoid
Decreased functional arc of motion as a result of a Hill-Sachs lesion
Poor rehabilitation of scapulothoracic rhythm

Correct Answer: Concavity-compression of the humeral head in the glenoid

Explanation:

Question 41:

Options:

MRI
Electromyography
Open repair of the supraspinatus
Arthrography
Arthroscopic labral repair

Correct Answer: MRI

Explanation:

DISCUSSION: In patients older than age 40 years, a high suspicion of a rotator cuff tear should be kept in those patients with weakness after shoulder dislocation. Both posterior rotator cuff and subscapularis injuries have been documented. The next most appropriate step in management should be MRI. If the findings are negative, suspicion of nerve injury should lead to electromyography.
REFERENCES: Stayner LR, Cumming J, Andersen J, et al: Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231-239.
Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 1988;70:1308-1311.

Question 42:

Options:

Lachman test
Pivot-shift test
Posterior drawer test
Posterolateral (PL) drawer test

Correct Answer: Pivot-shift test

Explanation:

Question 43:

Figure 1 is the MRI scan of a 15-year-old boy who has had knee pain with running for 5 months. What is the most appropriate treatment?

Options:

Arthroscopic or open reduction and internal fixation
Arthroscopic loose body removal
Activity restriction for up to 9 months
Subchondral drilling The MRI reveals an osteochondritis dissecans (OCD) lesion that is unstable and has a large osseous component. OCDs are acquired lesions of the subchondral bone. Patients with OCD initially report nonspecific pain and variable amounts of swelling. Initial radiographs help identify the lesion and establish the status of the physes. An MRI scan is useful for assessing the potential for the lesion to heal with nonsurgical treatment. Nonsurgical treatment is appropriate for small, stable lesions in patients with open physes and focuses on activity restriction for 3 to 9 months. Surgical treatment is necessary for unstable or detached lesions. Stable lesions with intact articular cartilage can be treated with subchondral drilling to stimulate vascular ingrowth, with radiographic healing at an average of 4.4 months. Fixation is indicated for unstable or hinged lesions, and stabilization of the fragment can be achieved using a variety of implants through an arthroscopic or open approach. The fragment should be salvaged, and the normal articular surface restored whenever possible. In this patient, the fragment is unstable and therefore stabilization of the fragment with internal fixation would be the best treatment option.

Correct Answer: Arthroscopic loose body removal

Explanation:

Question 44:

Options:

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

Correct Answer: Closed reduction with a towel clip

Explanation:

Question 45:

Which of the following is the preferred treatment for symptomatic localized pigmented villonodular synovitis (PVNS) of the knee?

Options:

Observation
External beam radiation therapy
Intra-articular radiation therapy
Resection of nodule only
Open complete synovectomy

Correct Answer: Resection of nodule only

Explanation:

DISCUSSION: Localized PVNS is a variant of the disease process where the synovial proliferation occurs in one area and usually presents as a discrete mass. It has been effectively treated with complete excision. This may be performed arthroscopically or with arthrotomy. Complete synovectomy and radiation therapy are unnecessary to eradicate the localized form of PVNS.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.
J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 46:

Figures 3a and 3b show the inversion stress radiographs of a patient’s ankle. What is the most likely ligament injury pattern?

Options:

Calcaneofibular alone
Posterior talofibular alone
Posterior talofibular and deltoid
Anterior talofibular and deltoid
Anterior talofibular and calcaneofibular

Correct Answer: Anterior talofibular and calcaneofibular

Explanation:

Question 47:

Options:

split-thickness skin graft.
thenar flap.
cross-finger flap.
lateral arm flap.
Moberg (volar advancement) flap.

Correct Answer: cross-finger flap.

Explanation:

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger
flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 48:

Options:

Chronic deep infection
Heterotopic bone
Femoral loosening
Parkinsonism
Acetabular loosening

Correct Answer: Femoral loosening

Explanation:

DISCUSSION: The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain.
REFERENCES: Harris WH, McCarthy JC, O’Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067.
Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.
Maloney WJ, Schmalzreid T, Harris WH: Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res 2002;405:70-78.

Question 49:

Options:

observation.
a rigid collar for 6 weeks.
halo vest application.
open reduction and posterior stabilization.
open reduction, diskectomy, grafting, and anterior plate stabilization.

Correct Answer: a rigid collar for 6 weeks.

Explanation:

Question 50:

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Options:

Lack of ankle dorsiflexion
Lack of ankle plantarflexion
Lack of knee extension
Loss of bowel and/or bladder control
Lack of great toe extension

Correct Answer: Lack of ankle dorsiflexion

Explanation:

Question 51:

The cortical injury to the posterolateral distal fibula shown in Figure 25 indicates involvement of which of the following structures?

Options:

Deltoid ligament
Anterior talofibular ligament
Calcaneal fibular ligament
Superior peroneal retinaculum
Syndesmosis

Correct Answer: Superior peroneal retinaculum

Explanation:

Question 52:

The direct anterior (Smith-Peterson) approach to hip arthroplasty is most commonly associated with injury to what nerve?

Options:

Lateral femoral cutaneous
Sciatic
Pudendal
Superior gluteal

Correct Answer: Lateral femoral cutaneous

Explanation:

Question 53:

Options:

Brachioradialis (BR)
Extensor carpi radialis brevis (ECRB)
Extensor carpi ulnaris (ECU)
Extensor indicis proprius (EIP) The incidence of radial nerve palsy after a humeral shaft fracture has been estimated as being between 7% and 22%. Controversy remains regarding the need for early exploration in a patient presenting with a closed humerus fracture and concurrent radial nerve palsy, because approximately 77% of patients treated without exploration have spontaneous recovery of radial nerve function. Within 3 to 4 months of the injury, the BR and extensor carpi radialis longus (ECRL) should begin to show signs of reinnervation. Anatomic studies have demonstrated a relatively consistent order of the radial nerve motor branches in the forearm (proximal to distal): BR, ECRL, supinator, ECRB, extensor digitorum communis, ECU, extensor digit quinti, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and EIP. Because the EIP is the last motor branch from the radial nerve, it is likely to be the last to recover following a high radial nerve palsy.

Correct Answer: Extensor indicis proprius (EIP) The incidence of radial nerve palsy after a humeral shaft fracture has been estimated as being between 7% and 22%. Controversy remains regarding the need for early exploration in a patient presenting with a closed humerus fracture and concurrent radial nerve palsy, because approximately 77% of patients treated without exploration have spontaneous recovery of radial nerve function. Within 3 to 4 months of the injury, the BR and extensor carpi radialis longus (ECRL) should begin to show signs of reinnervation. Anatomic studies have demonstrated a relatively consistent order of the radial nerve motor branches in the forearm (proximal to distal): BR, ECRL, supinator, ECRB, extensor digitorum communis, ECU, extensor digit quinti, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, and EIP. Because the EIP is the last motor branch from the radial nerve, it is likely to be the last to recover following a high radial nerve palsy.

Explanation:

Question 54:

Options:

Profunda femoris B. Middle genicular C. Medial sural
Inferior medial genicular

Correct Answer: Profunda femoris B. Middle genicular C. Medial sural

Explanation:

Question 55:

Options:

Continue wet-to-dry dressing changes until the wound heals by secondary intention.
Perform a volar advancement flap (ie, Moberg flap).
Perform a V-Y advancement flap.
Perform a thenar flap.
Perform a cross-finger flap to the ring finger.

Correct Answer: Continue wet-to-dry dressing changes until the wound heals by secondary intention.

Explanation:

DISCUSSION: The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.
REFERENCES: Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 56:

Options:

Increase his current opioid medication regimen prior to and after surgery as needed to control his pain.
Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.
Avoid using narcotics in the perioperative period to prevent overdose, and use acetaminophen only for pain control.
Stop all his opioids 5 days before surgery, and place the patient on a morphine pain control pump postoperatively with a basal rate.

Correct Answer: Decrease his preoperative opioid use, and work with his pain management physician to decrease his postoperative opioid requirement.

Explanation:

Question 57:

Options:

Complex regional pain syndrome
Osteoarthritis
Osteosarcoma
Osteonecrosis
Inflammatory arthritis

Correct Answer: Osteonecrosis

Explanation:

DISCUSSION: Osteonecrosis of the tibial plateau occurs infrequently. The symptoms are similar to those of idiopathic osteonecrosis of the medial femoral condyle and include pain and tenderness of the medial aspect of the knee and a slight synovitis. The range of motion of the knee remains within normal limits, and no gross deformity is present. Osteonecrosis of the tibial plateau is easily misdiagnosed as degenerative meniscus or osteoarthritis of the compartment of the knee. Review of lateral radiographs may reveal an osteopenic area in the subchondral bone of the medial tibial plateau. The diagnosis is more easily established with a bone scan where increased uptake of radionucleides is shown over the medial tibial plateau. In osteoarthritic involvement of the medial compartment, uptake is over both the medial femoral condyle and the medial tibial plateau, whereas if osteoarthritis involves the entire knee, uptake is diffuse over the entire joint. Radiographic findings in complex regional pain syndrome are normal as opposed to the findings for osteonecrosis or osteoarthritis. Osteosarcoma has a characteristic radiographic appearance of a bone-forming tumor. Loose bodies can derive from osteochondral fractures; a history of trauma is usually elicited. Osteoarthritis usually presents with joint space narrowing accompanying the weight-bearing pain.
REFERENCES: Soucacos PN, Berris AE, Xenakis TH, et al: Knee osteonecrosis: Distinguishing features in differential diagnosis, in Urbanik JR, Jones JD (eds): Osteonecrosis. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 413-424.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am 1995;77:596-601.

Question 58:

What is the most common nonanesthetic-related reversible cause of changes in intraoperative neurophysiologic monitoring data? Review Topic

Options:

Pedicle screw misplacement
Patient positioning
Spinal cord ischemia
Retractor placement
Hypotension

Correct Answer: Patient positioning

Explanation:

Question 59:

Options:

Giant cell tumor of the tendon sheath
Gouty tophi
Aggressive fibromatosis
Tendon rupture
Synovial cell sarcoma

Correct Answer: Tendon rupture

Explanation:

Question 60:

Options:

McCune-Albright syndrome
Neurofibromatosis, type I (NF-1)
Neurofibromatosis, type II (NF-2)
Paget’s disease
Ollier’s disease

Correct Answer: McCune-Albright syndrome

Explanation:

Question 61:

Options:

continued use of a sling for 3 to 4 weeks, followed by repeat radiographs.
open reduction and internal fixation of the greater tuberosity fracture.
repeat reduction and placement of an abduction orthosis.
hemiarthroplasty.
percutaneous pinning.

Correct Answer: open reduction and internal fixation of the greater tuberosity fracture.

Explanation:

Question 62:

Revision of failed hip resurfacing arthroplasty should involve

Options:

the acetabular component only.
the femoral component only.
both femoral and acetabular components.
only components that are loose or malpositioned.

Correct Answer: both femoral and acetabular components.

Explanation:

Question 63:

Options:

The athlete must wear a functional brace for all athletic activities for 2 years following reconstruction.
The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.
The athlete must wear a functional brace for 2 years following reconstruction for basketball only; other athletic activities such as running and tennis are allowed without the brace.
The athlete must wear a custom-fit functional brace for 2 years following reconstruction because off-the-shelf braces produce inferior results.

Correct Answer: The athlete may wear a functional brace for athletic activities; however, no evidence exists to show the brace decreases the rate of ACL retear.

Explanation:

DISCUSSION FOR QUESTIONS 89 THROUGH 95
The athlete most likely suffered an acute ACL rupture however the presence of a lipohemarthrosis is concerning for the possibility of an intraarticular fracture. Because of this, the patient should not be allowed full weight bearing until a fracture is ruled out with radiographs. Given the athlete’s inability to perform a straight leg raise, the extensor mechanism is not functioning and a telescoping knee brace locked in extension should be utilized. A neoprene knee sleeve does not have a role in the
treatment of this acute injury.The radiographs reveal a lateral avulsion fracture off of the proximal tibial epiphysis which is known as a Segond fracture. It is indicative of an ACL injury and the fracture fragment seen is the consequence of the lateral capsule injury sustained during the pivot-shift mechanism. There is no radiographic evidence of a medial tibial plateau fracture. A radiographic sign of a chronic MCL injury is known as a Pellegrini-Stieda lesion and this is seen as calcification of the femoral origin of the MCL. A radiographic sign of an acute LCL rupture would be an avulsion fracture of the tip of the fibula.The MRI shows kissing contusions of the posterolateral tibial plateau and the midpoint of the lateral femoral condyle. These “kissing lesions” are seen as a result of a pivot shift mechanism of injury and are diagnostic for an ACL rupture. The most common associated injury in an acute ACL rupture is a lateral meniscus tear. Medial meniscus tears are more common in chronic ACL injuries. PCL rupture and PLC injury are all associated injuries seen in acute ACL rupture; however, these are much less common than meniscal tears. The team physician has a role in encouraging, but
not demanding, the athlete to report the injury andtreatment to the scholarship school’s coaching staff. What the athlete decides to do is his decision; the physician would be violating the athlete’s HIPAA rights as well as their confidence by reporting it directly to the scholarship school. Clearly the physician should not discourage the athlete from reporting the injury. The athlete is 18 years old and, as such, the physician would need the athlete’s permission to discuss any medical issues with the family in keeping with HIPAA.
The athlete’s exam demonstrates incompetence of both bundles of the ACL as demonstrated by the loss of stability with anterior translation of the tibia (Lachman test) as well as with rotation (pivot shift). The external rotation stress with the knee in 30 degrees of flexion tests the competence of the posterolateral corner while rotation at 90 degrees of flexion tests the PCL. Since the athlete’s knee is stable to posterior drawer testing demonstrating an intact PCL and the external rotation at 30 degrees is equivalent to that at 90 degrees, the posterolateral corner in intact.
The ACL has two separate and distinct bundles, the AM and PL. Each bundle takes on tension at varying degrees of knee flexion and therefore each bundle is thought to have a varying contribution to the stability of the knee. The AM bundle takes on tension with the knee in flexion and the PL bundle is tight in extension. Neither bundle is isometric during knee range of motion. Both bundles have contributions to rotational stability of the knee throughout the range of motion.
The success of traditional trans-tibial single-bundle ACL reconstruction has recently been called into question given the demonstration of persistent rotational instability following reconstruction. The persistence of rotational instability in trans-tibial single bundle ACL reconstruction has been attributed to the location of the graft in a vertically malpositioned femoral tunnel. The goal of double-bundle ACL reconstruction is to more accurately reproduce the native ACL and provide grafts that contribute to anteroposterior stability as well as rotational stability by placing the grafts in more anatomic locations not central in the knee axis. There is an increased cost and surgical time associated with double-bundle reconstruction.
The use of functional braces following ACL reconstruction is a surgeon’s preference because there is no difference in retear rate with or without a brace. Some authors recommend brace use for one to two years following ACL reconstruction for all athletic activities, but this is not supported by the literature. No literature exists showing a higher rate of reinjury with a functional brace and off-the shelf and custom braces have been found to be equivalent leading those who advocate for braces to recommend off-theshelf braces given their significantly lower cost.

Question 64:

Options:

Allograft reconstruction with semitendinosis weave to the humerus
Latissimus dorsi tendon transfer
Electrical stimulation
Shoulder arthrodesis
Arthroscopic pectoralis major tendon repair

Correct Answer: Allograft reconstruction with semitendinosis weave to the humerus

Explanation:

Question 65:

Options:

Fracture
Patella baja
Patella alta
Osteonecrosis
Maltracking

Correct Answer: Patella baja

Explanation:

DISCUSSION: Patella baja is commonly encountered when converting a high tibial osteotomy (HTO) to a TKA. Patella baja most likely occurs because of scarring. Meding and associates’ study did not show an increased rate of lateral release when converting a knee that had undergone a previous HTO.
REFERENCES: Yoshino N, Shinro T: Total knee arthroplasty after failed high tibial osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE, et al (eds): The Adult Knee. Philadelphia, PA,
JB Lippincott, 2003, vol 2, pp 1265-1271.
Meding JB, Keating EM, Ritter MA, et al: Total knee arthroplasty after high tibial osteotomy:
A comparison study in patients who had bilateral total knee replacement. J Bone Joint Surg Am 2000;82:1252-1259.

Question 66:

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 67:

Options:

Decreased extent of cord edema only
Decreased extent of cord hemorrhage only
Decreased extent of both cord edema and hemorrhage
Increased extent of cord hemorrhage but decreased edema
No difference in extent of hemorrhage and edema

Correct Answer: Decreased extent of cord hemorrhage only

Explanation:

Question 68:

Options:

Reduced radial artery pulse
Double break in the ipsilateral superior shoulder suspensory complex
Elevated hemidiaphragm
Musculocutaneous nerve deficit
Drooping of the left eyelid

Correct Answer: Reduced radial artery pulse

Explanation:

Question 69:

- Figure 12 shows the frog-lateral radiograph of a 45-year-old man who has a painful left hip. What is the most likely diagnosis?

Options:

traumatic femoral head fracture
osteonecrosis
osteoarthritis
neuropathic joint
rheumatoid arthritis

Correct Answer: osteonecrosis

Explanation:

Question 70:

Options:

Lining up of collagen fibers within the ligaments
Stretching of elastin within the disk and ligaments
Transition between flexion and extension
Reversible elongation of the soft tissues
Traumatic range of motion, resulting in damage to the soft tissues

Correct Answer: Traumatic range of motion, resulting in damage to the soft tissues

Explanation:

Question 71:

Venous thromboembolism may occur after total joint arthroplasty. The risk of this complication is elevated in patients with

Options:

a BMI lower than 30.
diabetes mellitus, with a hemoglobin A1c test result less than 7.
tranexamic acid use.
metabolic syndrome.

Correct Answer: metabolic syndrome.

Explanation:

Question 72:

Which of the following lesions most closely resembles Ewing’s sarcoma histologically?

Options:

Metastatic neuroblastoma
Osteosarcoma
Osteomyelitis
Fibrous dysplasia
Fracture healing

Correct Answer: Metastatic neuroblastoma

Explanation:

Question 73:

Options:

Decompression and posterior fusion at L4-L5
Epidural steroid injection at L4-5
Nonsteroidal medications and physical therapy for 6 weeks
Measurement of the ankle-brachial index
CT myelogram

Correct Answer: Measurement of the ankle-brachial index

Explanation:

DISCUSSION: The patient has symptoms that are more consistent with vascular claudication than with the pseudoclaudication anticipated from lumbar spinal stenosis. Therefore, the patient is a candidate for further vascular work-up. The radiographs reveal early spinal stenosis and spondylolisthesis at L4-5 but also show significant calcification of the iliac arteries, suggestive of peripheral vascular disease. Vascular claudication is a manifestation of peripheral vascular disease and presents with crampy leg pain that is exacerbated by physical exertion. The pain is easily relieved by standing still or sitting. Unlike pseudoclaudication, a forward-flexed posture and/or sitting does not improve the symptoms. Night pain is common in vascular claudication due to the elevation of the extremities and patients often report pain improvement by hanging their extremities in a dependent position. In evaluation of a patient with suspected vascular claudication, the five “P’s” of vascular insufficiency should be monitored, including pulselessness, paralysis, paresthesia, pallor, and pain. While pain and paresthesias can be common in both vascular claudication and pseudoclaudication, the presence of any of the remaining symptoms is suggestive of vascular disease.
REFERENCES: Aufderheide TP: Peripheral arteriovascular disease, in Rosen P, Barkin R (eds): Emergency Medicine: Concepts and Clinical Practice, ed 4. St Louis, MO, Mosby, 1998,
pp 1826-1844.
Mirkovic S, Garfin SR: Spinal stenosis: History and physical examination. Instr Course Lect 1994;43:435-440.

Question 74:

After closed reduction of the dislocation shown in Figure 42, it is essential to avoid placing the upper extremity in what position for the first 4 to 6 weeks?

Options:

Abduction
External rotation
Internal rotation
Extension
Elevation

Correct Answer: Internal rotation

Explanation:

Question 75:

Options:

Halo-vest orthosis
C1-C2 posterior cervical fusion
Occiput to C2 posterior cervical fusion
Cervical traction and closed reduction
Open reduction and internal fixation of C1

Correct Answer: C1-C2 posterior cervical fusion

Question 76:

Options:

Higher Constant scores at 12 months
Increased rates of re-rupture as determined by ultrasound
Equivalent functional outcomes
Less pain at 6 months
Inceased range of motion at 12 months

Correct Answer: Higher Constant scores at 12 months

Explanation:

Question 77:

Options:

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

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

Explanation:

Question 78:

Options:

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

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

Question 79:

Options:

Keeping a smooth plastic cannula in each portal after it is established
Using an image intensifier to localize the loose body
Distending the elbow joint capsule prior to establishing the anterolateral portal
Placing the scope in the proximal anteromedial portal and then enlarging the anterolateral portal so that it is bigger than the maximum diameter of the loose body
Breaking up the loose body into several pieces prior to extracting it

Correct Answer: Distending the elbow joint capsule prior to establishing the anterolateral portal

Explanation:

Question 80:

What vessel is marked with an asterisk in Figure 44?

Options:

Obturator artery
Inferior epigastric artery
Superior gluteal artery
Internal pudendal artery
Lateral sacral artery

Correct Answer: Superior gluteal artery

Explanation:

DISCUSSION: The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column.
REFERENCES: Agur AM, Dalley AF (eds): Grant’s Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.
Uflacker R: Atlas of Vascular Anatomy: An Angiographic Approach, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006.

Question 81:

What is the most common reason an individual with a malignant soft-tissue tumor in the extremities seeks medical attention?

Options:

Incidental finding on imaging tests
Pain
Presence of a mass
Deformity
Neurologic symptoms

Correct Answer: Presence of a mass

Explanation:

Question 82:

Options:

Rheumatoid factor
HLA-B27
Synovial fluid analysis
MRI of the upper cervical spine
Urine screen for tetrahydrocannabinol (THC)

Correct Answer: MRI of the upper cervical spine

Explanation:

Question 83:

A 22-year-old woman injured her ankle when she fell off a ladder. Radiographs reveal a displaced large posterior malleolus fracture of about 45% of the joint. What is the best definitive treatment?

Options:

Open reduction and internal fixation with absolute stability
Open reduction and internal fixation with relative stability
Closed reduction with casting
Reamed locked intramedullary nailing
External fixation

Correct Answer: Open reduction and internal fixation with absolute stability

Explanation:

Basic understanding of fracture care requires a fundamental knowledge of the principles regarding absolute and relative stability. Compression plating and anatomic reduction of articular fractures are examples of absolute stability. Bridge plating, external fixation, casting, and intramedullary nailing are all examples of relative stability. Both bone forearm fractures have long been treated with open reduction and internal fixation even in the light of open wounds. Results have been excellent with plate fixation. Recently, intramedullary nails that are contoured and locked have been used in the treatment of both bone forearm fractures, but they are not reamed. It is well established that with restoring the proper radial bow, length, and alignment,
optimal function can be achieved. Open reduction and internal fixation allows this achievement. In cases where comminution exists, absolute stability may have to be sacrificed so as to not strip small comminuted bone fragments. Therefore, a bridging technique is worthwhile. External fixation can be used as a temporary technique until the soft tissues are more amenable to definitive fixation. Cast treatment is not indicated in adult forearm fractures. Locking nails for forearm use are not reamed. With regards to articular fractures, anatomic reduction and rigid stabilization are required to achieve the best results and allow for fracture healing. This environment also allows for the best chance of the cartilage repair process to form "hyaline-like" cartilage. Open reduction and internal fixation with absolute stability is the mainstay of treatment for partial articular fractures such as split depression tibial plateau fractures and posterior malleolus fractures involving greater than about 25% to 30% of the joint. The gold standard for the treatment of a closed femur fracture is a reamed intramedullary locked nail. Results are uniformly excellent. This can be done without stripping of the soft tissues such as in open reduction and internal fixation. External fixation can be used as a temporary device in patients in extremis for damage control reasons.Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986 Sep;68(7):1008-17.
http://www.ncbi.nlm.nih.gov/pubmed/3745238')">View Abstract at PubMedJones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am. 2011 Jul;36(7):1216-9. Epub 2011 May

Question 84:

- A 10-year-old boy twisted his ankle while skateboarding and has pain and swelling around the lateral ankle just distal to the fibula. Radiographs are obtained and a lesion is identified in the distal tibia as seen in Figures 273a and 273b. Two weeks later he has no pain to palpation in the region and denies antecedent pain. What is the most appropriate treatment for this lesion?

Options:

Biopsy
Naprosyn
Observation
Radio frequency ablation
Curettage and bone grafting

Correct Answer: Curettage and bone grafting

Explanation:

Question.1 .A 49-year-old weekend athlete has a 4-week history of pain in his unilateral plantar heel that is most severe for the first 20 steps upon arising in the morning. He has an area of maximal tenderness on the plantar medial aspect of the heel pad at the origin of the plantar fascia. He has only improved 30% after a 3-week course of physical therapy with toe intrinsic muscle strengthening and arch- and tendo-Achilles stretching. What is the best next treatment step?
Release the plantar fascia.
Inject the plantar fascia with platelet-rich plasma.
Prescribe a night splint and continue physical therapy.
Administer extracorporeal shockwave therapy to the heel.
Perform a series of 3 steroid injections into the plantar fascia.
Question.2 .Figures 16a and 16b are the radiographs of a 38-year-old carpenter with progressively worsening ankle pain; 14 years ago, he was involved in an all-terrain vehicle collision. Anti-inflammatory medication,corticosteroid injections, and bracing no longer effectively control his pain. The pain now interferes with his work and family responsibilities. Examination reveals an antalgic limp, varus deformity, limited ankle motion, limited eversion, and normal strength. Treatment should now consist of
ankle arthrodesis.
total ankle arthroplasty.
distal tibia osteotomy.
lateral ligament repair.
deltoid ligament release.
Question. 3 .A 48-year-old woman had total knee arthroplasty. She is unable to “lift her toes or ankle to her nose.”After 2 months of physical therapy, she has a slapping gait. What is the best next treatment step?
Ankle fusion
Ankle-foot orthosis
Sural nerve graft
Medial heel post
Laminectomy of L4/5
Question. 4 .Figures 46a through 46c are the CT scans of an 18-year-old who sustained an injury 3 weeks ago and now has ankle pain. Examination reveals an ankle effusion and painful range of motion. Recommended treatment should consist of
transtalar drilling.
fixation of the fragment.
osteochondral autograft.
weight bearing in a boot with early range of motion.
cast immobilization and nonweight-bearing activity for 6 weeks.
Question. 5 .A 47-year-old woman has a closed, displaced, Weber C bimalleolar ankle fracture. Past medical history includes diabetes mellitus for 7 years controlled with diet and an oral hypoglycemic agent. Semmes-Weinstein sensory testing reveals absence of sensation to the 5.07/10-gm monofilament on the plantar aspect of both feet. The skin is intact with 2+ pedal pulses. Treatment should include
open reduction with limited internal fixation.
closed reduction and application of an external fixator.
closed reduction and total contact cast immobilization.
retrograde intramedullary rod fixation with ankle fusion.
internal fixation and an extended period of immobilization.
Question. 6 .Figures 68a and 68b are the clinical photographs of a 55-year-old woman who had a right hindfoot fusion 3 years ago for a pes planovalgus deformity. Since the surgery, she has had lateral hindfoot pain and places most of the weight-bearing load on the lateral border of her foot when walking. What is the most likely cause of her symptoms?
Deltoid insufficiency
Excessive forefoot abduction
Residual heel valgus
Residual Achilles tendon contracture
Malposition of the transverse tarsal joint

Question 85:

Induction coupling stimulates bone growth through all of the following direct effects EXCEPT:

Options:

Increased proliferation of osteoblasts
Decreased osteoclast differentiation
Increase release of TGF-beta1
Increased expression of BMP2
Increased expression of BMP7

Correct Answer: Increased proliferation of osteoblasts

Explanation:

Question 86:

Options:

Incomplete corticotomy
Knee subluxation
Wire breakage
Poor regenerate bone formation
Premature consolidation

Correct Answer: Premature consolidation

Explanation:

DISCUSSION: Premature consolidation is a complication that is unique to gradual bone lengthening after corticotomy. Causes include excessive latency period, inadequate distraction rate, exuberant bone formation, patient compliance problems, and mechanical failure of the distraction apparatus. The femur and fibula are most commonly involved. This patient did not have an incomplete corticotomy, as initial distraction occurred before the distraction device was noted to seize up. The radiographs show bowing of the Ilizarov wires and mature regenerate bone, both suggestive of premature consolidation. No wire breakage or joint subluxation is seen on the radiographs. Treatment for premature consolidation includes continuing distraction until the consolidation bridge ruptures, or additional surgery may include closed rotational osteoclasis or repeat corticotomy.
REFERENCES: Paley D: Problems, obstacles and complications of limb lengthening, in Maiocchi AB, Aronson J (eds): Operative Principles of Ilizarov. Baltimore, MD, Williams & Wilkins, 1991, p 360.
Herring JA: Limb length discrepancy, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics,
ed 3. Philadelphia, PA, WB Saunders, 2002, p 1088.

Question 87:

Options:

An unknown prognosis until they can participate in an examination.
Higher rates of neurologic deficit and mortality than other same-age people.
Higher rates of neurologic deficit than other same-age people, but comparable mortality rates.
Similar rates of neurologic deficit and mortality as other same-age people.

Correct Answer: Higher rates of neurologic deficit and mortality than other same-age people.

Explanation:

DISCUSSION
Several studies have found that rates of neurologic deficit and mortality are higher for patients with ankylosing spondylitis and a spinal fracture than for age-matched controls. The 2011 work of Schoenfeld and associates, which directly compared patients with cervical fractures in ankylosed spines to age-and sex-matched controls who also had cervical fractures but no ankylosing condition, demonstrated that those with ankylosing spondylitis were at elevated risk for mortality for up to 2 years after sustaining a fracture. In a study by Westerveld and associates, the rate of neurologic deficit among patients with ankylosing spondylitis and a spinal fracture was 57.1% compared to 12.6% among controls.
RECOMMENDED READINGS
Westerveld LA, van Bemmel JC, Dhert WJ, Oner FC, Verlaan JJ. Clinical outcome after traumatic spinal fractures in patients with ankylosing spinal disorders compared with control patients. Spine J. 2014 May 1;14(5):729-40. doi: 10.1016/j.spinee.2013.06.038. Epub 2013 Aug 27. PubMed PMID: 23992936.
View
Abstract at PubMed
Schoenfeld AJ, Harris MB, McGuire KJ, Warholic N, Wood KB, Bono CM. Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study. Spine J. 2011 Apr;11(4):257-64. doi: 10.1016/j.spinee.2011.01.018. Epub 2011 Mar 5. PubMed PMID: 21377938.
View
Abstract at PubMed

Question 88:

Options:

UCBL orthoses.
triple arthrodesis with Achilles tendon lengthening.
medial calcaneal osteotomy with posterior tibial tendon reconstruction and flexor digitorum longus tendon transfer.
medial calcaneal osteotomy with posterior tibial tendon reconstruction, flexor digitorum longus tendon transfer, and lateral column lengthening.
gastrocnemius lengthening and serial casting.

Correct Answer: triple arthrodesis with Achilles tendon lengthening.

Explanation:

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 89:

Options:

Sling immobilization and rest
Physical therapy for aggressive stretching
Intra-articular corticosteroid injection and stretching program
Manipulation of the shoulder under anesthesia
Arthroscopic subacromial decompression and capsular release

Correct Answer: Intra-articular corticosteroid injection and stretching program

Explanation:

Question 90:

Which of the following is a recognized predictor of mortality after hip fracture?

Options:

American Society of Anesthesiologist (ASA) classification
Post-operative weight bearing status
Fracture comminution
Fixation device used
Hip fracture type

Correct Answer: American Society of Anesthesiologist (ASA) classification

Explanation:

Question 91:

Options:

a soft cervical collar.
a rigid cervical collar.
halo vest immobilization for 3 months.
simple midline (Rogers) wiring.
lateral mass plate fixation at C4-C6.

Correct Answer: lateral mass plate fixation at C4-C6.

Explanation:

Question 92:

Options:

remain essentially unchanged in size.
result in neurologic deterioration.
gradually resorb and widen the spinal canal.
potentially migrate within the spinal canal.
increase the risk of further injury to the adjacent dural sac.

Correct Answer: gradually resorb and widen the spinal canal.

Explanation:

Question 93:

The posterior horn of the medial meniscus receives its primary blood supply from what artery?

Options:

Middle genicular
Medial inferior genicular
Medial superior genicular
Lateral superior genicular
Inferior lateral genicular

Correct Answer: Middle genicular

Explanation:

DISCUSSION: The middle genicular artery supplies the posterior capsule and intracapsular structures (anterior cruciate ligament, posterior cruciate ligament, posterior horns of the meniscus). The medial and lateral inferior geniculates anastomose anteriorly to form a capillary network to supply the fat pad, synovial cavity, and patellar tendon. The lateral superior and inferior genicular arteries supply the lateral retinaculum.
REFERENCES: Insall J, Scott WN: Anatomy, in Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, pp 64-70.
Scapinelli R: Vascular anatomy of the human cruciate ligaments and surrounding structures. Clin Anat 1997;10:151-162.

Question 94:

What tendon is closest to an appropriately placed anterolateral portal for ankle arthroscopy?

Options:

Peroneus brevis
Extensor digitorum longus
Extensor hallucis
Tibialis anterior
Peroneus tertius

Correct Answer: Peroneus tertius

Explanation:

Question 95:

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

Options:

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

Correct Answer: Age 40 or younger for women

Explanation:

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

Question 96:

Which of the following is considered an advantage of arthroscopic distal clavicle excision compared with open distal clavicle excision?

Options:

Fewer complications
Lower infection rate
Evaluation of the glenohumeral joint
Preservation of the inferior acromioclavicular ligament
Decreased surgical time

Correct Answer: Evaluation of the glenohumeral joint

Explanation:

Question 97:

Options:

Arthroscopic labral debridement and biceps tenodesis
Shoulder arthroscopy with undersurface cuff debridement and acromioplasty
Cyst decompression at the spinoglenoid notch with possible labral repair
Cyst decompression at the suprascapular notch with possible labral repair This patient’s clinical and MRI findings are consistent with a posterior paralabral cyst with compression of the suprascapular nerve, specifically at the spinoglenoid notch. Compression of the suprascapular nerve can occur at either the suprascapular or spinoglenoid notch. Compression of the nerve at the suprascapular notch affects innervation to both the supraspinatus and infraspinatus muscles, resulting in weakness in both shoulder abduction and external rotation. However, compression at the spinoglenoid notch only affects innervation to the infraspinatus muscle, resulting in isolated weakness in external rotation. Compression at the spinoglenoid notch often is seen in overhead athletes, and studies have shown associated posterior labral tears (Piatt and associates). Several studies have addressed nonsurgical and surgical treatment options. The treatment decision should focus on the underlying cause (Martin and associates)—in this patient, the cyst. Nonsurgical treatment in the presence of a known lesion has been associated with a higher failure rate than addressing the lesion, which can result in functional improvement (Chen and associates, Cummins and associates). The best response in this scenario is decompression of the cyst at the spinoglenoid notch with possible labral repair.

Correct Answer: Shoulder arthroscopy with undersurface cuff debridement and acromioplasty

Explanation:

Question 98:

Options:

Kaposi sarcoma
Squamous cell carcinoma
Pigmented basal cell carcinoma
Melanoma
Basillary angiomatosis

Correct Answer: Melanoma

Explanation:

Question 99:

Options:

Child abuse workup
Closed reduction
Open reduction with possible osteotomy
Observation DISCUSSION-The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child’s history to suggest abuse.

Correct Answer: Observation DISCUSSION-The most appropriate management of this condition is observation. The patient most likely has a congenital dislocation of the radial head, although this may also represent a posttraumatic deformity. The absence of findings on physical examination speaks against an acute injury. The appearance of the radial head reveals the typical findings of a congenital dislocation, namely the convex appearance of the proximal radial articular surface. These children typically have very functional range of motion and do not require treatment unless they are symptomatic. There is nothing in this child’s history to suggest abuse.

Question 100:

Options:

Physical therapy including ultrasound and gentle stretches
Closed manipulation of the shoulder
MRI and possible rotator cuff repair
Open glenohumeral reduction, with possible lesser tuberosity transfer
Shoulder hemiarthroplasty

Correct Answer: Open glenohumeral reduction, with possible lesser tuberosity transfer

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

OITE & ABOS Ortho Board Prep: Trauma, Foot & Ankle, Elbow MCQs | Part 166

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 166

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index