OITE & ABOS Orthopedic Board Prep MCQs | Part 168

About This Board Review Set

This is Part 168 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

How to Use the Interactive Quiz

Two distinct learning modes are available:

Study Mode — After selecting an answer, you immediately see whether you are correct or incorrect, together with a full clinical explanation and literature references.
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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 168

This module focuses heavily on: Dislocation, Foot, Knee, Scoliosis, Shoulder.

Sample Questions from This Set

Sample Question 1: Figures 36a and 36b show the MRI scans of a patient who has shoulder weakness. What is the most likely diagnosis?...

Sample Question 2: A 25-year-old recreational soccer player has recurrent shoulder dislocations. He first dislocated his shoulder playing football in high school, was treated in a sling for 6 weeks, and returned to play for the remainder of the season. He did...

Sample Question 3: Figures 33a and 33b show the standing posteroanterior and lateral radiographs of a 59-year-old woman with adult idiopathic scoliosis. She underwent a prior decompressive laminectomy and fusion at L4-S1 to address lumbar stenosis. She now re...

Sample Question 4: A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in F...

Sample Question 5: A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of...

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

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

Explanation

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

Question 2

A 25-year-old recreational soccer player has recurrent shoulder dislocations. He first dislocated his shoulder playing football in high school, was treated in a sling for 6 weeks, and returned to play for the remainder of the season. He did well until 2 years later when he reinjured the shoulder. He says that his shoulder dislocates with little injury and always "feels loose." Examination reveals anterior instability and an MR arthrogram reveals an anterior-inferior labral tear and surgical treatment is recommended. He inquires about the benefits of arthroscopic vs open procedure. Which of the following statements reflects an advantage associated with arthroscopic procedures compared to open stabilization? Review Topic

Explanation

There is much debate in the literature regarding optimal techniques for treatment of shoulder instability. Most studies have suggested a slightly better range of motion of the shoulder after an arthroscopic repair. Recurrent instability rates have been slightly higher with arthroscopic procedures in some studies, while others show the rates are not statistically different. Return to work and/or sports has been shown to be equal or slightly better with open procedures.

Question 3

Figures 33a and 33b show the standing posteroanterior and lateral radiographs of a 59-year-old woman with adult idiopathic scoliosis. She underwent a prior decompressive laminectomy and fusion at L4-S1 to address lumbar stenosis. She now reports progressive lower back pain and a feeling of being shifted to the right. If surgical intervention is considered, what is the most important goal in improving her health-related quality of life (HRQL) outcomes? Review Topic

Explanation

Nonoperative management with NSAIDS and physical therapy is effective for 50% of patients
Surgical treatment is indicated in patients with diminished sensation
Surgical treatment is equivalent to nonoperative management in terms of pain and function
Good surgical outcome is associated with mainly back complaints
Size of disc herniations typically decrease over time without surgical intervention
The patient is presenting with a lumbar disc herniation at the L4-L5 level. The size of disc herniations decrease in most patients over time without surgical intervention.
Lumbar disc herniations are the result of recurrent torsional strain, which leads to small tears of the annulus fibrosus, ultimately allowing herniation of the nucleus pulposis. First line treatment consists of NSAIDS, muscle relaxants and physical therapy and is effective in 90% of patients. Second line treatment typically involves epidural and selective nerve root corticosteroid injections. Microdiscectomy is reserved for patients with more than 6 weeks of disabling pain that has failed nonoperative management, progressive weakness, or cauda equina syndrome.
In the Spine Patient Outcomes Research Trial (SPORT), Weinstein et al. investigated patient outcomes and satisfaction after operative and nonoperative management of lumbar disc herniations. While the randomized arm of the study did show statistically significant differences in the intent-to-treat analysis due to significant crossover of patients, the observational cohort revealed a significant improvement in pain, function, and disability for patients treated with surgery versus nonoperative measures.
Benson et al. looked at the natural history of massive herniated discs in 37 patients with 7-year follow up. They found a more than 60% reduction in disc size over this time period. Reduction in disc size did not correlate with clinical improvement.
Figure A and B are sagittal and axial T2 MRI images, respectively, showing a right sided lumbar disc herniation at the L4-L5 level.
Incorrect Answers:

Question 4

A 24-year-old female soccer player has had lateral joint line pain and a recurrent effusion in the left knee after sustaining a twisting injury 6 weeks ago. She reports that symptoms worsen with athletic activities. MRI scans are shown in Figures 2a through 2c. What is the most likely diagnosis?

Explanation

DISCUSSION: The MRI scans show the typical findings of a torn discoid lateral meniscus. The average transverse diameter of the lateral meniscus is 11 or 12 mm. A discoid lateral meniscus is suggested when three or more contiguous 5-mm sagittal sections on the MRI scan show continuity of the menicus between the anterior and posterior horns, or when two adjacent peripheral sagittal 5-mm sections show equal meniscal height. Normally the black “bow tie” would be seen on two contiguous sagittal sections. The presence of a discoid meniscus can be further confirmed if coronal views reveal increased width.
REFERENCES: Jordan MR: Lateral meniscal variants: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:191-200.
Resnick D, Kang HS: Internal Derangement of Joints: Emphasis on MRI Imaging. Philadelphia, PA, WB Saunders, 1997, pp 625-630.

Question 5

A paraplegic 32-year-old man was pulling himself up in bed by grasping the headboard rails when he felt a pop and immediate pain. A radiograph and CT scan are shown in Figures 2a and 2b. Based on these findings, management should consist of

Explanation

DISCUSSION: The coracoid process is an essential component of the superior shoulder suspensory complex and must be maintained. Open reduction and internal fixation is recommended if the fragment is large and displaced more than 1 cm.
REFERENCES: Froimson AI: Fracture of the coracoid process of the scapula. J Bone Joint Surg Am 1978;60:710-711.
Gil JF, Haydar A: Isolated injury of the coracoid process: Case report. J Trauma

1991;31:1696-1697.

Question 6

Figure A is the radiograph of an 11-year-old boy who fell directly on his left shoulder while riding a bicycle. He complained of pain in his left shoulder. An MRI scan of the injury is likely to reveal what findings? Review Topic

Explanation

In children, fractures of the distal clavicle are almost always through the distal physis and adjacent metaphysis, and, consequently, the acromioclavicular joint is rarely dislocated. The coracoclavicular ligaments usually remain attached to the thick periosteum on the undersurface of the clavicle and are rarely damaged. Because of the thick periosteum and intact ligaments, these fractures are inherently stable and heal well with conservative treatment. In contrast, similar injuries in adults pose a higher risk for surgical intervention.

Question 7

Regarding the role of the orthopaedic surgeon in addressing domestic and family violence, all of the following statements are true EXCEPT:

Explanation

DISCUSSION: Reporting requirements for adult spousal or intimate partner abuse is not standardized among states and it is the responsibility of the orthopaedic surgeon to understand the laws of his or her
state. The AAOS Advisory statement gives information to assist in meeting the ethical and legal obligations on Domestic and Family Violence and Abuse.
Domestic and family violence affects over 10% of the US population (approximately 32 million Americans). Child abuse and neglect contributed to 1,400 fatalities in 2002 and there was 565,747 reports of suspected elder abuse.
Reporting of suspected child abuse is required in all states. The orthopaedic surgeon should hospitalize elderly victims who are in immediate danger and help develop a plan to insure their safety.

Question 8

What is the most common location of osteosarcoma?

Explanation

DISCUSSION: The most common location of osteosarcoma is the knee area (50% to 55%), followed by the proximal humerus and iliac wing. The most commonly involved long bone is the femur (40% to 45%), followed by the tibia (15% to 25%). Within these bones, tumors are typically adjacent to the epiphyses in most patients. The flat bones of the pelvis and spine are less frequently involved.
REFERENCES: Malawer MM, Sugarbaker PH, Malawer M: Musculoskeletal Cancer Surgery: Treatment of Sarcomas and Allied Diseases. Kluwer Academic Publishers, 2001.
Wold LA, et al: Osteogenic Sarcoma: Atlas of Orthopedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 14-15.

Question 9

What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

Explanation

Proximal humeral locking plates have been associated with screw penetration (incidence 23%). The rotator cuff injury is not due to the plate or its application and is associated with dislocations in the elderly. Axillary nerve damage, while possible, has a low reported incidence from open reduction and internal fixation of the proximal humerus with locking constructs. Impingement and fracture of the humeral shaft are also unlikely. More likely but not offered as a choice is the problem of varus
reduction which can result in failure. However, penetration of the screws remains the most commonly reported complication.

Question 10

A cord-like middle glenohumeral ligament and absent anterosuperior labrum complex can be a normal anatomic capsulolabral variant. If this normal variation is repaired during arthroscopy, it will cause Review Topic

Explanation

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 11

An 18-year-old male soccer player sustains a knee injury during a game. Examination is notable for a positive pivot shift test. What other physical examination finding is most likely to be present? Review Topic

Explanation

The patient has sustained a tear of his anterior cruciate ligament (ACL), as demonstrated by the positive pivot shift test; therefore, he would most likely exhibit lateral joint line tenderness indicative of a lateral meniscus tear, the most common intraarticular injury associated with an ACL tear.
ACL tears usually occur as a result of a non-contact pivoting injury. Abnormal anterior translation results in bone contusions of mid-lateral femoral condyle and posterolateral tibia, which can be seen on MRI. Other concomitant intraarticular injuries include meniscal tears (lateral > medial), chondral damage and other ligamentous injury (MCL, LCL, PLC) usually found in cases of higher energy trauma such as a knee dislocation.
Piasecki et al prospectively analyzed intraarticular injuries associated with ACL tears in high school athletes by gender and sport. There was no significant difference in mechanism of injury between sexes. Female basketball and soccer players had fewer intraarticular injuries (medial femoral condyle lesions, medial and lateral meniscus tears) compared to male athletes. The authors hypothesized that women may therefore enjoy a better prognosis following reconstruction.
Spindler et al performed a prospective cohort study investigating concomitant intraarticular injuries in patients who underwent ACL reconstruction. Eighty percent of patients had a bone bruise on MRI, 68% involving the lateral condyle. At time of arthroscopic reconstruction, meniscal tears were identified in 56% of lateral menisci and 37% of medial menisci.
Incorrect Responses:

Question 12

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Explanation

What is the most common organism implicated in periprosthetic infection of the shoulder?
A. Methicillin-resistant Staphylococcus aureus (MRSA)
B. Cutibacterium acnes
C. Enterococcus species
D. Staphylococcus epidermidis
C acnes is the most common organism recovered in prosthetic shoulder infections (33%), Coagulase-negative Staphylococcus is second (21%), Methicillin-sensitive S aureus (13%), and S epidermidis (10%). MRSA accounts for 5% and Enterococcus species, 1.5%.

Question 13

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 14

Figure 23 is the T2 axial MRI scan of a 21-year-old man who was injured while playing for his college football team. His pain was aggravated with blocking maneuvers and alleviated with rest, and he had to stop playing because of the pain. What examination maneuver most likely will reproduce his pain? Review Topic

Explanation

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

Question 15

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

Explanation

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

Question 16

A 13-year-old boy has a mild deformity of the left sternoclavicular joint after being involved in a rollover accident while riding an all-terrain vehicle. Examination in the emergency department reveals that he is hemodynamically stable, and his neurovascular examination is normal. The CT scan shown in Figure 22 was obtained because radiographs were inconclusive. Management should consist of

Explanation

DISCUSSION: The CT scan reveals a completely displaced physeal fracture of the medial clavicle with marked posterior displacement of the distal fragment. This fracture pattern is associated with potential injury to the vascular structures of the mediastinum. Reduction should be performed for this fracture and generally can be done closed with shoulder retraction and upward pull on the clavicle with a towel clip. Once reduced, the fracture is relatively stable and typically will heal in good position. Reduction should be performed in the operating room in the event that a vascular injury is detected once compression is removed from the clavicle. Open reduction may be necessary if closed reduction is not possible; however, pinning or ligament reconstruction usually is not necessary.
REFERENCES: Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA,

WB Saunders, 1998, p 581.
Wirth MA, Rockwood CA Jr: Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268-278.

Question 17

Figures 1 and 2 are the radiographs of a 35-year-old right-hand-dominant man who has had progressive right wrist pain for 1 year. There is no history of trauma, and he has had no treatment to date. He reports some pain at rest with limited motion and substantial pain with use. He is currently out of work on short-term disability because of this wrist problem. An examination reveals mild dorsal wrist swelling, decrease wrist range of motion, and decreased grip strength. Contralateral wrist examination findings are normal. What is the most appropriate course of treatment?

Explanation

EXPLANATION:
This patient has late-stage Kienböck disease. According to the Lichtman classification for Kienböck disease, this would represent stage IIIB, with lunate collapse/fragmentation, loss of carpal height secondary to proximal capitate migration, and a flexed scaphoid. The lateral radiograph reveals a radioscaphoid angle exceeding 60 degrees, so disease stage is IIIB. According to Condit and associates, when the presurgical radioscaphoid angle exceeds 60 degrees, results are poor when an attempt to maintain the lunate is made. As a result, the procedure with the most predictable outcome is a proximal row carpectomy. A radial-shortening osteotomy could be performed because the ulnar variance is negative. Considering the marked lunate fragmentation and collapse, a vascularized bone graft likely is contraindicated and associated with less predictable results than a proximal row carpectomy. There is no role for supervised hand therapy and splinting in the setting of advanced Kienböck disease. Similarly, there is no role for maintenance of the lunate in the setting of advanced collapse and fragmentation.

Question 18

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Explanation

This patient has sustained a displaced extension-type supracondylar fracture. The most commonly affected nerve in this setting is the anterior interosseous nerve (AIN). This will affect thumb IP flexion.
The most common neurapraxia after pediatric extension-type supracondylar fractures involve the AIN. It supplies the FPL (thumb IP flexion), the pronator quadratus, and the FDP of the index/long fingers. Subsequently, patients are often unable to make an “a-ok” sign. Most of these neuropraxias resolve without complication. The ulnar nerve is most commonly implicated with flexion-type supracondylar fractures.
Abzug et al. review management of supracondylar fractures. They note that the AIN
is most commonly injured nerve in extension type supracondylar fractures. They note that nerve injuries often resolve within 6-12 weeks.
Babal et al. completed a meta-analysis to determine the risk of neurapraxia associated with pediatric supracondylar fractures. The rate of traumatic neurapraxia was 11.4% amongst 5000 patients. The AIN was affected 34.1% of the time. AIN neurapraxia was most common in extension type injuries.
Figures A and B show an AP and lateral radiographs of a displaced pediatric supracondylar fracture
Incorrect Answers

Question 19

A transverse humeral shaft fracture that occurs between a stiff arthritic shoulder joint; a stiff, arthritic elbow joint is treated nonsurgically in a hanging-arm cast

Explanation

DISCUSSION
In 1977, Perren and Cordey penned a German manuscript that first described an interpretation of mechanical influences on tissue differentiation. This became known as the Strain Theory of Perren. In 1980, a second manuscript by the same authors was published in English. Within this manuscript, Perren wrote, "These thoughts about the mechanical influences on tissue differentiation are not intended as conclusive evidence since precise data are still not available, but we hope that they will stimulate thought and provide a basis for discussion." More than 30 years later, these thoughts continue to stimulate discussion and research on cell mechanotransduction. This theory is still being manipulated in surgical theatres all around the world in an attempt to more consistently achieve fracture healing. Strain is a magnitude of deformation. As typically defined, it is the change in dimension of a deformed object during loading divided by its original dimension. This is difficult to work with intraoperatively. The fraction below illustrates a simpler way to regard this concept:
Strain = Magnitude of displacement between fragments during loading / Total resting distance between fragments after stabilization
By remembering that low strain generally leads to bone formation and healing, it is possible to manipulate this fraction intraoperatively to achieve success. When a simple fracture pattern is anatomically reduced and compressed, then the total resting distance between fragments after stabilization approaches 0. This means the numerator must be near 0 to achieve a low-strain environment. This is what occurs in absolute stability (no motion between fracture fragments under physiologic load) and primary bone healing occurs. When a multifragmentary fracture pattern is treated with bridge plating, the total resting distance between fragments after stabilization is a larger number (consider the additive distance between the different fragments). In this case, the numerator can be larger to achieve a low-strain environment. This is what happens in relative stability (controlled motion between fracture fragments under physiologic load). Secondary bone healing occurs. Now consider the third scenario: a simple fracture pattern that is fixed with a small gap. The total resting distance is still a small number. Based on the theory, eliminating motion by creating a stiff construct should lead to healing, but it does not. Creating absolute stability with a gap means that primary bone healing cannot occur (because cutting cones cannot cross the gap) and secondary bone healing cannot occur (because there is not enough motion to induce callus formation). This is where the strain theory breaks down and how many nonunions occur. In the fourth scenario, a high-strain environment is present and commonly leads to a nonunion (as predicted by the theory). The simple fracture pattern is too mobile, and nonfunctional callus often occurs.
RECOMMENDED READINGS
Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002 Nov;84(8):1093-110. Review. PubMed PMID: 12463652. View Abstract at PubMed
Epari DR, Duda GN, Thompson MS. Mechanobiology of bone healing and regeneration: in vivo models. Proc Inst Mech Eng H. 2010 Dec;224(12):1543-53. Review. PubMed PMID: 21287837.View Abstract at PubMed

Question 20

Scapular notching following reverse shoulder arthroplasty may be minimized by what technical modification? Review Topic

Explanation

Biomechanical studies have shown that a 10-degree inferior inclination may decrease scapular notching; whereas superior inclination may worsen notching. Scapular notching has been recognized as a complication following reverse shoulder arthroplasty. Mechanical abutment of the humeral component possibly leads to erosion of the anteroinferior scapular neck, with progressive vulnerability of the inferior baseplate screws. A horizontal humeral cut does not affect notching because the humeral component causes the notching, not the bone on the humerus. Glenosphere size has not been shown to correlate with scapular notching.

Question 21

A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:

Explanation

DISCUSSION: CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions. Kellam et al reviewed their initial experience
with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT.

Question 22

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

Explanation

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

Am J Orthop 2006;35:285-291.

Question 23

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Explanation

Several studies have shown worse functional results in patients older than 40 or 50 years of age compared to younger patients after open reduction and internal fixation of tibial plateau fractures. Two studies showed that older patients with less severe fractures performed less favorably than younger patients with more severe injuries. Only 35% of patients older than 50 years were satisfied with their results independent of fracture type.

Question 24

A deficiency of which of the following is associated with an increased risk of venous thromboembolism?

Explanation

Protein C and Protein S are endogenous proteins whose action is to inhibit the coagulation cascade. Deficiencies in these proteins are a risk factor for the development of thrombus. Prothrombin is the precursor to thrombin, which is the final common pathway for both the intrinsic and extrinsic coagulation cascade. Thrombin acts to convert fibrinogen to fibrin and thus clot formation.

Question 25

A total knee arthroplasty is recommended to a mentally competent 68-year-old woman who has disabling knee pain caused by degenerative arthritis. Her son has researched the procedure on the internet and prefers the Acme Female Knee for his mother. You have designed the Axis Woman's Knee, for which you receive royalties, and use it exclusively. Which of the following ethical principles takes precedence in guiding her treatment?

Explanation

Informed consent incorporates a number of ethical principles relevant to this case. The fundamentals of medical ethics include nonmaleficence, beneficence, autonomy, and justice. The patient is competent and capable of exercising her autonomy in choosing the Acme Female Knee. She also depends on her physician's paternalism and knowledge in looking out for her best interests, which in his opinion, may be use of the Axis Woman's Knee. The physician has a fiduciary responsibility to inform the patient that he has a financial interest in the implant system he recommends. A thorough informed consent will respect the patient's autonomy, explain the rationale for the physician's recommendation, and notify the patient that there may be a perceived conflict of interest. The ethical principle of justice has no relevance in this case.

Question 26

Figure A shows intraoperative images of a right knee in an 8-year-old boy after he sustained an injury. Which of the following is the most common indication for performing this procedure? Review Topic

Explanation

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment? Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 27

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Explanation

Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.

Question 28

What effect does deep freezing have on allograft tissue?

Explanation

DISCUSSION: Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue.
REFERENCES: Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in

knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.
Caspari RB, Botherfield S, Horwitz RL, et al: HIV transmission via allograft organs and tissues. Sports Med Arthroscopy Rev 1993;1:42-46.

Question 29

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

Explanation

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

Question 30

When treating thoracic disk herniations, which of the following surgical approaches has the highest reported rate of neurologic complications?

Explanation

DISCUSSION: Numerous surgical approaches have been used for thoracic diskectomy, including the most recent VATS. One of the first approaches described, posterior laminectomy, involves manipulation of the spinal cord, which the other approaches avoid. The posterior approach had dismal results, including further neurologic deterioration and even paralysis.
REFERENCES: Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864.
Benjamin V: Diagnosis and management of thoracic disc disease. Clin Neurosurg

1983;30:577-605.
Russell T: Thoracic intervertebral disc protrusion: Experience of 67 cases and review of the literature. Br J Neurosurg 1989;3:153-160.
Fessler RG, Sturgill M: Review: Complications of surgery for thoracic disc disease. Surg Neurol 1998;49:609-618.

Question 31

An 11-year-old boy with bipolar disorder fell from a tree and sustained an open fracture dislocation of the right ankle with extensive abrasions of the leg. Immediate irrigation, debridement, reduction, and provisional fixation with Kirschner wires was performed. Twenty-four hours later, the patient’s blood pressure is 190/100 mm Hg and pulse rate is 120. He has required only 1 dose of an oral analgesic for pain control. His foot and ankle are markedly swollen, but there is no pain on passive extension of the toes. The dorsalis pedis pulse cannot be palpated. What is the most appropriate next treatment step? Review Topic

Explanation

In situ pinning of right hip
Protected weight bearing and MRI of right hip
Immediate endocrine referral and treatment
Open biopsy right hip
In situ pinning bilateral hips PREFERRED RESPONSE 5
In patients with slipped capital femoral epiphysis (SCFE) and concomitant endocrinopathy, bilateral pinning is the recommended treatment.
This patient's laboratory values reveal hypothyroidism, which increases the risk of bilateral involvement. Thus, the most appropriate treatment recommendation is surgical fixation of both hips.
Wells et al. analyzed 131 SCFEs over a 30-year period. The authors noted that 100% of patients with associated endocrinopathy went onto contralateral slip and recommended not only prophylactic pinning, but in those with open triradiate cartilage, recommended preventative screening with TSH/Free T4 laboratory studies.
Riad et al. followed 90 patients and analyzed impact of age, gender and race on contralateral slip development. Girls under the age of 10 and boys under the age of 12 had a significantly increased risk of contralateral involvement. Therefore, the authors recommended contralateral pinning for girls and boys that met those age criteria, respectively.
Figure A exhibits a right SCFE on bilateral frog lateral views. Incorrect Answers:

Question 32

Which of the following is not a characteristic of synovial sarcomas?

Explanation

DISCUSSION: Synovial sarcomas have a number of features that differentiate them from other soft-tissue sarcomas. They often have small areas of calcifications within the lesion. They occur in a younger patient population than most soft-tissue sarcomas. A subset of patients with synovial sarcoma tend to be chemosensitive. They often contain the SYT-SSX translocation. Although they can occur intra-articular, this is rare, despite their name.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 1109-1126.
Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.

Question 33

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

Explanation

DISCUSSION: The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
REFERENCE: Lansinger O, Bergman B, Korner L, et al: Tibial condylar fractures: A twenty-year follow-up. J Bone Joint Surg Am 1986;68:13-19.

Question 34

maximize physical capacity and 4) obtain local control of the disease. Other trivia from the references include: After the lung and liver the skeletal system is the third most common site of metastasis. The spine is the most common site of skeletal metastasis. 60% of all skeletal lesions and 36% are asymptomatic. Breast, prostate, lung and renal carcinoma comprise 80% of the carcinomatous skeletal metastasis. 70% metastasis occur in the thoracic and thoracolumbar regions. 21% had involvement of the lumbar and sacral regions. 8% involved the cervical and cervicothoracic regions together. As many as 90% of patients who die of cancer may have Spinal metastasis at autopsy, and only half of patients who die from cancer will have symptoms from spinal mets. Fewer than 10% with spinal mets are treated surgically. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL., American academy of orthopaedic surgeons, 2002, pp 723-736. back to this question next question 03 What is the most frequently encountered complication following juvenile hallux valgus correction?

Explanation

Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a juvenile hallux valgus deformity.

OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 35

Figure 37 shows the clinical photograph of a 1-day-old infant who weighed 10.25 lb at birth. Examination reveals an absent right Moro reflex and limited active motion of the right shoulder, elbow, and wrist, but flexion of the fingers. Passive range of motion of the shoulder and elbow is normal. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient’s right upper extremity is held in the “head waiter’s” posture with the shoulder internally rotated, the elbow extended, and the wrist in flexion. The Erb type of obstetrical brachial plexus palsy involves the C5 and C6 nerve root, and occasionally, as in this child, the C7 nerve root. Obstetrical palsy is a traction injury, and is associated with a high birth weight, shoulder dystocia, cephalopelvic disproportion, or the use of forceps. Erb palsy is four times more common than injury to the entire plexus or injury to the C8 and T1 nerve roots. It results from the shoulder being depressed while the head and neck are laterally rotated, extended, and tilted in the opposite direction. Most patients recover wrist extension and elbow flexion. Patients with residual weakness of shoulder external rotation and abduction will benefit from release of the pectoralis major, latissimus dorsi, and teres major, with transfer of the latissimus dorsi and the teres major to the posterosuperior aspect of the rotator cuff. Recent studies using arthrograms and CT scans have shown a higher incidence of posterior glenoid deficiency and posterior subluxation than that observed with plain radiographs. The posterior subluxation or dislocation can be effectively reduced by tendon release and transfer procedures.
REFERENCES: Hoffer MM, Phipps GJ: Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:997-1001.
Pearl ML, Edgerton BW: Glenoid deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:659-667.
Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondary to brachial plexus birth palsy. J Bone Joint Surg Am 1998;80:668-677.

Question 36

A 41-year-old man who plays golf regularly has had ulnar-sided wrist pain for the past several days after striking a tree root with a golf club. Examination reveals significant pain with resisted flexion of the ring and small fingers and tenderness over the hook of the hamate. Which of the following radiographic views would be most helpful in identifying the pathology of this injury?

Explanation

DISCUSSION: The history and examination findings suggest an acute fracture of the hook of the hamate. The radiographic study considered most helpful in identifying this type of fracture is the carpal tunnel view. PA and lateral views of the wrist will not adequately visualize the hook of the hamate. Bruerton’s view is intended for the assessment of the metacarpophalangeal joints. Pathology would not be suspected in the scaphoid, metacarpals, or the phalanges, so the scaphoid view and the PA, lateral, and oblique views of the hand would not be helpful.
REFERENCES: Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, p 855.
Manske PR (ed): Hand Surgery Update. Rosemont, IL, American Society for Surgery of the Hand, 1994, pp 77-84.

Question 37

In patients with Crowe types III and IV developmental dysplasia of the hip with high hip centers, acetabular reconstruction often requires lowering the acetabular component into the native acetabulum. In doing so, considerable risk for limb lengthening beyond 4 cm exists, making the hip difficult to reduce and raising the risk for nerve injury. Which technique is used to overcome this problem?

Explanation

DISCUSSION:
When substantial lengthening of a dysplastic hip will occur because a high dislocation is relocated into a considerably lower acetabulum, a femoral shortening may be necessary to reduce the hip and avoid a stretch injury to the sciatic nerve. No other choice specifically addresses the need for femoral shortening, and high offset stems and lateralized liners may exacerbate the problem if used alone and without femoral shortening.

Question 38

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

Explanation

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

Question 39

Which of the following tissues has the highest maximum load to failure?

Explanation

DISCUSSION: All of the tissues noted above are stronger than native ACL. Although it is often thought that the bone-patellar tendon-bone graft is the strongest when selecting a graft source for ACL reconstruction, biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues listed.
REFERENCES: Woo SL, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225.
Staubli HU, Schatzmann L, Brunner P, et al: Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110.
Wilson TW, Zafuta MP, Zobitz M: A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207.

Question 40

Which of the following best describes athletic pubalgia?

Explanation

DISCUSSION: Athletic pubalgia refers to a distinct syndrome of lower abdominal and adductor pain that is mostly commonly seen in high performance male athletes. This condition must be distinguished from others such as painful inflammation of the symphysis pubis, referred to as osteitis pubis. Symptoms attributable to the iliopsoas tendon are most commonly associated with snapping of the tendon. Stress fracture of the pubic ramus may cause symptoms in this area, but it is usually confirmed by imaging studies. Neurapraxia of the pudendal nerve is associated with pressure from the seat in cycling sports and also as a complication associated with traction during surgical procedures.
REFERENCES: Meyers WC, Foley DP, Garrett WE, Lohnes JH, Mandlebaum BR: Management of severe lower abdominal or inguinal pain in high-performance athletes: PAIN (Performing Athletes with Abdominal or Inguinal Neuromuscular Pain Study Group). Am J Sports Med 2000;28:2-8.
Albers SL, Spritzer CE, Garrett WE Jr, Meyers WC: MR findings in athletes with pubalgia. Skeletal Radiol 2001;30:270-277.

Question 41

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

Explanation

DISCUSSION: V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of

the thumb.
REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

Question 42

A 73-year-old woman reports a 4-month history of severe left-sided posterior buttock pain and left leg pain. The leg pain radiates into the left lateral thigh and posterior calf with cramping. Examination reveals mild difficulty with a single-leg toe raise on the left side and a diminished ankle reflex. There is also a significant straight leg raise test at 45 degrees which exacerbates symptoms. An MRI scan is shown in Figure 4. What is the most appropriate treatment at this time? Review Topic

Explanation

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection? Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Question 43

Figures 1 and 2 are the most recent radiographs of an 18-year-old high school student who sustains an anterior shoulder dislocation playing recreational football. He has a low Beighton score on physical examination. He was closed reduced and underwent a course of physical therapy but had a second dislocation playing recreational basketball. What is the most appropriate course of treatment, with the lowest complication rate, to prevent further dislocation?

Explanation

The patient has recurrent instability and is at a high rate of further dislocations due to his young age. Therefore, therapy and bracing are unlikely to decrease his dislocation rate. The radiographs are normal, and there is no Hill-Sachs lesion or bony Bankart lesion. His instability severity index score is 3, and; therefore, a bony procedure such as Latarjet is not necessary. Furthermore, the rate of complication following a Latarjet procedure, especially nerve
injury and hardware problems, exceeds that of arthroscopic Bankart repair.

Question 44

What is the most likely cause of the lesion shown in Figures 35a and 35b?

Explanation

DISCUSSION: The most common cause of myositis ossificans is contusion. Certain regions, including the quadriceps and brachialis, are more commonly affected. The mechanisms of development have not been clearly established.
REFERENCES: Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al: Muscle injuries: Biology and treatment. Am J Sports Med 2005;33:745-764.

Question 45

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Explanation

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658. View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666. View Abstract at
PubMed

Question 46

In the first dorsal compartment of the wrist, what tendon most frequently contains multiple slips?

Explanation

DISCUSSION: The first extensor compartment of the wrist typically contains a single extensor pollicis brevis tendon and the abductor pollicis longus tendon that nearly always has multiple tendon slips. The extensor pollicis brevis tendon is frequently found to be separated from the slips of the abductor pollicis longus tendon by an intracompartmental septum. During surgery, this septum must be divided to complete the release of the compartment.
REFERENCES: Jackson WT, Viegas SF, Coon TM, Stimpson KD, Frogameni AD, Simpson JM: Anatomical variations in the first extensor compartment of the wrist: A clinical and anatomical study. J Bone Joint Surg Am 1986;68:923-926.
Minamikawa Y, Peimer CA, Cox WL, Sherwin FS: DeQuervain’s syndrome: Surgical and anatomical studies of the fibro-osseous canal. Orthopedics 1991;14:545-549.

Question 47

Figure 12 shows the lumbar CT scan of a 24-year-old man who was injured in a snowmobile accident. What is the mechanism of injury?

Explanation

DISCUSSION: A true compression fracture is a single-column injury that does not create canal compromise. A burst fracture is a two- or three-column injury that disrupts the middle column and thereby narrows the spinal canal. This patient has a burst fracture. The mechanism of injury is usually vertical compression or flexion compression.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Spivak JM, Vaccaro AR, Cotler JM: Thoracolumbar spine trauma: Principles of management. J Am Acad Orthop Surg 1995;3:353-360.

Question 48

Figure 33 shows the oblique radiograph of an 11-year-old boy who has a mild left flatfoot deformity. Examination reveals that subtalar motion is limited and painful. Despite casting for 6 weeks, the patient reports foot pain that limits participation in sport activities. A CT scan shows no subtalar joint abnormalities. Management should now include

Explanation

DISCUSSION: The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening

has been described for treatment of the peroneal spastic flatfoot without demonstrable

tarsal coalition.
REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Luhmann SJ, Rich MM, Schoenecker PL: Painful idiopathic rigid flatfoot in children and adolescents. Foot Ankle Int 2000;21:59-66.

Question 49

A 23-year-old professional baseball pitcher reports shoulder pain and decreased velocity while pitching. Physical examination reveals a side-to-side internal rotation deficit of 25 degrees. The O’Brien sign is negative; Neer and Hawkins signs are negative. Rotator cuff strength is full. Radiographs are unremarkable. What is the next step in management? Review Topic

Explanation

Throwing athletes with symptomatic internal rotation deficits often benefit from an intensive posterior capsular stretching program. Patients that fail to respond to nonsurgical management may benefit from an arthroscopic posterior capsular release.

Question 50

Which of the following pelvic injury types has the highest reported mortality rate?

Explanation

mechanism injuries all have lower mortality rates than APC injuries.

OrthoCash 2020

Question 51

Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?

Explanation

DISCUSSION: When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable.
REFERENCES: Phillips FM, Pfeifer BA, Leiberman IH, et al: Minimally invasive treatment of osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty. Instr Course Lect 2003;52:559-567.
Truumees E, Hilibrand A, Vaccaro AR: Percutaneous vertebral augmentation. Spine J 2004;4:218-229.
Rao RD, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 52

A middle-aged man sustains traumatic loss of the second, third, and fourth toes in a lawnmower accident. The wound is grossly contaminated with soil. Penicillin is added to his antibiotic regimen for coverage of what bacteria? Review Topic

Explanation

In farm or soil-contaminated wounds, including lawnmower injuries, penicillin is added to broad-spectrum cephalosporin and aminoglycoside therapy to cover against Clostridium. Psuedomonas is frequently seen after puncture wounds through the shoes. Acinetobacter is generally a hospital-acquired infection.

Question 53

Figures 1 and 2 are the radiographs of a 20-year-old college multisport athlete who has had longstanding pain in his left hip. He denies any specific event that initiated his pain, but he notes that he had hip problems when he was an infant. He denies pain with activities of daily living, but he believes his pain is increasingly limiting his ability to exercise. He localizes the pain to his groin. He denies low-back or buttock pain or pain that radiates down his leg. What is the most likely diagnosis for the source of this patient's pain?

Explanation

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 54

Which of the following nerves is most commonly injured when obtaining a bone graft from the posterior ilium?

Explanation

DISCUSSION: Cutaneous sensation to the buttock is provided by the superior, middle, and inferior cluneal nerves. The superior cluneal nerves are the lateral branches of the dorsal rami of the upper three lumbar nerves and penetrate deep fascia just proximal to the iliac crest. They pass distally to the skin of the buttock and will be injured if the exposure extends more than 8 cm anterolateral to the posterior superior iliac spine. The lateral femoral cutaneous nerve can be injured in an anterior ilium bone graft. The superior gluteal nerve or even the sciatic nerve can be injured if bone is removed from the sciatic notch or dissection is not kept subperiosteal; however, the rate of injury is far less than cluneal nerve injury. The L5 and S1 nerve roots are anterior and can be injured if the inner table bone is harvested and the dissection is not kept subperiosteal or is too medial; however, the rate of injury still is far less than cluneal nerve injury.
REFERENCES: Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, pp 295-297.
Hollinshead WH: Textbook of Anatomy, ed 3. Hagerstown, MD, Harper and Row, 1974, p 379.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 23.
Ebraheim NA, Elgafy H, Xu R: Bone-graft harvesting from iliac and fibular donor sites: Techniques and complications. J Am Acad Orthop Surg 2001;9:210-218.

Question 55

A 20-year-old basketball player has tenderness and bruising after sustaining a blow to the knee. A radiograph is shown in Figure 15. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a bipartite patella. The line between the fragment and the main patella is smooth and sclerotic, indicating a chronic, not acute, entity. The location is classic for a bipartite patella, not a tumor.
REFERENCES: Schmidt DR, Henry JH: Stress injuries of the adolescent extensor mechanism. Clin Sports Med 1989;8:343-355.
Weaver JK: Bipartite patellae as a cause of disability in the athlete. Am J Sports Med 1977;5:137-143.

Question 56

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

Explanation

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

Question 57

Radiographs of a 20-year-old college athlete who sustained an injury to the ankle reveal no fractures or widening of the ankle mortise. Examination shows swelling at the ankle region and pain with medial lateral compression of the distal tibiofibular joint. Which of the following studies would best help in confirming a diagnosis?

Explanation

Pain with medial-lateral compression of the distal tib-fib joint, swelling in the area and history of injury indicate disruption of the syndesmosis. External rotation stress of the ankle will open the joint space medially confirming the diagnosis.
2 and 3 are occasionally utilized when there is questionable involvement of surrounding bone or tendons. 4 rarely indicated for acute ankle sprain but can help in the diagnosis of RSD following ankle injury.

Question 58

During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery?

Explanation

DISCUSSION: The "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach.

Question 59

Posterior spinal fusion for scoliosis should be performed on a patient with Duchenne muscular dystrophy when

Explanation

DISCUSSION: Progressive scoliosis develops in most patients with Duchenne muscular dystrophy. The onset of spinal deformity typically follows the cessation of walking, and curves can be expected to progress about 10° per year. Posterior spinal fusion with instrumentation should be performed as soon as a curve of 25° or greater is documented and before deterioration of pulmonary function (a FVC of less than 30%) precludes surgery. Patients with kyphotic posture tend to progress more rapidly than those with lordotic posture. Brace treatment is contraindicated because it is not definitive and it may mask curve progression while pulmonary function is concomitantly worsening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, Ill, American Academy of Orthopaedic Surgeons, 1999, pp 635-651.
Mubarak SJ, Morin WD, Leach J: Spinal fusion in Duchenne muscular dystrophy: Fixation and fusion to the sacropelvis? J Pediatr Orthop 1993;13:752-757.

Question 60

below show the radiographs obtained from an year-old-woman who has had chronic left hip pain for several years. She now uses a walker and a wheelchair for ambulation. She is medically healthy. What is the most appropriate surgical intervention?

Explanation

DISCUSSION:
This 86-year-old woman has poor bone quality and osteoarthritis of the left hip. Her lateral radiograph confirms Dorr type C bone quality. A hybrid left THA with a cemented femoral stem would be the treatment of choice.

Question 61

Figure 27 shows the radiograph of a 68-year-old woman with a history of rheumatoid arthritis who was injured in a fall. History reveals that she has been asymptomatic since undergoing a left total knee arthroplasty 9 years ago. Management should consist of

Explanation

DISCUSSION: A supracondylar fracture of the femur that occurs after total knee replacement can be treated effectively by a number of methods. For this fracture, the use of a retrograde supracondylar nail has been found to be effective in several series. The treatment of these complex injuries needs to be individualized based on the stability of the implant, the quality of the bone, and the extent of comminution of the fracture. Revision with the use of an unstemmed implant will not result in effective stabilization of the knee or the fracture.
REFERENCE: Ayers DC: Supracondylar fracture of the distal femur proximal to a total knee replacement, in Springfield DS (ed): Instructional Course Lectures 46. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-203.

Question 62

Figures 25a and 25b show the radiograph and MRI scan of a 7 1/2-year-old boy who has been limping for 1 year. His pain has worsened over the past 2 weeks, and his parents note swelling over the dorsum of the foot for the past 4 days. Examination reveals no fever, and laboratory studies show a WBC of 6,700/mm 3 , an erythrocyte sedimentation rate of 26 mm/h, and a normal C-reactive protein level. What is the most likely diagnosis?

Explanation

DISCUSSION: The diagnosis of tuberculous osteomyelitis in children is often delayed. In one series of 23 children, the average interval between the onset of symptoms and definite diagnosis was 4.3 months. In these patients, the presenting signs and symptoms were found to be mild, with the most common signs being localized swelling (69.6%) and a painful disability of the involved limbs (65.2%). A mild elevation of the erythrocyte sedimentation rate may be present, but the C-reactive protein level is usually normal. In patients who have osteoarticular tuberculosis, an MRI scan generally shows large intra-articular effusions, periarticular osteoporosis, and gross thickening of the synovial membrane. Differential diagnosis between tuberculosis and pyogenic arthritis is difficult, and an accurate diagnosis usually requires biopsy of synovial tissue. Aspiration of synovial fluid often results in insufficient information to make a diagnosis. Treatment generally consists of surgical debridement and combined antituberculous chemotherapy with isoniazid, ethambutol, and rifampin.
REFERENCES: Wang MN, Chen WM, Lee KS, Chin LS, Lo WH: Tuberculous osteomyelitis in young children. J Pediatr Orthop 1999;19:151-155.
Watts HG, Lifeso RM: Tuberculosis of the bones and joints. J Bone Joint Surg Am 1996;78:288-298.

Question 63

-What is the most likely cause of an acute femur fracture in a 5-month-old child?

Explanation

Question 64

Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate treatment option?

Explanation

EXPLANATION:
This patient sustained a lesser-arc perilunate dislocation. As a result of the injury, he also developed acute carpal tunnel syndrome. The closed reduction attempt was unsuccessful; therefore, this injury is best managed with emergent surgery, an open carpal tunnel release, an open reduction of the perilunate dislocation, scapholunate ligament repair, and intercarpal pinning. Outpatient surgery in a delayed fashion is not advised because of the acuity and severity of the carpal tunnel syndrome. Closed reduction and casting is not advised, because it commonly leads to continued carpal instability with subsequent dorsal
intercalated segment instability deformity and scaphoid lunate advanced collapse wrist arthritis.

Question 65

The wear resistance of ultra-high molecular weight polyethylene can be improved by exposing the polymer to high-energy radiation (eg, gamma or electron beam), followed by a thermal treatment. What is one detrimental side effect of this process?

Explanation

DISCUSSION: Highly cross-linked polyethylene has gained widespread acceptance for joint arthroplasty components because of reported experimental and early clinical accounts of significant reductions in wear. Cross-linking is increased by imparting additional energy into the polymer (above that conventionally used for sterilization). The thermal treatments after cross-linking stabilize the material against oxidative degradation by quenching free radicals and also reduce the elastic modulus. One disadvantage of the increased cross-linking is a reduction in toughness that makes the polyethylene more susceptible to crack initiation and propagation. The reduced toughness raises concerns for gross component fracture and fracture at stress concentrations that can arise with the locking mechanisms used to secure polyethylene inserts into metallic backings. Nonconsolidated polyethylene particles have been associated with increased subsurface density secondary to oxidative degradation in conventional polyethylene implants. The quenching of free radicals by thermal treatment in highly cross-linked polyethylene should prevent this problem.
REFERENCES: Collier JP, Currier BH, Kennedy FE, et al: Comparison of cross-linked polyethylene materials for orthopaedic applications. Clin Orthop 2003;414:289-304.
Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 203-208.
Wright TM, Maher SA: Biomaterials, in Einhorn TA, O’Keefe RJ, Buckwalter JA (eds): Orthopaedic Basic Science: Foundations of Clinical Practice, ed 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, in press.

Question 66

A 22-year-old professional ballet dancer reports a 3-month history of posterior ankle pain that occurs when she changes from a flat foot to pointe (hyperplantar flexed position). Examination does not elicit the pain with forced passive plantar flexion. A radiograph is shown in Figure 8. What is the most likely cause of the pain?

Explanation

DISCUSSION: The most common causes of posterior ankle pain in ballet dancers are flexor hallucis longus tenosynovitis and os trigonum syndrome. Flexor hallucis longus tenosynovitis differs from a symptomatic os trigonum by the absence of pain with forced plantar flexion and the presence of pain with resisted plantar flexion of the great toe. The pain is often felt in the posterior ankle and can be associated with a snapping or triggering sensation. Os trigonum syndrome commonly occurs in ballet dancers who perform in a position of extreme plantar flexion. The pain occurs from entrapment of the os trigonum between the posterior portion of the talus and calcaneus.
REFERENCES: Hamilton WG, Geppert MJ, Thompson FM: Pain in the posterior aspect of the ankle in dancers: Differential diagnosis and operative treatment. J Bone Joint Surg Am 1996;78:1491-1500.
Khan K, Brown J, Way S, et al: Overuse injuries in classical ballet. Sports Med

1995;19:341-357.

Question 67

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 68

A 36-year-old man has a 2-day history of acute lower back pain with severe radicular symptoms in the left lower extremity. The patient has a positive straight leg test at 40 degrees on the left side and mild decreased sensation on the dorsum of the left foot. What is the most appropriate management at this time? Review Topic

Explanation

In the absence of any severe progressive neurologic deficits or other red flags, the most appropriate management for an acute lumbar disk herniation is nonsurgical care. Conservative treatments such as limited bed rest, anti-inflammatory medications, and judicious use of pain medications are appropriate in this clinical situation. Up to 90% of patients will experience a resolution of symptoms without the need for surgical intervention within a 3-month window. In the acute setting, with no neurologic deficits, immediate MRI of the lumbar spine is neither beneficial nor warranted. Likewise, without signs of an acute deficit, emergent surgical intervention and caudal epidural steroid injections are not needed.

Question 69

A 10-year-old child has leg discomfort with activity. A radiograph, bone scan, and biopsy specimen are shown in Figures 1a through 1c. What is the most likely diagnosis?

Explanation

DISCUSSION: The ground glass appearance on the radiograph, the hot bone scan, and histologic findings of bony spicules without osteoblastic rimming in a background of bland fibrous tissue all suggest fibrous dysplasia. Stress-related pain is common with activity because of the dysplastic bone. Parosteal osteosarcomas are surface lesions. Simple cysts, aneurysmal bone cysts, and eosinophilic granuloma are all possible radiographically; however, the histology is most consistent with fibrous dysplasia.
REFERENCES: Harris WH, Dudley HR Jr, Barry RS: The natural history of fibrous dysplasia: An orthopaedic, pathological and roentgenographic study. J Bone Joint Surg Am 1962;44:207.
Campanacci M: Bone and Soft Tissue Tumors. Vienna, Austria, Springer-Verlag, 1990.

Question 70

A 7-year-old male is struck by a motor vehicle while crossing the street and suffers an open tibia fracture with a crush injury of the ipsilateral foot. After multiple attempts at limb salvage, the family and treating surgeon elect to proceed with a knee disarticulation. What complication of pediatric amputations is avoided with a knee disarticulation as opposed to a transtibial amputation?

Explanation

DISCUSSION: Bone overgrowth is a poorly understood phenomenon in which the bone end undergoes disorganized appositional growth following amputation in a skeletally immature patient. Overgrowth is the most common complication following transosseous amputation in pediatric patients.
Krajbich reviews the management of pediatric patients with lower-limb deficiences and amputations. He advocates disarticulation as opposed to transosseous amputation when possible as bone overgrowth has not been observed in bone ends covered by articular cartilage.
O'neal et al retrospectively reviewed their rates of surgical revision for bone overgrowth in pediatric and adolescent amputees. The highest rates of revision were seen with metaphyseal-level amputations (50%) and with traumatic amputations (43%).
Benevenia et al reviewed their rates of overgrowth in skeletally immature transosseous amputees using an autogenous epiphyseal transplant from the amputated limb to cap the medullary canal. They found that only 1 of 10 patients undergoing amputation with this technique had complications due to bone overgrowth, compared with 6 of 7 patients undergoing traditional transosseous amputation.
Illustration A is a clinical photo of bone overgrowth eroding through the soft tissue in a transhumeral amputee. Illustration B demonstrates the radiographic appearance of bone overgrowth in a transtibial amputation.
Incorrect Answers:

Question 71

A patient is scheduled to undergo total knee arthroplasty (TKA) following failure of nonsurgical management. History reveals that she underwent a patellectomy as a teenager as the result of a motor vehicle accident. Examination reveals normal ligamentous stability. For the most predictable outcome, which of the following implants should be used?

Explanation

DISCUSSION: Paletta and Laskins performed a retrospective study of the results of TKA with cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate

ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar ligament thereby provides a strong reinforcing structure that functions to prevent excessive anterior translation of the femur during flexion of the knee. The absence of the patella results in the patellar ligament and the quadriceps tendon being relatively in line with one another. After a patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate ligament. This results in loss of the reinforcing function of the patellar ligament. The authors believe this loss of reinforcing function may place increased stresses on the posterior cruciate ligament and posterior aspect of the capsule, which may result in stretching of these structures over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum, and a high rate of loss of full active extension compared with passive extension in the posterior cruciate ligament-sparing group, which supports their theory.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.
Paletta GA Jr, Laskins RS: Total knee arthroplasty after a previous patellectomy. J Bone Joint Surg Am 1995;77:1708-1712.

Question 72

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Explanation

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.
Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, and
does not allow enough motion at the fracture site to form bone for healing by secondary intention.
Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.
Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.
Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.
Incorrect Answers:

OrthoCash 2020

Question 73

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures?

Explanation

DISCUSSION: Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.
REFERENCES: Clarke HD, Scott WN, Insall JN: Anatomic aberrations, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 67-85.
Patel D: Plica as a cause of anterior knee pain. Orthop Clin North Am 1986;17:273-277.

Question 74

A corset-type brace may help reduce symptoms during an episode of acute low back pain as the result of

Explanation

DISCUSSION: Although there is no significant alteration in motion with a corset, studies have shown a decrease in intradiskal pressure.
REFERENCES: Nachemson A, Morris JM: In vivo measurements of intradiscal pressure: Discometry, a method for determination of pressure in the low lumbar disc. J Bone Joint Surg Am 1964;46:1077-1092.
Axelsson P, Johnsson R, Stromqvist B: Effect of lumbar orthosis on intervertebral mobility: A roentgen stereophotogrammetric analysis. Spine 1992;17:678-681.

Question 75

A 58-year-old African-American female who sustained an injury to her upper arm six months ago presents with persistent arm pain. She was initially treated with splinting, with conversion to fracture bracing. She is neurovascularly intact. An injury radiograph and a current radiograph are shown in Figures A and B respectively. What nutritional or metabolic disturbance is the most likely associated with this patient's diagnosis? Review Topic

Explanation

This patient has sustained a humeral diaphyseal fracture that has gone on to an atrophic nonunion. Vitamin D deficiency is the most likely associated metabolic disturbance.
The incidence of nonunion with non-operative management of humeral shaft injuries ranges from 2-10%. Risk factors include vitamin D deficiency (most common), open fractures, segmental injuries, smoking and obesity. The optimal treatment is compression plating with bone grafting, which has been shown to be superior to intramedullary nailing with bone grafting or compression plating alone.
Ring et al. reviewed factors that contributed to humeral diaphyseal nonunion after fracture bracing. Fractures in the proximal to middle one-third of the shaft or fractures with a spiral/oblique pattern were more likely to go on to nonunion.
Brinker et al. reviewed 37 low-energy fractures that went onto nonunion. These patients were evaluated by clinical endocrinologists for evaluation of metabolic abnormalities. Thirty-one of the 37 patients (84%) had a metabolic issue, with 68% (25 of 37 patients) having Vitamin D deficiency.
Figure A demonstrates a humeral shaft fracture. Figure B demonstrates an atrophic nonunion of the humeral shaft fracture.
Incorrect Answers:

Question 76

A right-handed 24-year-old woman underwent an arthroscopic Bankart repair for recurrent anterior dislocations 9 months ago. Despite extensive physical therapy for 8 months, the patient has very limited range of motion (elevation to 130 degrees and external rotation to 10 degrees with the arm at the side). Shoulder radiographs are normal. The next step in management should consist of

Explanation

DISCUSSION: Arthroscopic capsular release is an effective means of treating stiffness that is the result of capsular contractures, such as in the case of a tight Bankart repair. Open release allows lengthening of a surgically shortened subscapularis, such as after a tight Putti-Platt repair. Additional physical therapy is unlikely to be effective because 8 months of treatment has failed to result in improvement. Accepting this degree of asymptomatic limited motion is not advisable because of the functional limitations for the patient and the increased risk of postoperative degenerative arthritis.
REFERENCES: Warner JJ, Allen AA, Marks PH, Wong P: Arthroscopic release of postoperative capsular contracture of the shoulder. J Bone Joint Surg Am 1997;79:1151-1158.
Harryman DT II, Matsen FA III, Sidles JA: Arthroscopic management of refractory shoulder stiffness. Arthroscopy 1997;13:133-147.

Question 77

A 77-year-old woman underwent semiconstrained right total elbow arthroplasty 4 weeks ago through a Bryan-Morrey approach. Her recovery was uneventful until 2 days ago when she began her physical therapy session at an outpatient clinic. During resisted extension exercises, she felt a "pop" in her elbow, accompanied with pain and inability to extend her elbow against resistance. What is the most likely cause of her symptoms? Review Topic

Explanation

During a Bryan-Morrey approach for total elbow arthroplasty, the triceps is dissected free from its ulnar insertion and reflected laterally. At the conclusion of the procedure, the triceps tendon is reattached to the ulna through drill holes. Whereas motion can be initiated postoperatively, 6 to 8 weeks of protection are recommended before initiation of resistance exercises to protect the triceps repair. A periprosthetic fracture or component failure is rare in the absence of more significant trauma, and they are usually late complications.

Question 78

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Explanation

DISCUSSION: The patient has a Salter-Harris type III fracture of the proximal phalanx of the thumb. It is usually caused by an abduction injury where the ulnar collateral ligament avulses a fragment away from the proximal epiphysis and is the most common childhood gamekeeper’s injury. If there is greater than 1 mm of separation or a significant articular step-off, an open reduction, performed through an extensor aponeurosis-splitting approach, is required to reestablish joint congruity and stability. Percutaneous or closed methods of reduction are usually ineffective. The dorsal approach avoids the volar neurovascular structures. Since the ulnar collateral ligament is still attached, this area does not need to be visualized. The major goal is to reestablish joint congruity and bony stability. This can be easily performed via the dorsal approach.
REFERENCES: Carey TP: Fracture and dislocations of the phalanges, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 435-436.
Ogden JA: Skeletal Injury in the Child. New York, NY, Springer-Verlag, 2000, p 668.

Question 79

A 34-year-old male arrives intubated with a closed head injury to the trauma bay after a motor vehicle accident. After initial hospital workup and resuscitation, he is transferred to the intensive care unit. In addition to multiple systemic injuries, he sustained the closed injury shown in Figure A. Intracompartmental pressure monitoring of the limb measure in a range from 28-30 mm Hg. Which of the following sustained blood pressure measurements would support the treatment of limb fasciotomy? Review Topic 1 110/60 mmHg 2 115/55 mmHg 3 92/64 mmHg

Explanation

A reported indication to perform fasciotomy includes an ICP measurement that is elevated to 30 mm Hg below the diastolic blood pressure. This would be the case if this patient's blood pressure was consistently around 115/55 mmHg (dBp=55; ICP=30; delta p = dBp-ICP = 25 mmHg).
Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam - especially with intubated patients. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy.
McQueen et al. prospectively reviewed 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of
30 mmHg is a more reliable indicator of compartment syndrome.
Olson et al. provide a review of compartment syndrome for the lower extremity. They discuss a variety of injuries and medical conditions that may initiate acute compartment syndrome, including fractures, bleeding disorders, and other trauma. Although the diagnosis is primarily a clinical one, they also recommend supplementation with compartment pressure measurements in equivocal cases.
Figure A shows a closed comminuted tibial shaft fracture. Incorrect Answers:

Question 80

The artery of Adamkiewicz (arteria radicularis, arteria magna) is most commonly found on the

Explanation

DISCUSSION: Approximately 75% of people have the artery on the left side between T9 and T11. Its relevance to iatrogenic spinal cord problems is still uncertain.
REFERENCES: Stambaugh J, Simeone F: Vascular complication in spine surgery, in Herkowitz HH (ed): The Spine, ed 4. Philadelphia, PA, WB Saunders, 1992, p 1715.
Lazorthes G: Arterial vascularization of the spinal cord. J Neurosurg 1971;35:253-262.

Question 81

-Figure 19 is the lateral weight-bearing radiograph of a 28-year-old man with a 3-week history of unrelenting heel pain after increasing his marathon training intensity. The pain never improves throughout the day. Each step he takes is painful. Examination reveals pain with medial-to-lateral compression of the

Explanation

Question 82

A 13-year-old boy has a painless “knot” over his left hip. History reveals that he injured his left hip playing soccer 4 months ago. A radiograph and MRI scan obtained at the time of injury are shown in Figures 7a and 7b. He is very active and is currently asymptomatic. A current radiograph is shown in Figure 7c. What is the next most appropriate step in management?

Explanation

DISCUSSION: The diagnosis is myositis ossificans resulting from an injury. The initial radiograph reveals a small amount of mineralization in the soft tissues overlying the left hip. The MRI scan shows signal abnormality of the entire gluteus minimus muscle with a mineralized mass in the center. The current radiograph shows a lesion within the abductor musculature with mature ossification peripherally. The imaging studies are diagnostic and the patient is asymptomatic; therefore, the management of choice is observation with no further evaluation or treatment indicated.
REFERENCES: Miller AE, Davis BA, Beckley OA: Bilateral and recurrent myositis ossificans in an athlete: A case report and review of treatment options. Arch Phys Med Rehabil 2006;87:286-290.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 15-27.

Question 83

A 23-year-old woman with a history of bilateral recurrent ankle sprains, progressive cavovarus feet, and a family history of high arches and foot deformities is seen for evaluation. Management consisting of bracing and physical therapy has been poorly tolerated. Heel varus is partially corrected with a Coleman block. There are thick calluses under the first metatarsal heads. Sensation to touch and Weinstein monofilament is normal. Tibialis anterior and peroneus brevis are weak but present. What is the most appropriate management?

Explanation

DISCUSSION: The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended.
REFERENCES: Younger AS, Hansen ST Jr: Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315.
Sammarco GJ, Taylor R: Cavovarus foot treated with combined calcaneus and metatarsal ostetotomies. Foot Ankle Int 2001;22:19-30.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL,

American Academy of Orthopaedic Surgeons, 2003, pp 135-143.

Question 84

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Explanation

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons

Figure 3Id Figure 31e

Question 85

At the first postoperative visit after mini-open carpal tunnel release, a patient reports hand weakness. Poor index finger interphalangeal joint extension and metacarpophalangeal joint flexion are present. This finding is most consistent with

Explanation

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If it were injured, the result would not be weakness of interphalangeal joint extension.

Question 86

A 36-year-old man was injured in a motorcycle collision and sustained the injury shown in Figure 70. He has a blood pressure (BP) of 70/40 mm Hg, pulse of 148 beats per minute (bpm), and Glasgow Coma Scale score of 6 (scores lower than 8 indicate severe brain injury), and there is negligible urine output. His airway is secure and intravenous (IV) access is obtained. Two liters of warm crystalloid solution are given; repeated vital signs reveal the same BP and a pulse of 142 bpm. What is the best next step?

Explanation

DISCUSSION
This patient has an anteroposterior compression pelvic fracture associated with shock. In patients with closed pelvic fractures and hypotension, mortality rises to approximately 1 in 4 (10%-42%) and hemorrhage is the major reversible contributing factor. Initial management of a major pelvic disruption associated with hemorrhage requires hemorrhage control and rapid fluid resuscitation. A pelvic binder should be placed to reduce pelvic volume. The patient has signs and symptoms of class IV hemorrhage, which include marked tachycardia exceeding 140, a significant decrease in BP, and a very narrow pulse pressure. Urinary output is negligible, and mental status is markedly depressed. The skin is cold and pale. The degree of exsanguination with class IV hemorrhage is immediately life threatening, and rapid transfusion and immediate surgical intervention are necessary. Nonresponse to fluid administration indicates persistent blood loss. Blood preparation should be emergency blood release. Type and cross-match of blood can be used for additional resuscitation in transient responders.
RECOMMENDED READINGS
Olson SA, Reilly MC, eds. Acetabular and Pelvic Fractures. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2007:15-42.
Advanced Trauma Life Support for Doctors, ed 8. Chicago, IL, American College of Surgeons, 2008.
RESPONSES FOR QUESTIONS 71 THROUGH 74
- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates
Which treatment option listed is best for each patient described?

71A

B
C

A 54-year-old healthy man with the condition seen in Figures 71a through 71d
- Retrograde intramedullary (IM) nailing
- Open reduction and internal fixation (ORIF) with screws alone
- Locking condylar plate
- Circular external fixation
- Lateral and medial plates

Question 87

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Explanation

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament

Question 88

-Figures a through c are the MRI scans of a 21-year-old woman with recurrent shoulder instability and pain after an open anterior stabilization procedure. Positive belly-press test findings were positive.At surgery she was found to have an irreparable tear of the tendon injury identified preoperatively. The procedure to address the dynamic stabilizer deficit places which nerve at most risk?

Explanation

Question 89

Hybrid locked plating for distal femoral fractures refers to the use of nonlocked and locked screws in the same construct. The advantages of using the combination of nonlocked and locked screws in both the proximal and distal fragments are that nonlocked screws

Explanation

Hybrid locked plating refers to the use of nonlocked and locked screws in the same fixation construct. Hybrid plating offers the advantages of both traditional plating and locked plating. Nonlocked screws are inserted first to "lag" the bone to the plate, thereby using the plate as a reduction tool. After fixation with nonlocked screws in both the proximal and distal fragments, locked screws can be added. Locked screws in the distal fragment create a fixed angle device that is resistant to varus collapse. Locked screws in the diaphyseal fragment are indicated when there is associated osteoporosis.

Question 90

A 10-year-old girl reports activity-related bilateral arm pain. Examination reveals no soft-tissue masses in either arm, and she has full painless range of motion in both shoulders and elbows. The radiograph and bone scan are shown in Figures 20a and 20b, and biopsy specimens are shown in Figures 20c and 20d. What is the most likely diagnosis?

Explanation

DISCUSSION: Based on these findings, the most likely diagnosis is fibrous dysplasia. Twenty percent of patients with fibrous dysplasia have multifocal disease. The lesions show a typical ground glass appearance. Fibrous dysplasia frequently involves the diaphysis of the long bones. There is no associated soft-tissue mass and no periosteal reactions to these lesions, suggesting a benign lesion. The histology shows proliferating fibroblasts in a dense collagen matrix. Trabeculae are arranged in an irregular or “Chinese letter” appearance. Osteogenic sarcoma and Ewing’s sarcoma have a much different radiographic appearance of malignant osteoid and small round blue cells. Periosteal chondroma does occur in the proximal humerus but is not typically multifocal. It appears as a surface lesion with saucerization of the underlying bone and a bony buttress adjacent to the lesion. Some patients with multifocal lesions have associated endocrine abnormalities (McCune-Albright syndrome).
REFERENCES: Wold LA, et al: Atlas of Orthopaedic Pathology. Philadelphia, PA, WB Saunders, 1990, pp 118-119.
Simon M, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 197.

Question 91

A 30-year-old man has had severe knee pain and swelling for 1 week. He reports he previously had acromioclavicular joint pain that disappeared. He denies any fever. Aspiration of a cloudy fluid from the knee reveals a WBC count of greater than 50,000 with 90% polymorphonucleocytes. While awaiting culture results, what is the most appropriate action?

Explanation

The patient has polyarticular gonococcal arthritis. Acute septic arthritis in adults can be separated into two major patient groups: young (age 15 to 40 years) healthy, sexually active patients with gonococcal pyogenic arthritis and elderly or immunocompromised patients with nongonococcal septic arthritis. In gonococcal septic arthritis, the infecting organism is Neisseria gonorrhea. It is the most common cause of acute joint infection in persons 15 to 40 years of age in the U.S. The clinical presentation is variable, but typically includes migratory polyarthralgias, fever, rash, urethral or vaginal discharge, and tenosynovitis. A patient with disseminated gonococcal infection may report few genital symptoms. More than 50% of these infections are polyarticular. Because patients with gonococcal septic arthritis are healthy, prompt antibiotic treatment results in a generally good prognosis. MRSA septic arthritis would be associated with fever, more rapid onset of symptoms, and is rarely polyarticular.

Question 92

-A collegiate offensive football lineman has decreased bench-press strength and shoulder pain as off-season workouts begin. Examination revealed no atrophy, and deltoid and rotator cuff strength testing findings were normal. Translational testing was difficult to achieve because of his large size.Apprehension and relocation test findings were negative. An O’Brien’s active compression test result was negative. Jerk testing was positive on the affected side. Which diagnosis is most likely revealed on an MRI arthrogram?

Explanation

Question 93

A 45-year-old man sustains the shoulder injury shown in the radiographs in Figure 55a and 55b and the CT scan in Figures 55c and 55d. Management should consist of

Explanation

Displaced intra-articular fractures of the glenoid fossa, as in this case, are best treated with open reduction and internal fixation through a posterior approach. ORIF through an anterior approach is very difficult and is not recommended. Significant disabilities are seen if these fractures are treated conservatively including chronic instability and DJD..............................................................

Question 94

You are interested in learning a new technique for minimally invasive total knee arthroplasty. The Keyhole Genuflex system seems appealing to you because the instrumentation comes with wireless controls. What is an acceptable arrangement to learn more about this system?

Explanation

Both the American Academy of Orthopaedic Surgeons (AAOS) and AdvaMed, the medical device manufacturer's trade organization, have written guidelines that address potential conflicts of interest regarding interactions between physicians and manufacturer's representatives when it comes to patients' best interest. The AAOS feels that the orthopaedic profession exists for the primary purpose of caring for the patient and that the physician-patient relationship is the central focus of all ethical concerns. When an orthopaedic surgeon receives anything of significant value from industry, a potential conflict of interest exists. The AAOS believes that it is acceptable for industry to provide financial and other support to orthopaedic surgeons if such support has significant educational value and has the purpose of improving patient care. All dealings between orthopaedic surgeons and industry should benefit the patient and be able to withstand public scrutiny. A gift of any kind from industry should in no way influence the orthopaedic surgeon in determining the most appropriate treatment for his or her patient. Orthopaedic surgeons should not accept gifts or other financial support with conditions attached. Subsidies by industry to underwrite the costs of educational events where CME credits are provided can contribute to the improvement of patient care and are acceptable. A corporate subsidy received by the conference's sponsor is acceptable; however, direct industry reimbursement for an orthopaedic surgeon to attend a CME educational event is not appropriate. Special circumstances may arise in which orthopaedic surgeons may be required to learn new surgical techniques demonstrated by an expert or to review new implants or other devices on-site. In these circumstances, reimbursement for expenses may be appropriate.

Question 95

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Explanation

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 96

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

Explanation

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

Question 97

A patient has multidirectional instability of the shoulder that has not responded to nonsurgical management. Successful surgical treatment will most likely include which of the following? Review Topic

Explanation

Published reports establish the importance of the rotator interval in shoulder stability and improvements achieved through suture closure of the interval. Multidirectional
instability treated surgically following failure to respond to nonsurgical management has been shown to be associated with classic Bankart lesions, Hill-Sachs defects, glenoid chondral lesions, and even SLAP lesions (Werner). However, these lesions were seen in a lower percentage than that found for unidirectional anterior dislocations. Likewise, these lesions do not appear to be significant in influencing treatment in the majority of patients.

Question 98

A 63-year-old woman with a history of poliomyelitis has a fixed 30-degree equinus contracture of the ankle, rigid hindfoot valgus, and normal knee strength and stability. She reports persistent pain and has had several medial forefoot ulcerations despite a program of stretching, bracing, and custom footwear. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient has a fixed deformity of the hindfoot and an Achilles tendon contracture; therefore, the treatment of choice is triple arthrodesis with Achilles tendon lengthening. Further bracing will not be helpful. Amputation is not indicated, and ankle arthrodesis will not address the hindfoot deformity. Palliative management would be more appropriate if the knee was unstable or the quadriceps were weak, because the equinus balances the ground reaction force across the knee.
REFERENCES: Perry J, Fontaine JD, Mulroy S: Findings in post-poliomyelitis syndrome: Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis. J Bone Joint Surg Am 1995;77:1148-1153.
Dehne R: Congenital and acquired neurologic disorders, in Mann RA, Coughlin MJ (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 552-553.

Question 99

The posterior circumflex artery provides blood supply to what portion of the proximal humerus?

Explanation

DISCUSSION: The posterior circumflex artery provides blood supply only to the posterior portion of the greater tuberosity and a small posteroinferior portion of the humeral head. The humeral head is supplied primarily by the anterolateral ascending branch of the anterior circumflex artery; the terminal branch of this artery is termed the arcuate artery.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 267-274.
Gerber C, Schneeberger AG, Vinh TS: The arterial vascularization of the humeral head:
An anatomical study. J Bone Joint Surg Am 1990;72:1486-1494.

Question 100

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

Explanation

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

2001;50:89-102.

Full Question & Answer Text (for Search Engines)

Question 1:

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

Options:

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

Correct Answer: Suprascapular nerve entrapment

Explanation:

Question 2:

Options:

Range of motion might be slightly better after an arthroscopic procedure.
Rate of recurrent instability is lower after an arthroscopic procedure.
Rates of return to work are higher after an arthroscopic procedure.
Rates of return to sports are higher after an arthroscopic procedure.

Correct Answer: Range of motion might be slightly better after an arthroscopic procedure.

Explanation:

Question 3:

Options:

Correction of the thoracolumbar curve
Sagittal balance
Coronal balance
Correction of the thoracic curve
Shoulder balance

Correct Answer: Correction of the thoracic curve

Explanation:

Sagittal balance is the most reliable predictor of clinical symptoms and HRQL outcomes on the SRS 29, SF-12, and Oswestry Disability Index. Coronal balance, shoulder balance, curve magnitude, and degree of curve correction are less critical in determining clinical symptoms and outcomes.
(SBQ12SP.24) A 39-year-old man presents to clinic with a 3-week history of low back pain that radiates to the right lower extremity. On examination, he has mildly decreased sensation over the dorsum of the foot and positive straight leg raise on the right side. MRI images are shown in Figure A and B. Which of the following is true regarding this patient's condition?
Review Topic
Nonoperative management with NSAIDS and physical therapy is effective for 50% of patients
Surgical treatment is indicated in patients with diminished sensation
Surgical treatment is equivalent to nonoperative management in terms of pain and function
Good surgical outcome is associated with mainly back complaints
Size of disc herniations typically decrease over time without surgical intervention
The patient is presenting with a lumbar disc herniation at the L4-L5 level. The size of disc herniations decrease in most patients over time without surgical intervention.
Lumbar disc herniations are the result of recurrent torsional strain, which leads to small tears of the annulus fibrosus, ultimately allowing herniation of the nucleus pulposis. First line treatment consists of NSAIDS, muscle relaxants and physical therapy and is effective in 90% of patients. Second line treatment typically involves epidural and selective nerve root corticosteroid injections. Microdiscectomy is reserved for patients with more than 6 weeks of disabling pain that has failed nonoperative management, progressive weakness, or cauda equina syndrome.
In the Spine Patient Outcomes Research Trial (SPORT), Weinstein et al. investigated patient outcomes and satisfaction after operative and nonoperative management of lumbar disc herniations. While the randomized arm of the study did show statistically significant differences in the intent-to-treat analysis due to significant crossover of patients, the observational cohort revealed a significant improvement in pain, function, and disability for patients treated with surgery versus nonoperative measures.
Benson et al. looked at the natural history of massive herniated discs in 37 patients with 7-year follow up. They found a more than 60% reduction in disc size over this time period. Reduction in disc size did not correlate with clinical improvement.
Figure A and B are sagittal and axial T2 MRI images, respectively, showing a right sided lumbar disc herniation at the L4-L5 level.
Incorrect Answers:

Question 4:

Options:

Osteochondral fracture of the lateral femoral condyle
Trabecular injury of the lateral tibial plateau
Lateral meniscal tear with a parameniscal cyst
Fibular collateral ligament tear
Discoid lateral meniscal tear

Correct Answer: Discoid lateral meniscal tear

Explanation:

Question 5:

Options:

rest and a sling for 3 to 6 weeks.
physical therapy with modalities for pain relief.
pain medication and activity as tolerated.
open reduction and internal fixation.
coracoid excision.

Correct Answer: open reduction and internal fixation.

Explanation:

Question 6:

Options:

Disruption of the coracoclavicular ligaments
Dislocation of the acromioclavicular joint
Impingement of the inferior fragment on the brachial plexus
Intact periosteal sleeve inferiorly

Correct Answer: Intact periosteal sleeve inferiorly

Explanation:

Question 7:

Regarding the role of the orthopaedic surgeon in addressing domestic and family violence, all of the following statements are true EXCEPT:

Options:

Report all cases of child abuse, as this is required by all states
Report all cases of adult spousal or intimate partner abuse, as this is required by all states
Hospitalize elderly victims who are in immediate danger and help develop a plan to ensure their safety
Advocate for appropriate legislation and public policy on violence and abuse related to health care
Orthopedic surgeons are responsible for knowing the reporting laws and procedures for suspected abuse

Correct Answer: Report all cases of child abuse, as this is required by all states

Explanation:

Question 8:

What is the most common location of osteosarcoma?

Options:

Shoulder
Spine
Pelvis
Knee
Skull

Correct Answer: Knee

Explanation:

Question 9:

What complication is most likely to occur following proximal humeral fixation with a locked plate-and-screw construct?

Options:

Screw penetration
Rotator cuff injury
Axillary nerve damage
Fracture of the humeral shaft
Impingement

Correct Answer: Screw penetration

Explanation:

Question 10:

Options:

anterior translation of the humeral head.
loss of external rotation.
excessive tightening of the biceps tendon.
superior migration of the humeral head.
no excessive changes

Correct Answer: loss of external rotation.

Explanation:

If the Buford complex is mistakenly reattached to the neck of the glenoid, severe painful restriction of external rotation will occur.

Question 11:

Options:

Medial joint line tenderness
Lateral joint line tenderness
Positive dial test at 30° of knee flexion
Varus laxity at 30° of knee flexion
Positive posterior drawer test

Correct Answer: Positive posterior drawer test

Explanation:

Question 12:

The fracture seen in Figure 1 is most likely associated with injury to what ligamentous structure?

Options:

Inferior glenohumeral ligament
Acromioclavicular (AC) ligaments
Coracoclavicular ligaments
Coracoacromial ligament The radiograph shows an extra-articular distal clavicle fracture lateral to the clavicular attachment point of the coracoclavicular ligaments (conoid and trapezoid). However, unlike a scenario featuring a typical Neer type I fracture, the interval between coracoid and clavicle is clearly widened, and there is marked fracture displacement. This signifies disruption to the coracoclavicular ligaments. The inferior glenohumeral ligament is important to glenohumeral joint stability, but has no effect on the relationship between clavicle and scapula. The AC ligaments are thickenings of the AC joint capsule. They have been shown to be responsible for 90% of anteroposterior stability of the AC joint. The coracoclavicular ligaments are responsible for 77% of stability for superior translation (as in this case). The coracoacromial ligament connects two parts of the scapula (coracoid and acromion) and is part of the arch that supports the rotator cuff.

Correct Answer: Acromioclavicular (AC) ligaments

Explanation:

Question 13:

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 14:

Options:

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

Correct Answer: Flexion, adduction, and internal rotation

Explanation:

Question 15:

Options:

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

Correct Answer: Posterior capsular stretching

Explanation:

Question 16:

Options:

ice, analgesics, and symptomatic treatment, with delayed reconstruction if necessary.
closed reduction in the emergency department.
closed reduction in the operating room under anesthesia.
open reduction and temporary stabilization with a threaded pin.
open reduction and reconstruction of the sternoclavicular joint ligaments.

Correct Answer: closed reduction in the operating room under anesthesia.

Explanation:

DISCUSSION: The CT scan reveals a completely displaced physeal fracture of the medial clavicle with marked posterior displacement of the distal fragment. This fracture pattern is associated with potential injury to the vascular structures of the mediastinum. Reduction should be performed for this fracture and generally can be done closed with shoulder retraction and upward pull on the clavicle with a towel clip. Once reduced, the fracture is relatively stable and typically will heal in good position. Reduction should be performed in the operating room in the event that a vascular injury is detected once compression is removed from the clavicle. Open reduction may be necessary if closed reduction is not possible; however, pinning or ligament reconstruction usually is not necessary.
REFERENCES: Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA,
WB Saunders, 1998, p 581.
Wirth MA, Rockwood CA Jr: Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268-278.

Question 17:

Options:

Proximal row carpectomy
Radial shortening osteotomy and vascularized bone grafting
Scaphoid excision and midcarpal arthrodesis
Capitate hamate fusion

Correct Answer: Proximal row carpectomy

Explanation:

EXPLANATION:
This patient has late-stage Kienböck disease. According to the Lichtman classification for Kienböck disease, this would represent stage IIIB, with lunate collapse/fragmentation, loss of carpal height secondary to proximal capitate migration, and a flexed scaphoid. The lateral radiograph reveals a radioscaphoid angle exceeding 60 degrees, so disease stage is IIIB. According to Condit and associates, when the presurgical radioscaphoid angle exceeds 60 degrees, results are poor when an attempt to maintain the lunate is made. As a result, the procedure with the most predictable outcome is a proximal row carpectomy. A radial-shortening osteotomy could be performed because the ulnar variance is negative. Considering the marked lunate fragmentation and collapse, a vascularized bone graft likely is contraindicated and associated with less predictable results than a proximal row carpectomy. There is no role for supervised hand therapy and splinting in the setting of advanced Kienböck disease. Similarly,
there is no role for maintenance of the lunate in the setting of advanced collapse and fragmentation.

Question 18:

A 6-year-old sustains the injury shown in Figures A and B. The nerve most commonly affected by this fracture pattern innervates which of the following motor groups?

Options:

Intrinsics of the hand
Wrist extensor
Thumb extensor
Thumb IP flexor
Digital extensor

Correct Answer: Intrinsics of the hand

Explanation:

Question 19:

A transverse humeral shaft fracture that occurs between a stiff arthritic shoulder joint; a stiff, arthritic elbow joint is treated nonsurgically in a hanging-arm cast

Options:

- High strain
- Low strain

Correct Answer: - High strain

Explanation:

DISCUSSION
In 1977, Perren and Cordey penned a German manuscript that first described an interpretation of mechanical influences on tissue differentiation. This became known as the Strain Theory of Perren. In 1980, a second manuscript by the same authors was published in English. Within this manuscript, Perren wrote, "These thoughts about the mechanical influences on tissue differentiation are not intended as conclusive evidence since precise data are still not available, but we hope that they will stimulate thought and provide a basis for discussion." More than 30 years later, these thoughts continue to stimulate discussion and research on cell mechanotransduction. This theory is still being manipulated in surgical theatres all around the world in an attempt to more consistently achieve fracture healing. Strain is a magnitude of deformation. As typically defined, it is the change in dimension of a deformed object during loading divided by its original dimension. This is difficult to work with intraoperatively. The fraction below illustrates a simpler way to regard this concept:
Strain = Magnitude of displacement between fragments during loading / Total resting distance between fragments after stabilization
By remembering that low strain generally leads to bone formation and healing, it is possible to manipulate this fraction intraoperatively to achieve success. When a simple fracture pattern is anatomically reduced and compressed, then the total resting distance between fragments after stabilization approaches 0. This means the numerator must be near 0 to achieve a low-strain environment. This is what occurs in absolute stability (no motion between fracture fragments under physiologic load) and primary bone healing occurs. When a multifragmentary fracture pattern is treated with bridge plating, the total resting distance between fragments after stabilization is a larger number (consider the additive distance between the different fragments). In this case, the numerator can be larger to achieve a low-strain environment. This is what happens in relative stability (controlled motion between fracture fragments under physiologic load). Secondary bone healing occurs. Now consider the third scenario: a simple fracture pattern that is fixed with a small gap. The total resting distance is still a small number. Based on the theory, eliminating motion by creating a stiff construct should lead to healing, but it does not. Creating absolute stability with a gap means that primary bone healing cannot occur (because cutting cones cannot cross the gap) and secondary bone healing cannot occur (because there is not enough motion to induce callus formation). This is where the strain theory breaks down and how many nonunions occur. In the fourth scenario, a high-strain environment is present and commonly leads to a nonunion (as predicted by the theory). The simple fracture pattern is too mobile, and nonfunctional callus often occurs.
RECOMMENDED READINGS
Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002 Nov;84(8):1093-110. Review. PubMed PMID: 12463652.
View Abstract at
PubMed
Epari DR, Duda GN, Thompson MS. Mechanobiology of bone healing and regeneration: in vivo models. Proc Inst Mech Eng H. 2010 Dec;224(12):1543-53. Review. PubMed PMID: 21287837.
View Abstract at PubMed

Question 20:

Scapular notching following reverse shoulder arthroplasty may be minimized by what technical modification? Review Topic

Options:

Horizontal humeral cut
Superior inclination of the baseplate
Inferior inclination of the baseplate
Use of a 36-mm glenosphere
Use of a retentive polyethylene liner

Correct Answer: Inferior inclination of the baseplate

Explanation:

Question 21:

A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:

Options:

Determination of surgical planning
Intra-articular loose bodies
Marginal impaction
Fracture piece size and position
Determination of pre-existing degenerative changes

Correct Answer: Determination of surgical planning

Explanation:

Question 22:

Options:

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

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

Explanation:

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

Question 23:

Patient outcome after open reduction and internal fixation of tibial plateau fractures shows that patients older than 50 years of age when compared to younger patients have

Options:

equal results for all fracture types.
better outcomes in high-energy fractures.
better outcomes in low-energy fractures.
a higher wound complication rate.
worse outcomes in low-energy fractures.

Correct Answer: worse outcomes in low-energy fractures.

Explanation:

Question 24:

A deficiency of which of the following is associated with an increased risk of venous thromboembolism?

Options:

Fibrinogen
Protein S
Factor VII
Factor VIII
Prothrombin

Correct Answer: Protein S

Explanation:

Question 25:

Options:

Informed consent
Patient autonomy
Fiduciary responsibility
Physician paternalism
Justice

Correct Answer: Informed consent

Explanation:

Question 26:

Options:

Prevention of knee hyperextension
Correct of valgus instability
Correction of varus malalignment
Treatment of symptomatic meniscal tear
Treatment of an asymptomatic abnormally shaped meniscus

Correct Answer: Correct of valgus instability

Explanation:

This patient has undergone arthroscopic saucerization of his discoid meniscus. The indication for this procedure is treatment of a symptomatic meniscal tear.
Arthroscopic treatment of lateral discoid meniscus injuries has the advantages of reducing trauma, precise resection or repair of the meniscus and saucerization of the remaining discoid meniscus. Operative treatment is usually limited to patients with pain and mechanical symptoms that are undergoing partial meniscectomy or repair. Asymptomatic discoid meniscus without tears are not considered a surgical indication for routine saucerization.
Kramer et al. reviewed the diagnosis and treatment of traumatic discoid meniscal tears in children. They report that knee shape, size and skeletal maturity must be considered when determining the optimal method of repair. However, all symptomatic torn discoid menisci are best treated with saucerization and repair.
Good et al. looked at the arthroscopic techniques of discoid meniscus repair. Arthroscopic saucerization was successful in 28 of 30 knees and meniscal repair in 23 of 30 knees. At final follow-up, all patients exhibited full knee flexion beyond 135 degrees. In 3 of 30 patients there was residual knee pain, and four reported intermittent mechanical symptoms.
Figure A shows a series of arthroscopic images of the right knee lateral compartment. There is a sequential saucerization of the discoid meniscus.
Incorrect Answers:
(SBQ13PE.83) 8-year-old boy complains of intermittent painless clicking in his knee. His physical examination is normal. His family doctor orders an MRI, which reveals an incomplete lateral discoid meniscus without evidence of tear. What is the most appropriate treatment?
Review Topic
Observation only
Diagnostic arthroscopy
Saucerization of meniscus
Saucerization of meniscus and microfracture
Saucerization and stabilization of the mensicus
The clinical presentation is consistent with a asymptomatic discoid meniscus. The most appropriate treatment at this time would be observation only.
MRI scans of the knee are very sensitive for identifying discoid menisci. Diagnosis is usually made when there are 3 or more 5mm sagittal MRI images showing meniscal continuity. Treatment is mostly focused on conservative modalities. Asymptomatic tears are usually treated with observation only. Saucerization is indicated for recurrent locking, swelling, persistent pain, or radiographic evidence of a meniscal tear.
Watanabe et al. described three types of discoid lateral menisci based on arthroscopic appearance. In this classification, discoid menisci with normal peripheral attachments are either type I (complete) or type II (incomplete). Type III discoid menisci, the so-called Wrisberg ligament type, are lacking posterior capsular attachments with the exception of the posterior meniscofemoral ligament.
Kramer et al. looked at the presentation of pediatric knee pain and discoid meniscus. They showed that the lateral meniscus is more commonly affected than the medial meniscus. The majority of discoid tears occur in the posterior or middle aspect of the meniscus.
Illustration A shows the cross-section of normal meniscus. Illustration B shows the Watanabe classification.
Incorrect Answers:

Question 27:

Which of the following clinical scenarios represents the strongest indication for locked plating technique in a 70-year-old woman?

Options:

Segmentally comminuted ulnar fracture
Simple diaphyseal fracture of the humerus
Transverse midshaft displaced clavicle fracture
Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty
Schatzker 2 fracture of the tibia with severe joint depression and comminution

Correct Answer: Periprosthetic femur fracture distal to a well-fixed total hip arthroplasty

Explanation:

Question 28:

What effect does deep freezing have on allograft tissue?

Options:

Causes no deleterious clinical effect on ligamentous grafts
Causes a less deleterious effect on cartilage than on ligamentous grafts
Causes degradation of the extracellular matrix
Allows for preservation of cells with tissue
Eliminates the chance of human immunodeficiency virus (HIV) transmission

Correct Answer: Causes no deleterious clinical effect on ligamentous grafts

Explanation:

DISCUSSION: Deep freezing is the simplest and most widely used method of ligament allograft storage. All cells in the tissue are destroyed with the freezing. However, for this reason, it is not a preferred storage method for menisci or cartilage allografts. Although this method may enhance success because it removes potential antigens located on the cells, it cannot guarantee elimination of HIV transmission. The advantage of cryopreservation storage is that a significant number of cells will survive the process, a factor important in meniscal allograft survival after implantation. No deleterious effects are noted clinically because of the acellularity of the tissue.
REFERENCES: Shelton WR, Treacy SH, Dukes AD, Bomboy AL: Use of allografts in
knee reconstruction: I. Basic science aspects and current status. J Am Acad Orthop Surg 1998;6:165-168.
Caspari RB, Botherfield S, Horwitz RL, et al: HIV transmission via allograft organs and tissues. Sports Med Arthroscopy Rev 1993;1:42-46.

Question 29:

Options:

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

Correct Answer: Discoid lateral meniscus

Explanation:

Question 30:

When treating thoracic disk herniations, which of the following surgical approaches has the highest reported rate of neurologic complications?

Options:

Video-assisted thoracoscopic approach (VATS)
Posterior
Posterior-lateral
Transthoracic
Transpedicular

Correct Answer: Posterior

Explanation:

DISCUSSION: Numerous surgical approaches have been used for thoracic diskectomy, including the most recent VATS. One of the first approaches described, posterior laminectomy, involves manipulation of the spinal cord, which the other approaches avoid. The posterior approach had dismal results, including further neurologic deterioration and even paralysis.
REFERENCES: Belanger TA, Emery SE: Thoracic disc disease and myelopathy, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 855-864.
Benjamin V: Diagnosis and management of thoracic disc disease. Clin Neurosurg
1983;30:577-605.
Russell T: Thoracic intervertebral disc protrusion: Experience of 67 cases and review of the literature. Br J Neurosurg 1989;3:153-160.
Fessler RG, Sturgill M: Review: Complications of surgery for thoracic disc disease. Surg Neurol 1998;49:609-618.

Question 31:

Options:

Remove the Kirschner wires and reposition the ankle
Measure foot compartment pressures
Order an echocardiogram
Order serum blood urea nitrogen and creatinine levels

Correct Answer: Remove the Kirschner wires and reposition the ankle

Explanation:

The most common symptom of compartment syndrome in the extremities is intense pain. Compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. In compartment syndrome of the leg, pain on passive extension of the toes is the most frequent clinical diagnostic finding. However, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present. Swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Repositioning the ankle will add to further swelling. The clinician must be alerted regarding elevations in blood pressure and pulse because such elevations may be the only manifestation of the deeper problem. The transient blood pressure elevation does not require cardiac screening with electrocardiogram or echocardiogram as in chronic hypertension. Kidney function testing is not necessary because the blood pressure elevation is not renal in origin. Compartment pressures should be measured immediately in the foot and will require anesthesia in the pediatric age group.
(SBQ13PE.91) An 12-year-old girl presents with right hip pain. Bilateral frog laterals are shown in Figure A. Laboratory work-up reveals TSH 11 mIU/L (Ref range: 0.4-4.0 mIU/L) and Free T4 is 0.5 ng/dL (Ref range: 0.7-1.9 ng/dL). What is the most appropriate treatment recommendation?
Review Topic
In situ pinning of right hip
Protected weight bearing and MRI of right hip
Immediate endocrine referral and treatment
Open biopsy right hip
In situ pinning bilateral hips PREFERRED RESPONSE 5
In patients with slipped capital femoral epiphysis (SCFE) and concomitant endocrinopathy, bilateral pinning is the recommended treatment.
This patient's laboratory values reveal hypothyroidism, which increases the risk of bilateral involvement. Thus, the most appropriate treatment recommendation is surgical fixation of both hips.
Wells et al. analyzed 131 SCFEs over a 30-year period. The authors noted that 100% of patients with associated endocrinopathy went onto contralateral slip and recommended not only prophylactic pinning, but in those with open triradiate cartilage, recommended preventative screening with TSH/Free T4 laboratory studies.
Riad et al. followed 90 patients and analyzed impact of age, gender and race on contralateral slip development. Girls under the age of 10 and boys under the age of 12 had a significantly increased risk of contralateral involvement. Therefore, the authors recommended contralateral pinning for girls and boys that met those age criteria, respectively.
Figure A exhibits a right SCFE on bilateral frog lateral views. Incorrect Answers:

Question 32:

Which of the following is not a characteristic of synovial sarcomas?

Options:

may contain calcifications.
occur in younger patients than most soft-tissue sarcomas.
are usually intra-articular.
often respond well to chemotherapy.
often contain a known genetic abnormality.

Correct Answer: are usually intra-articular.

Explanation:

DISCUSSION: Synovial sarcomas have a number of features that differentiate them from other soft-tissue sarcomas. They often have small areas of calcifications within the lesion. They occur in a younger patient population than most soft-tissue sarcomas. A subset of patients with synovial sarcoma tend to be chemosensitive. They often contain the SYT-SSX translocation. Although they can occur intra-articular, this is rare, despite their name.
REFERENCES: Campanacci M: Bone and Soft Tissue Tumors, ed 2.
New York, NY, Springer-Verlag, 1999, pp 1109-1126.
Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 219-276.

Question 33:

A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

Options:

MRI scan
Physical examination
Workers’ compensation status
Surgeon availability
Patient age

Correct Answer: Physical examination

Explanation:

DISCUSSION: The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
REFERENCE: Lansinger O, Bergman B, Korner L, et al: Tibial condylar fractures: A twenty-year follow-up. J Bone Joint Surg Am 1986;68:13-19.

Question 34:

Options:

Recurrence of the deformity
Hallux varus
back answer
Transfer metatarsalgia
Nonunion of the first metatarsal osteotomy
Osteonecrosis of the first metatarsal osteotomy 77.03

Correct Answer: Recurrence of the deformity

Explanation:

Coglin’s referenced paper is a study out of Idaho. 11 year retrospective study of 45 patients (60 feet). A multiprocedural approach was used to surgically correct the deformity. There were 6 recurrences of the deformities and eight
complications (6 cases of hallux varus, one case of wire breakage and one case of undercorrection.) So according to their reference this question has two correct answers.
Postoperative complications have been frequently reported following juvenile hallux valgus corrections. Recurrence following surgery is probably the most frequently reported complication and is likely due to the high rate of congruency associated with a
juvenile hallux valgus deformity.
OKU Foot and Ankle 2 Rosemont IL., American academy of orthopaedic surgeons, pp135-150.
back to this question next question

Question 35:

Options:

Pseudoparalysis secondary to fracture of the proximal humerus
Cervical myelomeningocele
Erb palsy
Arthrogryposis
Cerebral palsy and spastic hemiplegia

Correct Answer: Erb palsy

Explanation:

Question 36:

Options:

PA and lateral views of the wrist
PA, lateral, and oblique views of the hand
Scaphoid view
Bruerton’s view
Carpal tunnel view

Correct Answer: Carpal tunnel view

Explanation:

Question 37:

Options:

Subtrochanteric osteotomy with femoral shortening
An offset femoral component
A lateralized liner
Extended trochanteric osteotomy

Correct Answer: Subtrochanteric osteotomy with femoral shortening

Explanation:

Question 38:

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

Options:

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

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

Explanation:

Question 39:

Which of the following tissues has the highest maximum load to failure?

Options:

Native anterior cruciate ligament (ACL)
Bone-patellar tendon-bone with a width of 10 mm
Central quadriceps tendon with a width of 15 mm
Quadruple semitendinosus and gracilis tendons
Tibialis tendon allograft

Correct Answer: Quadruple semitendinosus and gracilis tendons

Explanation:

Question 40:

Which of the following best describes athletic pubalgia?

Options:

A syndrome of lower abdominal and adductor pain
Painful symptoms emanating from the symphysis pubis
Painful symptoms associated with dysfunction of the iliopsoas tendon
Stress fracture of the pubic ramus
Entrapment of the pudendal nerve

Correct Answer: A syndrome of lower abdominal and adductor pain

Explanation:

Question 41:

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

Options:

Dressing changes and healing by secondary intention
Split-thickness skin grafting
V-Y advancement flap
Moberg (volar advancement flap)
First dorsal metacarpal artery-island pedicled flap

Correct Answer: V-Y advancement flap

Explanation:

DISCUSSION: V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of
the thumb.
REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.
Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

Question 42:

Options:

Lumbar laminectomy with synovial cyst excision
Repeat epidural steroid injection
Microdiskectomy at L4-5
Nonsteroidal medication and outpatient physical therapy
Left-sided facet blocks at L4-5 and L5-S1

Correct Answer: Repeat epidural steroid injection

Explanation:

Lumbar spinal stenosis with lumbar radiculopathy can be commonly caused by a synovial cyst arising from the facet joints. Lyons and associates reported on the surgical treatment of synovial cysts in 194 patients. Of the 147 with follow-up data, 91% reported good pain relief and 82% had improvement of their motor deficits. Epstein reported a 58% to 63% incidence of good/excellent results and a 38 to 42
point improvement on the SF-36 Physical Function Scale. It was also suggested that since the presence of a synovial cyst indicates facet pathology, possible fusion should be considered in these patients, especially those with underlying spondylolisthesis.
(SBQ12SP.20) Amphotericin B is most appropriate for the treatment of which type of spine infection?
Review Topic
Fungal osteomyelitis
Bacterial osteomyelitis with a gram-positive organism
Bacterial osteomyelitis with a gram-negative organism
Tuberculous osteomyelitis
Viral meningomyelitis
Amphotericin B would be most appropriate for the treatment of fungal infections of the spine.
Amphotericin B is a broad-spectrum anti-fungal medication. It is commonly used as the first-line agent for treatment of fungal infections of the spine. The most common fungi involving the spine include cryptococcus, candida, and aspergillus. The indications for débridement and stabilization with spinal fusion, includes resistance to antibiotic therapy, spinal instability, and/or neurologic deficits.
Kim et al. reviewed fungal infections of the spine. They comment that fungus infections are most commonly spread by hematogenous or direct spread. Access to the vascular system may include intravenous lines, during implantation of prosthetic devices, or during surgery.
Frazier et al. retrospectively reviewed 11 patients with fungal osteomyelitis of the spine. Nine of the patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. All were treated with anti-fungal medication. 10 of 11 patients were also treated with surgical debridement. Paralysis secondary to the spine infection developed in eight patients. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients.
Illustration A shows the mechanism of action of Amphotericin. Illustration B shows T1- (Image A and B) and T2-weighted (Image C) images of the lower thoracic and lumbar spine. There are hypointense signals within the T12 and L1 vertebral bodies (Images A and B) indicative of fungal osteomyelitis.
IncorrectAnswers:

Question 43:

Options:

Arthroscopic Bankart procedure
Physical therapy
SAWA shoulder brace
Latarjet procedure

Correct Answer: Physical therapy

Explanation:

Question 44:

What is the most likely cause of the lesion shown in Figures 35a and 35b?

Options:

Surgery
Contusion
Parathyroid tumor
Bisphosphonate use
Corticosteroid use

Correct Answer: Contusion

Explanation:

DISCUSSION: The most common cause of myositis ossificans is contusion. Certain regions, including the quadriceps and brachialis, are more commonly affected. The mechanisms of development have not been clearly established.
REFERENCES: Beiner JM, Jokl P: Muscle contusion injuries: Current treatment options. J Am Acad Orthop Surg 2001;9:227-237.
Jarvinen TA, Jarvinen TL, Kaariainen M, et al: Muscle injuries: Biology and treatment. Am J Sports Med 2005;33:745-764.

Question 45:

Figure 12 shows an arthroscopic view from an inferolateral portal of a right knee. The asterisk indicates which structure?

Options:

Anterior cruciate ligament, anteromedial bundle
Anterior cruciate ligament, anterolateral bundle
Anterior cruciate ligament, posteromedial bundle
Anterior cruciate ligament, posterolateral bundle

Correct Answer: Anterior cruciate ligament, anteromedial bundle

Explanation:

DISCUSSION
The asterisk indicates the anteromedial bundle of the anterior cruciate ligament. The anterior cruciate ligament consists of 2 functional bundles: anteromedial and posterolateral. During extension of the knee, the posterolateral bundle becomes taut. In flexion, the anteromedial bundle is tight and the posterolateral bundle relaxes. Recently, techniques for double-bundle reconstruction have been described to recreate the normal anatomic relationship of the 2 bundles.
RECOMMENDED READINGS
Chhabra A, Zelle BA, Feng MT, Fu FH. The arthroscopic appearance of a normal anterior cruciate ligament in a posterior cruciate ligament-deficient knee: the posterolateral bundle (PLB) sign. Arthroscopy. 2005 Oct;21(10):1267. PubMed PMID: 16226658.
View Abstract at PubMed
Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. Arthroscopy. 2005 Oct;21(10):1275. PubMed PMID: 16226666.
View Abstract
at
PubMed

Question 46:

In the first dorsal compartment of the wrist, what tendon most frequently contains multiple slips?

Options:

Extensor pollicis longus
Extensor pollicis brevis
Extensor carpi radialis longus
Extensor carpi radialis brevis
Abductor pollicis longus

Correct Answer: Abductor pollicis longus

Explanation:

Question 47:

Figure 12 shows the lumbar CT scan of a 24-year-old man who was injured in a snowmobile accident. What is the mechanism of injury?

Options:

Flexion extension
Flexion distraction
Vertical compression
Extension compression
Extension distraction

Correct Answer: Vertical compression

Explanation:

Question 48:

Options:

manipulation of the foot under general anesthesia.
peroneal lengthening.
coalition resection with interposition of fat or muscle.
distal calcaneal lengthening osteotomy.
triple arthrodesis.

Correct Answer: coalition resection with interposition of fat or muscle.

Explanation:

DISCUSSION: The radiograph shows an incompletely ossified calcaneonavicular coalition. When symptomatic, a trial of cast immobilization is reasonable. If this fails to provide relief, the preferred treatment is resection of the coalition. Before attempting surgery, a CT scan should be obtained to rule out ipsilateral subtalar coalition. Recurrence of the coalition is usually prevented with interposition of autogenous fat graft or with local interposition of the extensor digitorum brevis muscle. Approximately 80% of patients treated in this manner have decreased pain and improved subtalar motion. When the flatfoot deformity is mild, calcaneal lengthening or medial translation osteotomy is unnecessary. Primary triple arthrodesis may be indicated if degenerative changes are present in the subtalar or midfoot joints. Peroneal lengthening
has been described for treatment of the peroneal spastic flatfoot without demonstrable
tarsal coalition.
REFERENCES: Gonzalez P, Kumar SJ: Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am 1990;72:71-77.
Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Luhmann SJ, Rich MM, Schoenecker PL: Painful idiopathic rigid flatfoot in children and adolescents. Foot Ankle Int 2000;21:59-66.

Question 49:

Options:

MRI-arthrogram to evaluate the rotator cuff
Rotator cuff strengthening program
Posterior capsular stretching program
Shoulder arthroscopy with SLAP repair
Shoulder arthroscopy with posterior capsular release

Correct Answer: Posterior capsular stretching program

Explanation:

Question 50:

Which of the following pelvic injury types has the highest reported mortality rate?

Options:

Anterior posterior compression (APC) III injury
Lateral compression (LC) III injury
Transverse-posterior wall acetabular fracture
Vertical Shear
Combined mechanical injury (CMI) Corrent answer: 1 Anterior posterior compression (APC) injuries have the highest mortality rates of the fracture patterns listed. APC injuries have high rates of concomitant thoracic and abdominal visceral injuries leading to the highest rates of mortality among pelvic fractures. Lateral compression (LC) fractures have particularly high incidences of associated brain and head injury with lower mortality than APC injuries. Overall, as the grade of pelvic ring injury increases the rates of associated injuries increases, regardless of exact mechanism of injury. The overall mortality rate for any pelvic trauma is roughly 15%, with APC III mortality around 37%, and overall APC mortality rates around 26%. LC of any grade has an estimated mortality around 13%. Vertical shear and CMI have estimated mortality of 25% and 17.1%, respectively. The lowest mortality rates are following acetabular fractures with estimates around 1.5%. Dalal et al retrospectively reviewed 340 trauma patients with pelvic injuries to analyze organ injury, resuscitative requirements, and outcomes. They found the highest mortality rates were in APC III and that more severe APC injuries had greater organ damage and mortality. They conclude that the mechanical force type and classification of injury are predictors of organ injury pattern, resuscitation needs, and mortality. Eastridge et al reviewed 1,014 injured pedestrians for pelvic injuries, associated injuries, and relationship of treatments to outcomes. They found the highest mortality rates were associated with APC III and LC III injuries patterns at 50%. They conclude that pelvic fractures are a sign of significant energy imparted on the body and severity of associated injuries lead to the high rates of morbidity and mortality. Illustration A and B show an APC III and LC III injury, respectively. Incorrect Answers:

Correct Answer: Lateral compression (LC) III injury

Explanation:

mechanism injuries all have lower mortality rates than APC injuries.
OrthoCash 2020

Question 51:

Which of the following is considered a contraindication to cement injection techniques, such as kyphoplasty or vertebroplasty, in the treatment of osteoporotic compression fractures?

Options:

Patient age of more than 85 years
Retropulsion of the posterior vertebral wall
Acute fracture in a hospitalized patient
Prior compression fracture
Fracture age of 4 months

Correct Answer: Retropulsion of the posterior vertebral wall

Explanation:

DISCUSSION: When retropulsion of the posterior vertebral wall is present, nothing prohibits the cement from following the path of least resistance into the canal or from pushing a bone fragment further into the canal; most clinicians consider it a contraindication to these techniques. Patient age itself is not a contraindication as long as there are no medical contraindications to surgery. An acute fracture in a patient who remains immobile and hospitalized because of pain may be a good indication for such a technique. Prior compression fracture and older compression fractures are not contraindications, but pain relief may be less predictable.
REFERENCES: Phillips FM, Pfeifer BA, Leiberman IH, et al: Minimally invasive treatment of osteoporotic vertebral compression fractures: Vertebroplasty and kyphoplasty. Instr Course Lect 2003;52:559-567.
Truumees E, Hilibrand A, Vaccaro AR: Percutaneous vertebral augmentation. Spine J 2004;4:218-229.
Rao RD
, Singrakhia MD: Painful osteoporotic vertebral fracture: Pathogenesis, evaluation, and roles of vertebroplasty and kyphoplasty in its management. J Bone Joint Surg Am 2003;85:2010-2022.

Question 52:

Options:

Clostridium
Acinetobacter
Pseudomonas
Mycobacterium
Staphylococcus aureus

Correct Answer: Clostridium

Explanation:

Question 53:

Options:

Cam-type femoroacetabular impingement
Pincer-type femoroacetabular impingement
Hip flexor strain
Athletic pubalgia

Correct Answer: Cam-type femoroacetabular impingement

Explanation:

This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement. Surgical treatment for cam impingement can be effective for symptomatic patients. Even among high-level athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable with those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment. Byrd and Jones described five patients who developed transient neurapraxias that resolved uneventfully. The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a
periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 54:

Which of the following nerves is most commonly injured when obtaining a bone graft from the posterior ilium?

Options:

Lateral femoral cutaneous
Superior gluteal
Cluneal
L5 nerve root
S1 nerve root

Correct Answer: Cluneal

Explanation:

Question 55:

A 20-year-old basketball player has tenderness and bruising after sustaining a blow to the knee. A radiograph is shown in Figure 15. What is the most likely diagnosis?

Options:

Patellar fracture
Patellar dislocation
Bipartite patella
Vastus lateralis tear
Tumor

Correct Answer: Bipartite patella

Explanation:

Question 56:

Options:

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

Correct Answer: Type II error

Explanation:

Question 57:

- Radiographs of a 20-year-old college athlete who sustained an injury to the ankle reveal no fractures or widening of the ankle mortise. Examination shows swelling at the ankle region and pain with medial lateral compression of the distal tibiofibular joint. Which of the following studies would best help in confirming a diagnosis?

Options:

Inversion stress radiograph
MRI scan
CT scan
Nuclear bone scan
External rotation stress radiograph

Correct Answer: External rotation stress radiograph

Explanation:

Question 58:

Options:

Pudendal
Deep illiac circumflex
Hypogastric
Obturator
Testicular

Correct Answer: Pudendal

Explanation:

Question 59:

Posterior spinal fusion for scoliosis should be performed on a patient with Duchenne muscular dystrophy when

Options:

the patient is still ambulatory.
lordotic posture is present.
the forced vital capacity (FVC) is less than 30% of the predicted value.
curve magnitude measures 25° or greater.
orthotic management fails.

Correct Answer: curve magnitude measures 25° or greater.

Explanation:

Question 60:

Options:

Cemented left total hip arthroplasty (THA)
Cementless left THA with a proximally porous coated femoral stem
Hybrid left THA
Cementless left THA with a diaphyseal engaging conical femoral stem

Correct Answer: Hybrid left THA

Explanation:

Question 61:

Options:

skeletal traction.
immediate application of a cast brace.
a retrograde supracondylar nail.
revision total knee replacement.
resection arthrodesis.

Correct Answer: a retrograde supracondylar nail.

Explanation:

Question 62:

Options:

Acute hematogenous osteomyelitis
Kohler’s disease
Tarsal coalition
Tuberculosis
Lisfranc fracture-dislocation

Correct Answer: Tuberculosis

Explanation:

Question 63:

-What is the most likely cause of an acute femur fracture in a 5-month-old child?

Options:

Metabolic bone disease
Birth trauma
Accidental trauma
Nonaccidental trauma (abuse) DISCUSSION-Although femur fractures are common in children, fractures in nonambulatory children carry a very high specificity for abuse. Metabolic bone disease is less commonly a cause of femur fractures. Birth trauma,from which femur fractures have been reported, would have been healed by 5 months of age. Accidental trauma generally does not occur in nonambulatory children. Orthopaedic surgeons, like all physicians, are mandated to report suspected cases of child abuse.

Correct Answer: Nonaccidental trauma (abuse) DISCUSSION-Although femur fractures are common in children, fractures in nonambulatory children carry a very high specificity for abuse. Metabolic bone disease is less commonly a cause of femur fractures. Birth trauma,from which femur fractures have been reported, would have been healed by 5 months of age. Accidental trauma generally does not occur in nonambulatory children. Orthopaedic surgeons, like all physicians, are mandated to report suspected cases of child abuse.

Question 64:

Options:

Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open carpal tunnel release, closed reduction of the perilunate dislocation, and casting
Elective outpatient surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
Emergent surgery, including open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Correct Answer: Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Explanation:

Question 65:

Options:

Decreased resistance to oxidative degradation
Decreased toughness
Increased density of nonconsolidated particles
Increased elastic modulus
High levels of residual free radicals

Correct Answer: Decreased toughness

Explanation:

Question 66:

Options:

Mild subtalar arthritis
Posterior tibialis tendinitis
Os trigonum entrapment syndrome
Flexor hallucis longus tenosynovitis
Retrocalcaneal bursitis

Correct Answer: Flexor hallucis longus tenosynovitis

Explanation:

Question 67:

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 68:

Options:

Urgent admission to the hospital for surgical intervention
Immediate MRI of the lumbar spine as an outpatient
Anti-inflammatory medications and activity modification
Caudal epidural steroid injection
Electromyography

Correct Answer: Anti-inflammatory medications and activity modification

Explanation:

Question 69:

A 10-year-old child has leg discomfort with activity. A radiograph, bone scan, and biopsy specimen are shown in Figures 1a through 1c. What is the most likely diagnosis?

Options:

Parosteal osteosarcoma
Unicameral bone cyst
Aneurysmal bone cyst
Eosinophilic granuloma
Fibrous dysplasia

Correct Answer: Fibrous dysplasia

Explanation:

Question 70:

Options:

Neurogenic pain
Bone overgrowth
Hip flexion contracture
Hip adduction contracture
Leg length inequality

Correct Answer: Leg length inequality

Explanation:

Question 71:

Options:

Mobile-bearing knee
Posterior cruciate ligament-sparing knee
Posterior cruciate ligament-substituting knee
Semiconstrained-style knee
Triaxial hinged knee

Correct Answer: Posterior cruciate ligament-substituting knee

Explanation:

DISCUSSION: Paletta and Laskins performed a retrospective study of the results of TKA with cement in 22 patients who had a previous patellectomy. Nine of the patients had insertion of a posterior cruciate ligament-substituting implant. Thirteen patients had insertion of a posterior cruciate ligament-sparing implant. The 5-year postoperative knee scores were 89 for the posterior cruciate ligament-substituting knee versus 67 for the posterior cruciate
ligament-sparing knee (P < 0.01). The patella functions to increase the lever arm of the extensor mechanism and to position the quadriceps tendon and the patellar ligament roughly parallel to the anterior cruciate ligament and posterior cruciate ligament, respectively. The patellar ligament thereby provides a strong reinforcing structure that functions to prevent excessive anterior translation of the femur during flexion of the knee. The absence of the patella results in the patellar ligament and the quadriceps tendon being relatively in line with one another. After a patellectomy, the resultant quadriceps force is no longer parallel to the posterior cruciate ligament. This results in loss of the reinforcing function of the patellar ligament. The authors believe this loss of reinforcing function may place increased stresses on the posterior cruciate ligament and posterior aspect of the capsule, which may result in stretching of these structures over time. They found a high rate of anteroposterior instability, a high prevalence of recurvatum, and a high rate of loss of full active extension compared with passive extension in the posterior cruciate ligament-sparing group, which supports their theory.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 559-582.
Paletta GA Jr, Laskins RS: Total knee arthroplasty after a previous patellectomy. J Bone Joint Surg Am 1995;77:1708-1712.

Question 72:

What is a known risk factor for lateral distal femoral locking plate failure when used for the fixation of comminuted extra-articular fractures?

Options:

Early post-operative knee range of motion
Delayed weightbearing
Short working length of the construct
Bridge plate fixation
Plate-screw density less than 0.5

Correct Answer: Plate-screw density less than 0.5

Explanation:

Question 73:

Figure 51 shows an arthroscopic view of the patellofemoral joint from an inferolateral portal. The arrow points to which of the following structures?

Options:

Loose body
Plica
Displaced meniscus tear
Torn retinaculum
Osteochondral defect

Correct Answer: Plica

Explanation:

DISCUSSION: Synovial folds or plicae are the result of incomplete or partial resorption of the synovial membranes during fetal development of the knee. The arthroscopic view shows a medial patellar plica, which has been noted in 5% to 55% of all individuals but becomes symptomatic in only a small number of patients. Symptoms may include crepitus, pain, snapping, and swelling and often respond to nonsurgical management.
REFERENCES: Clarke HD, Scott WN, Insall JN: Anatomic aberrations, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 4. Philadelphia, PA, Churchill Livingstone, 2006, vol 1, pp 67-85.
Patel D: Plica as a cause of anterior knee pain. Orthop Clin North Am 1986;17:273-277.

Question 74:

A corset-type brace may help reduce symptoms during an episode of acute low back pain as the result of

Options:

decreased intervertebral motion in the sagittal plane.
decreased intervertebral motion in the coronal plane.
decreased intervertebral motion in the axial plane.
decreased intradiskal pressure.
increased intradiskal temperature.

Correct Answer: decreased intradiskal pressure.

Explanation:

Question 75:

Options:

Vitamin A deficiency
Low serum testosterone
Low serum thyroxine
Vitamin D deficiency
Hypocalcemia

Correct Answer: Vitamin A deficiency

Explanation:

Question 76:

Options:

cessation of physical therapy and acceptance of the limited range of motion.
additional physical therapy for 3 to 4 months.
arthroscopic capsular release.
open release with Z-plasty lengthening of the subscapularis tendon.
closed manipulation under anesthesia.

Correct Answer: arthroscopic capsular release.

Explanation:

Question 77:

Options:

Fracture of the ulnar component
Disengagement of the axle of the prosthesis
Failure of the triceps mechanism repair
Periprosthetic fracture of the humerus
Periprosthetic fracture of the ulna

Correct Answer: Failure of the triceps mechanism repair

Explanation:

Question 78:

Figure 19 shows the radiograph of a 12-year-old boy who sustained an injury to his hand when another child fell on him. Management should consist of

Options:

early motion and muscle strengthening.
immobilization in a thumb spica cast with the thumb abducted.
open reduction and internal fixation through a volar approach.
open reduction and internal fixation through a dorsal approach.
closed reduction and percutaneous pin fixation.

Correct Answer: open reduction and internal fixation through a dorsal approach.

Explanation:

Question 79:

Options:

both a and b
a, b and c

Correct Answer: both a and b

Explanation:

Question 80:

The artery of Adamkiewicz (arteria radicularis, arteria magna) is most commonly found on the

Options:

right side between T5 and T7.
right side between T9 and T11.
left side between T5 and T7.
left side between T9 and T11.
left side between L1 and L3.

Correct Answer: left side between T9 and T11.

Explanation:

Question 81:

Options:

calcaneal tuberosity. What is the most likely diagnosis?
Plantar fasciitis
Achilles tendinopathy
Tarsal tunnel syndrome
Calcaneal stress fracture
Posterior tibialis tendinopathy

Correct Answer: Tarsal tunnel syndrome

Question 82:

Options:

Observation
Anti-inflammatory medication
Referral to a rheumatologist
Biopsy
Resection of the lesion

Correct Answer: Observation

Explanation:

DISCUSSION: The diagnosis is myositis ossificans resulting from an injury. The initial radiograph reveals a small amount of mineralization in the soft tissues overlying the left hip. The MRI scan shows signal abnormality of the entire gluteus minimus muscle with a mineralized mass in the center. The current radiograph shows a lesion within the abductor musculature with mature ossification peripherally. The imaging studies are diagnostic and the patient is asymptomatic; therefore, the management of choice is observation with no further evaluation or treatment indicated.
REFERENCES: Miller AE, Davis BA, Beckley OA: Bilateral and recurrent myositis ossificans in an athlete: A case report and review of treatment options. Arch Phys Med Rehabil 2006;87:286-290.
Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 15-27.

Question 83:

Options:

Continued bracing, physical therapy, and Botox injections in the triceps surae
Peroneus longus to brevis transfer, medializing calcaneal osteotomy, and transfer of the extensor digitorum longus to the peroneus tertius
Peroneus longus to brevis transfer, and transfer of the posterior tibial tendon to the tibialis anterior tendon
Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation
Triple arthrodesis

Correct Answer: Peroneus longus to brevis transfer, first metatarsal cuneiform dorsal closing wedge osteotomy, and lateralizing calcaneal osteotomy with proximal translation

Explanation:

DISCUSSION: The history and presentation are consistent with type I Charcot-Marie-Tooth (CMT), the most common form of hereditary peripheral motor sensory neuropathy. Type I CMT is the most common, occurring in 50% of patients with CMT, and is characterized by marked slowing of motor neuron velocities, and inconsistent slowing of sensory neuron velocities. Peroneus longus to brevis transfer is indicated to release the overpull of the peroneus longus, and restore the eversion and dorsiflexion function of the peroneus brevis. A lateralizing calcaneal osteotomy with proximal translation is indicated to correct heel varus given that the Coleman block only allows for partial correction of heel varus. Proximal translation of the posterior tuber corrects for the increased calcaneal dorsiflexion, improving the lever arm for the triceps surae. A medial column closing wedge osteotomy is often required to correct a rigid, or semirigid plantar flexed first ray to allow for a balanced, plantigrade foot. Triple arthrodesis is indicated for rigid, arthritic hindfoot deformities. Transfer of the posterior tibial tendon to the tibialis anterior is not indicated since it is an out-of-phase transfer. Transfer of the posterior tibial tendon, when performed, should be to the lateral aspect of the foot. A medializing calcaneal osteotomy would accentuate the heel varus. There is no indication for Botox in CMT; Botox injection of the calf would further weaken push-off during gait. Bracing of a progressive semirigid or rigid deformity is not recommended.
REFERENCES: Younger AS, Hansen ST Jr: Adult cavovarus foot. J Am Acad Orthop Surg 2005;13:302-315.
Sammarco GJ, Taylor R: Cavovarus foot treated with combined calcaneus and metatarsal ostetotomies. Foot Ankle Int 2001;22:19-30.
Richardson EG (ed): Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL,
American Academy of Orthopaedic Surgeons, 2003, pp 135-143.

Question 84:

The anterior approach to total hip arthroplasty requires dissection between which of the following muscle planes?

Options:

Sartorius and gluteus maximus
Gluteus minimus and rectus femoris
Rectus femoris and sartorius
Tensor fascia lata and sartorius
Tensor fascia lata and rectus femoris

Correct Answer: Tensor fascia lata and sartorius

Explanation:

AL-Madena Copy
DISCUSSION: The anterior approach to the hip joint involves identifying the plane between the tensor fascia lata and the sartorius muscles.
REFERENCES: Berger RA, Duwelius PJ: The two-incision minimally invasive total hip arthroplasty: Technique and results. Orthop Clin North Am 2004;35:163-172.
Matta JM, Shahrdar C, Ferguson T: Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-124.
28 • American Academy of Orthopaedic Surgeons
Figure 3Id Figure 31e

Question 85:

Options:

unrecognized injury to the recurrent motor branch.
neuropraxia of the proper palmar digital nerve.
new-onset stenosing flexor tenosynovitis.
injury to the flexor digitorum profundus to the index finger.

Correct Answer: neuropraxia of the proper palmar digital nerve.

Explanation:

EXPLANATION:
Complications after carpal tunnel release are relatively uncommon. The clinical picture described above is most consistent with lumbrical muscle weakness secondary to neuropraxia of the proper palmar digital nerve to the index finger supplying motor innervation to that muscle. The recurrent motor branch of the median nerve innervates the thenar musculature and would not present as index finger weakness. A new onset of trigger finger may result from a loss of the pulley effect of the transverse carpal ligament, postoperative tendon inflammation, or previously unrecognized flexor tendon triggering. Flexor digitorum profundus to the index finger lies deep within the carpal tunnel, making its injury unlikely. If
it were injured, the result would not be weakness of interphalangeal joint extension.

Question 86:

Options:

- Administer IV fluids and then reassess vital signs before making further decisions
- Pelvic binder and IV fluids
- Pelvic binder and immediate transfusion
- Pelvic binder, IV fluids, type and cross-match, and then transfuse

Correct Answer: - Pelvic binder and immediate transfusion

Explanation:

Question 87:

In a pilon fracture, the Chaput fragment typically maintains soft tissue attachment via which of the following structures?

Options:

Interosseous ligament
Anterior inferior tibiofibular ligament
Posterior inferior tibiofibular ligament
Deltoid ligament
Tibiotalar ligament

Correct Answer: Interosseous ligament

Explanation:

Question 88:

Options:

Ulnar
Radial
Axillary
Median
Musculocutaneous

Correct Answer: Musculocutaneous

Question 89:

Options:

placed prior to locked screws allow use of the plate as a reduction aid and locked screws provide fixed angle support to resist varus collapse.
placed after locked screws allow use of the plate as a reduction aid and locked screws provide improved fixation in osteoporotic bone.
provide bicortical fixation and locked screws provide improved fixation in osteoporotic bone.
provide bicortical fixation and locked screws provide fixed angle support to resist varus collapse.
provide better fixation in the diaphysis and locked screws provide better fixation in the distal fragment.

Correct Answer: placed prior to locked screws allow use of the plate as a reduction aid and locked screws provide fixed angle support to resist varus collapse.

Explanation:

Question 90:

Options:

Enchondroma
Fibrous dysplasia
Osteogenic sarcoma
Aneurysmal bone cyst
Periosteal chondroma

Correct Answer: Fibrous dysplasia

Explanation:

Question 91:

Options:

Cortisone injection
Open surgical debridement
Immediate arthroscopic lavage
Intravenous vancomycin for presumptive MRSA infection
Obtain sexual activity history and select appropriate antibiotic

Correct Answer: Obtain sexual activity history and select appropriate antibiotic

Explanation:

Question 92:

Options:

SLAP tear
Subscapularis tear
Supraspinatous tear
Anterior labral tear
Posterior labral tear

Correct Answer: Posterior labral tear

Question 93:

- A 45-year-old man sustains the shoulder injury shown in the radiographs in Figure 55a and 55b and the CT scan in Figures 55c and 55d. Management should consist of

Options:

a sling and swathe, with pendulum exercises in 10 days
open reduction and internal fixation through an anterior approach
open reduction and internal fixation through a posterior approach
immobilization with a splint in 45 degrees of abduction for 6 weeks
arthroscopically assisted reduction and percutaneous screw fixation

Correct Answer: open reduction and internal fixation through a posterior approach

Explanation:

Question 94:

Options:

You and your spouse attend dinner at a local restaurant with the local representative to discuss the Keyhole Genuflex knee.
Keyhole pays your tuition to attend a CME course sponsored by the American Association of Hip & Knee Surgeons where both the Genuflex and the competing Styph total knee are discussed and demonstrated.
Keyhole will pay your expenses to attend a workshop at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.
Keyhole will pay you $500 for each knee that you implant if you switch from your current total knee system.
After you have implanted 25 Genuflex knees, Keyhole will list you on their website as a consultant, pay you a consulting fee of $5,000 per year, and invite you to a golf tournament for their consultants at a resort.

Correct Answer: Keyhole will pay your expenses to attend a workshop at their company headquarters, to learn how to implant the Genuflex knee and to see how the implant is manufactured and tested.

Explanation:

Question 95:

Which of the following studies best increases the ability to diagnose femoral neck fractures in patients with femoral shaft fractures?

Options:

MRI
Fine-cut CT scan
Bone scan
AP radiograph of the femur
AP radiograph of the pelvis

Correct Answer: Fine-cut CT scan

Explanation:

DISCUSSION: Tornetta and associates and Yang and associates found that nearly half of all femoral neck fractures associated with femoral shaft fractures were being missed at their institution. On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. In addition, postoperative AP and lateral radiographs of the hip are made in the operating room to specifically evaluate the femoral neck before the patient is awakened. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures, whereas 8 of the 13 fractures were visible on the dedicated preoperative AP internal rotation hip radiographs.
REFERENCES: Tornetta P III, Kain MS, Creevy WR: Diagnosis of femoral neck fractures in patients with a femoral shaft fracture: Improvement with a standard protocol. J Bone Joint Surg Am 2007;89:39-43.
Yang KH, Han DY, Park HW, et al: Fracture of the ipsilateral neck of the femur in shaft nailing: The role of CT in diagnosis. J Bone Joint Surg Br 1998;80:673-678.

Question 96:

Options:

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

Correct Answer: shorter hospital stay

Explanation:

Question 97:

Options:

Abrasion arthroplasty of the anterior glenoid rim
Posterior capsular advancement into a Hill-Sachs defect
Repair of an inferior glenohumeral ligament detachment
Repair of an unstable SLAP tear
Closure of the rotator interval

Correct Answer: Closure of the rotator interval

Explanation:

Question 98:

Options:

CROW walker
Hyperbaric oxygen treatment
Triple arthrodesis with Achilles tendon lengthening
Transtibial amputation
Ankle arthrodesis

Correct Answer: Triple arthrodesis with Achilles tendon lengthening

Explanation:

Question 99:

The posterior circumflex artery provides blood supply to what portion of the proximal humerus?

Options:

Almost the entire humeral head
Lesser tuberosity
Lesser tuberosity and posteroinferior humeral head
Posterior portion of the greater tuberosity only
Posterior portion of the greater tuberosity and a small portion of the posteroinferior humeral head

Correct Answer: Posterior portion of the greater tuberosity and a small portion of the posteroinferior humeral head

Explanation:

Question 100:

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

Options:

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

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

Explanation:

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

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

OITE & ABOS Orthopedic Board Prep MCQs: Spine, Foot, Shoulder & Knee | Part 168

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 168

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index