Orthopedic Board Prep MCQs: Arthroplasty & Infection

About This Board Review Set

This is Part 170 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

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

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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 170

This module focuses heavily on: Arthroplasty, Hip, Infection, Knee, Nerve.

Sample Questions from This Set

Sample Question 1: Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?...

Sample Question 2: What is an example of cognitive rest after concussion? Review Topic...

Sample Question 3: Which of the following structures is predominantly composed of Type 1 collagen? Review Topic...

Sample Question 4: An injury to the axillary nerve would result in deltoid muscle weakness. 5 . An injury to the thoracodorsal nerve would result in latissimus dorsi weakness and would not cause scapular winging....

Sample Question 5: A B...

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

Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?

Explanation

DISCUSSION
The diagnosis of acute PJI is associated with different criteria than the diagnosis of a chronic PJI. There is no agreed-upon threshold for ESR during the acute period (6 weeks) following total joint arthroplasty. The CRP threshold is higher during the acute period (100 mg/L vs 10 mg/L for a chronic infection). The threshold for synovial fluid analysis for an acute PJI is 10000 cells/µL and more than 90% PMN neutrophils vs 3000 cells/µL and more than 80% PMN neutrophils for a chronic infection.

Question 2

What is an example of cognitive rest after concussion? Review Topic

Explanation

Physical and cognitive rest are recommended as treatment for sports-related concussion. Cognitive rest involves minimizing activities that require concentration and attention such as reading, schoolwork, video games, text messaging, working online, and playing games that require concentration such as chess. Limiting or eliminating video games after concussion is a form of cognitive rest.

Question 3

Which of the following structures is predominantly composed of Type 1 collagen? Review Topic

Explanation

The most common fiber type in the Anterior cruciate ligament is Type 1 collagen.
Type 1 collagen accounts for more than 90% of the total collagen content in the body. Type 1 collagen is found in bone, ligament, tendon, meniscus, annulus of intervertebral discs, skin, healed cartilage, scar tissue, and nerves.
Duthon et al present a review of the ACL and its histologic and mechanical properties. The ACL has a mean length of 32 mm and a width of 7-12 mm. They state that the ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans with multiple functional interactions.
Incorrect
1: Epithelial
2: L4 disc
Basement
Membrane is made up of Type
nucleus pulposus is composed of mostly Type
4 collagen.
2 collagen
4: Medial femoral condyle articular cartilage is comprised mostly of Type 2 collagen. 5: Dupuytren's contracture tissue is mostly Type 3 collagen.

Question 4

An injury to the axillary nerve would result in deltoid muscle weakness. 5 . An injury to the thoracodorsal nerve would result in latissimus dorsi weakness and would not cause scapular winging.

Explanation

A 14-year-old elite basketball player develops acute medial elbow pain after a fall. Physical examination reveals medial elbow tenderness over the submlime tubercle, but full range of motion. The provocative tests seen in Figure A exacerbate his elbow pain. Radiographs of the elbow are normal. What would be the next best step in treatment?

Supervised elbow stretching program Therapeutic elbow arthroscopy

Static elbow external fixation for 3 to 6 weeks, then MR arthrography if pain continues Activity avoidance for 6 weeks

Serial inflammatory markers and rheumatology referral
Figure A shows a moving valgus stress, which is a provocative test for ulnar collateral ligament (UCL) injury and elbow valgus instability. The initial treatment would be a short period of immobilization, rest and flexor pronator strengthening in this patient population.
Adolescent UCL injuries can be effectively treated with a short period of rest and NSAIDs to control pain. As the acute inflammation resolves, the patient can be started on a supervised therapy program. This should target flexor pronator muscles, as they are important secondary dynamic stabilizers of valgus stress. Once symptoms have improved and the athlete has regained full range of motion and strength, a mediated throwing program may be initiated. Throwing athletes should be educated to avoid provocative activities during this period.
Chen et al. wrote a JAAOS article on shoulder and elbow injuries in the skeletally immature athlete. They state that surgery is reserved for older athletes with persistent valgus instability despite > 6 months of non-surgical management.
Murthi et al. reviewed recurrent elbow instability. They state the anterior bundle of the medial ulnar collateral ligament complex is the primary valgus stabilizer of the elbow. The anterior band is taut for the first 60° of elbow flexion, and the posterior band is taut from 60° to 120° of flexion. The secondary valgus stabilizers of the elbow joint include the radial head, the anterior and posterior aspects of the capsule, and the muscular forces around the joint.
Figure A is showing a moving valgus stress. Illustration A shows provocative tests for valgus instability of the elbow. The image on the left shows a valgus stress test. This assesses the anterior bundle of the medial ulnar collateral ligament complex by flexing the elbow to 25-30 degrees and applying a valgus load across the elbow. The image on the right shows milking maneuver. This assesses the posterior bundle of the medial ulnar collateral ligament complex by pulling on the

beyond 90°. Incorrect Answers:

A young, healthy male undergoes a distal biceps repair and sustains an iatrogenic nerve injury during the procedure. Which of the following clinical findings are most likely to be seen in this circumstance? Inability to extend the thumb

Lateral volar forearm numbness Inability to flex the middle finger Medial volar forearm numbness Dorsal thumb numbness
The most commonly injured nerve during a distal biceps repair is the lateral antebrachial cutaneous nerve (LABCN). Injury to this nerve would result in lateral volar forearm numbness.
Distal biceps avulsions can be partial or complete. Indications for surgical management include young, healthy patients who do not wish to sacrifice function, as well as partial biceps avulsions that do not respond to conservative management. Repair of a distal biceps avulsion can be approached through either an anterior one-incision technique or a two-incision technique (BoydAnderson). The one-incision technique uses the interval between the brachioradialis (radial nerve) and pronator teres (median nerve), while the two-incision technique uses this same interval in addition to a second posterolateral elbow incision. The lateral antebrachial cutaneous nerve is the most common nerve injured during either approach.
Kelly et al. retrospectively reviewed 74 distal biceps tendon repairs, and found five sensory nerve paresthesias. The lateral antebrachial cutaneous nerve was most commonly injured, followed by the superficial radial nerve.
Cain et al. retrospectively reviewed 198 distal biceps tendon repairs, and found a 36% complication rate. Lateral antebrachial cutaneous nerve paresthesias were found in 26%, while radial sensory nerve paresthesias were found in 6%, and posterior interosseous nerve (PIN) injury in 4%.
Illustration A shows the close relationship between the lateral antebrachial cutaneous nerve (LABCN) and the distal biceps. Illustration B shows the sensory nerves of the upper extremity and their respective areas of innervation.
Incorrect Answers:

A 33-year-old female presents with left shoulder weakness. Two weeks prior to presentation, the patient experienced sudden-onset, left shoulder pain, which occurred a few days after receiving the influenza vaccine. The pain subsided over the next day, followed by gradual weakness of her shoulder and eventual general disuse of her left upper extremity. An initial visit to her primary care provider resulted in the recommendation of observation. On physical exam, there is weakness and gross atrophy of the shoulder girdle. Figures A & exhibit T2-weighted MRI images of her left shoulder. To further confirm her suspected diagnosis, she is sent for electromyography.
What is the expected result?

Normal results
Fibrillation potentials consistent with compression at the spinoglenoid notch 3 . Sharp waves and fibrillations potentials associated with the deltoid and biceps

Acute denervation of both peripheral nerve and nerve root distribution with sharp waves and fibrillation potentials

Early reinnervation with polyphasic motor unit potentials
This patient has Parsonage-Turner Syndrome, which, when tested on EMG during the first 3 weeks, exhibits acute denervation of both peripheral nerve and nerve root distributions with positive sharp waves and fibrillation potentials.
Parsonage-Turner Syndrome is an idiopathic disorder with an etiology that is still unknown. Typical antecedent events can involve a viral illness, recent immunization, or elective surgery. Clinical presentation is usually initiated by acute onset shoulder pain, which quickly subsides and is followed by gradual weakness. Early MRI exhibits edema in the effected muscles, and fatty infiltration in later stages. Treatment is typically non-operative, and resolution can be seen as early as 6 weeks from onset.
Tjoumakaris et al. provide a thorough review of the diagnosis and management of ParsonageTurner Syndrome. The authors report the usefulness of MRI, which exhibits early edema and later fatty infiltration in the affected muscles, and urge the use of EMG as a confirmatory diagnostic measure as well as a monitoring tool to track resolution. Early identification and diagnosis may be treated with a short course of steroids, which may help shorten symptoms.
Stutz et al. concisely summarize Parsonage-Turner Syndrome and provide typical presentation, diagnosis and management principles. The authors note the common association with viral illness and/or recent immunization along with the importance of obtaining a baseline chest radiograph to rule out a compressive Pancoast tumor. Management is typically supportive with eventual resolution.
Figures A, B, and C are T2-weighted coronal, sagittal, and axial cuts of the shoulder girdle with associated edema in the supraspinatus and infraspinatus typically seen in Parsonage-Turner Syndrome.
Incorrect answers:
A total shoulder arthroplasty (TSA) would be the most appropriate treatment in which of the following arthritic patients?

Question 5

A B

Explanation

DISCUSSION
The radiographs reveal a tibial pilon fracture with an extruded and rotated anterior tibial fragment that lies deep to the anterior compartment neurovascular bundle, which contains the deep peroneal nerve. This nerve innervates the anterior compartment muscles and the extensor digitorum brevis and extensor hallucis brevis muscles and provides sensation to the dorsal aspect of the first interspace. An injury to the deep peroneal nerve at this level will only affect the innervation to the extensor digitorum brevis and extensor hallucis brevis muscles and the innervation of the first interspace. The superficial peroneal nerve innervates
the lateral compartment muscles above the level of this injury and innervates the dorsum of the foot. The medial forefoot is innervated by the saphenous nerve and the posterior tibial nerve innervates the posterior compartment muscles above the level of the injury. The sural nerve innervates the lateral foot and has no motor component, and the superficial peroneal nerve innervates the peroneus longus, which plantar flexes the first metatarsal above the level of the injury.
RECOMMENDED READINGS
Agur AM, Dalley AF, eds. Grant’s Atlas of Anatomy. 13th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:362-370.
Hoppenfeld S, de Boer P, Buckley R, eds. Surgical Exposures in Orthopaedics: The Anatomic Approach. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009:625-673.

Question 6

A 69-year-old patient with diabetes has had acute-onset back pain and difficulty with ambulation for several hours. Evaluation reveals a temperature of 38.3°C, a white blood cell (WBC) count of 14000/µL (reference range [rr], 4500-11000/µL), C-reactive protein (CRP) level of 120 mg/L (rr, 0.08-3.1 mg/L), erythrocyte sedimentation rate of 130 mm/h (rr, 0-20 mm/h), normal rectal examination findings, and normal sensation to light touch. Motor function testing of the lower extremities reveals 3/5 ankle dorsiflexion and 4/5 plantar flexion strength bilaterally. An MR image reveals a large epidural abscess from L1-5. What is the most appropriate treatment at this time?

Explanation

DISCUSSION
Epidural abscess is a serious and potentially disastrous condition. Although medical management is effective in some situations, surgical decompression is considered urgent with the presence of a neurological deficit. Medical management can be considered in the case of a neurologically intact patient, particularly when the microorganism has been identified. If medical management is chosen, careful observation and serial examination for neurologic deterioration is required. Surgical decompression is indicated if a patient's neurologic status worsens or if medical management failure is noted. Additionally, diabetes, a CRP level higher than 115 mg/L, WBC higher than 12500/µL , and bacteremia have proven predictive of medical treatment failure. This patient would be a better candidate for urgent surgical decompression and subsequent IV antibiotics than for medical management.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.View Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 7

.A 22-year-old collegiate baseball pitcher has had posterior shoulder pain with decreased throwing velocity and accuracy over the past several months. Examination of the abducted shoulder in the supine position reveals 120 degrees of external rotation, 40 degrees of internal rotation on the throwing side, 100 degrees of external rotation, and 70 degrees of internal rotation on the nonthrowing side. The remainder of the clinical examination is unremarkable. An MRI scan shows a small partial articular-sided infraspinatus tear. Initial treatment should consist of

Explanation

Question 8

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

Explanation

DISCUSSION: In osteopenic individuals, even those with excellent obtained or maintained balance, long instrumented fusions to the sacrum impart a high degree of strain, and the sacrum may fail in a transverse fracture or fracture-dislocation pattern. The risk of proximal functional kyphosis is unrelated to distal fixation as are coronal plane correction and rod contouring. Pubic ramus fractures have been shown to be associated with both fixation to the sacrum alone as well as to the ilium.
REFERENCE: Hu SS, Berven SH, Bradford DS: Adult spinal deformity, in Frymoyer JW, Wiesel SW (eds): The Adult and Pediatric Spine, ed 3. Philadelphia, PA, Lippincott Williams and Wilkins, 2004, pp 465-477.

Question 9

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 10

A high school distance runner reports a 3-week history of heel pain while running. Examination elicits no pain with dorsiflexion or with palpitation of the plantar fascia; however, pain is evident with palpitation over the muscular origin of the abductor hallucis. What is the most likely etiology of the pain?

Explanation

The tibial nerve gives off two branches. In the distal 1/3 of the leg, the tibial nerve curves anteroinferiorily into the sole of the foot behind the medial malleolus, deep to the flexor retinaculum and between the tendons of the flexor hallicus longus and the flexor digitorum longus muscles. Just distal to the flexor retinaculum, the tibial nerve divides into the medial and lateral plantar nerve. At this site, the lateral plantar nerve gives off its first branch which lies anterior and adjacent to the abductor hallicus.

Question 11

A 67-year-old female presents with shoulder pain for 3 months after falling down stairs. Imaging demonstrates a large rotator cuff tear involving multiple tendons. You perform an arthroscopic rotator cuff repair and biceps tenodesis. At her 2 month follow up, she reports worsening shoulder pain and decreased range of motion. Examination reveals active forward flexion to 80°. Passive range of motion is full. There is a positive external rotation lag sign. An MRI is performed and is pictured in Figure A. Which is the best treatment for this patient? Review Topic

Explanation

The next best step for this patient's failed rotator cuff repair is a revision repair of the infraspinatus.
Failed rotator cuff repair is multifactorial. Structural failure of repair is the result of both intrinsic and extrinsic factors. Intrinsic factors include advancing patient age, increasing tear size, poor tendon and muscle quality, systemic disease and smoking history. Extrinsic factors include inadequate biomechanical construct or repair configuration and overaggressive postoperative rehabilitation.
Denard et al authored a review article on revision rotator cuff repair. Indications for revision repair are persistent symptoms despite nonoperative management in whom infection and advanced degenerative changes have been ruled out. Satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques. Female sex and preoperative forward flexion < 135° is associated with poorer outcomes.
Lambers Heerspink et al found that increasing age, larger tear size and additional biceps or acromioclavicular (AC) joint procedures have a negative influence on cuff integrity at follow up. Smoking, duration of symptoms, obesity and medical comorbidities were not found to influence cuff integrity in this study. Only AC procedures and workers’ compensation status were associated with worse functional outcomes.
Figure A is a coronal T2 MRI demonstrating a failed rotator cuff repair with retear. Incorrect Responses:

Question 12

A 42-year-old woman who has had an 18-month history of severe low back pain is referred to your office for surgical evaluation. She reports that the pain initially began with right lower extremity pain and management consisted of oral analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. She has seen a chiropractor as well as a pain management specialist and she is status-post epidural steroid injections. She has also completed exhaustive physical therapy, as she is a certified athletic trainer and runs a health fitness program at a community hospital. Currently, she denies lower extremity pain and her pain is isolated to her low back and is subjectively graded as 8/10, with 10 being the worst pain she has ever experienced. The pain is interfering with her activities of daily living and she is seeking definitive treatment. Figures 32a through 32c show current MRI scans. Based on the current available medical literature, what is the most appropriate treatment?

Explanation

DISCUSSION: The MRI scans reveal advanced degenerative disk disease at L5-S1. Nonsurgical management has failed to provide relief and the patient is quite debilitated as a result of her back pain. Fritzell and associates demonstrated that in a well-informed and selected group of patients with severe low back pain, lumbar fusion can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatments. In a recent updated Cochrane Review of surgery for degenerative lumbar spondylosis, it was noted that while Fritzell and associates appeared to provide strong evidence in favor of fusion, a more recent trial by Brox and associates demonstrated no difference between those patients undergoing lumbar fusion compared to those receiving cognitive intervention and exercise. The Cochrane Review suggests that this may reflect a difference between the control groups. Fritzell and associates compared lumbar fusion to standard 1990s “usual care,” whereas Brox and associates compared lumbar fusion to a “modern rehabilitation program.” Bear in mind that this patient is a certified athletic trainer and runs a hospital health fitness department; therefore, at least for purposes of this question, it can be assumed that she has participated in a “modern rehabilitation program.” The Cochrane Review goes on to state that preliminary results of three small trials of intradiskal electrotherapy suggest that it is ineffective and that preliminary data from three trials of disk arthroplasty do not permit firm conclusions.
REFERENCES: Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: Updated Cochrane Review. Spine 2005;30:2312-2320.
Fritzell P, Hagg O, Wessberg P, et al: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521-2532.
Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.

Question 13

A 20-year-old man is brought to the emergency department after a high-speed motor vehicle accident. His initial blood pressure is 70/40 mm Hg. He is currently receiving intravenous fluids as well as blood. His Focused Assessment with Sonography for Trauma examination did not show any free fluid in his abdomen and his chest radiograph is unremarkable. An AP pelvis radiograph is shown in Figure 15. What is the next most appropriate step in the management of his pelvic injury? Review Topic

Explanation

This hypotensive patient has an obvious open book injury of the pelvic ring on the AP pelvis radiograph and further radiographs are not needed prior to the initiation of treatment. Although angiography may be indicated if he does not respond to stabilization of his pelvis and fluid/blood administration, temporary stabilization of the pelvis with a sheet or binder should be performed first because it is simple, quick, and has been shown to be effective. This patient does not need a laparotomy at this point since the FAST examination did not show any free intra-abdominal fluid and his chest radiograph was unremarkable, leaving the most likely source of bleeding the pelvic fracture. Open reduction with internal fixation of a pelvic injury is not indicated in an acutely ill patient.

Question 14

An otherwise healthy 57-year-old woman has limited range of motion and moderate effusion after undergoing total knee arthroplasty 6 months ago. One of two cultures of joint aspirate reveals methicillin-resistant Staphylococcus epidermidis. Management should now consist of

Explanation

DISCUSSION: The rapidly increasing prevalence of infection from Staphylococcus epidermidis has made this the most frequently cultured organism. In most patients, the infection occurred intraoperatively, thereby resulting in a chronic infection if not detected within the first 6 weeks after surgery. Irrigation of the joint may be successful during this time in 60% of patients, but the most successful treatment is extirpation for 6 weeks, followed by delayed reimplantation. This approach may result in a salvage rate of as high as 90% in some patients.
REFERENCES: Drancourt M, Stein A, Argenson JN, et al: Oral rifampin plus ofloxacin for treatment of staphylococcus-infected orthopedic implants. Antimicrob Agents Chemother 1993;37:1214-1218.
Duncan CP, Beauchamp C: A temporary antibiotic-loaded joint replacement system for the management of complex infections involving the hip. Orthop Clin North Am 1993;24:751-759.
Oyen WJ, Claessens RA, van Horn JR, et al: Scintiographic detection of bone and joint infections with indium-111-labeled nonspecifonal human immunoglobulin G. J Nucl Med 1990;31:403-412.

Question 15

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Explanation

DISCUSSION: A C5-6 herniation compresses the C6 root, which innervates the radial forearm, thumb, and index finger. The lateral shoulder is innervated by C5. The dorsal forearm and the middle finger typically are innervated by C7. The ulnar forearm, ring finger, and little finger are innervated by C8. There is no specific nerve associated with the volar forearm and palm.
REFERENCE: Hoppenfeld S: Evaluation of nerve root lesions involving the upper extremity, in Orthopaedic Neurology. Philadelphia, PA, JB Lippincott, 1977, pp 7-23.

Question 16

A 35-year-old rock climber sustains an L1 burst fracture from a 30-foot fall while climbing. He sustained no other fractures or serious injuries. He is neurologically intact and has minimal posterior tenderness without increased spinous process separation on examination. Radiographs reveal kyphosis of 20 degrees between T12 and L2 with 30% vertebral height loss. A CT scan shows 55% canal compromise. What is the most appropriate management? Review Topic

Explanation

Wood and associates have shown that the use of a TLSO or a body jacket was equally effective as surgery for the treatment of thoracolumbar burst fractures without neurologic deficit. The only difference in any of the measured parameters (including pain, functional outcome, residual canal compromise, and kyphosis) was a decreased complication rate in the nonsurgical group compared with the surgical group. The maximum time to mobilization in the nonsurgical group was 5 days.

Question 17

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

Explanation

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.

Question 18

Two weeks after undergoing total knee arthroplasty, a 68-year-old woman experiences moderate, yet worsening, knee pain. Upon examination, she can walk with a cane but she has swelling with mild reactive erythema. She has a well-healed incision with no drainage. A review of her medications reveals the she has been taking warfarin and has an international normalized ratio (INR) of 4.0. Her erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level are slightly elevated, and radiographs are unremarkable other than for effusion. What is the most likely diagnosis?

Explanation

DISCUSSION
This patient likely has a hemarthrosis related to INR elevation. The slight elevations in ESR and CRP are likely attributable to the nature of the surgery itself rather than an infection, and the mild reactive erythema is likely attributable to the hemarthrosis.

Question 19

Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with

Explanation

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.

J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. J Sports Med 1998;26:41-45.

Question 20

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

Explanation

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

Question 21

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

Explanation

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

Question 22

A 30-month-old boy underwent open reduction of his right hip to address developmental hip dysplasia. The reduction was performed through an anterior approach, and a shortening femoral osteotomy was not performed. Four months after surgery, hip radiographs reveal absence of ossification of the femoral epiphysis and fragmentation of the ossific nucleus. What is the likely cause of this complication?

Explanation

DISCUSSION
The incidence of pediatric hip dysplasia is approximately 1 per 100 live births, with hip dislocation present in 1 in 1000 births. Two surgical approaches primarily are used for surgical reduction in the dislocated pediatric hip: the modified medial approach as described by Weinstein and the
anterior Smith-Peterson approach. The Weinstein modification of the Ludloff approach exploits the interval between the pectineus muscle and the femoral neurovascular bundles rather than the interval between the pectineus and the adductor longus and brevis. The modified “bikini” anterior Smith-Peterson approach passes between the sartorius and tensor fascia lata superficially and between the rectus and gluteus medius during deep dissection.
When using the medial approach, the neurovascular bundle is particularly at risk, including the medial circumflex femoral vessels that supply blood to the femoral head ossific nucleus. Damage to this structure increases risk for osteonecrosis of the femoral head. Unlike the anterior approach, the medial approach does not allow for the performance of a capsulorrhaphy, poses higher risk for postprocedure redislocation, and is less useful in children of walking age. Identification of the ligamentum teres during deep dissection assists in localization of the true bony acetabulum.
The anatomic structure primarily at risk during the anterior approach is the lateral femoral cutaneous nerve. Excessive traction or transection of this structure will result in numbness in the proximal lateral thigh. This surgical approach allows for identifying and addressing all potential impediments to reduction: the redundant capsule, hypertrophic labrum, hypertrophic ligamentum teres, pulvinar, iliopsoas tendon, and transverse acetabular ligament. In older children who undergo open reduction with periacetabular osteotomy without a concomitant proximal femoral shortening osteotomy, reduction may be accompanied by increased pressure on the femoral head which, in turn, may result in secondary osteonecrosis of the femoral head.
RECOMMENDED READINGS
Karol LA. Developmental dysplasia of the hip. In: Song KM, ed. Orthopaedic Knowledge Update: Pediatrics 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:159-167.
Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg. 2001 Nov-Dec;9(6):401-11. Review. PubMed PMID: 11730331. View Abstract at PubMed
Weinstein SL, Ponseti IV. Congenital dislocation of the hip. J Bone Joint Surg Am. 1979 Jan;61(1):119-

Question 23

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Explanation

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 24

The standard Bankart lesion involves detachment of the labrum along with which of the following capsular ligaments? Review Topic

Explanation

The Bankart lesion involves detachment of the labrum corresponding to the attachment of the middle and inferior glenohumeral ligaments. The superior glenohumeral ligament and the coracohumeral ligament are too superior, inserting near the biceps tendon, and play no role in the Bankart lesion.

Question 25

A 29-year-old male sustained a mid-shaft femur fracture in a motor cycle accident. Even if asymptomatic, what additional radiographs must be obtained either preoperatively or intraoperatively before performing intramedullary nailing of the femoral shaft fracture?

Explanation

DISCUSSION: Ipsilateral femoral neck fractures are seen in 1-9% of femoral shaft fractures and the femoral neck must be properly imaged either preoperatively or intraoperatively in any patient with a femoral shaft fracture. Dedicated hip films, possibly including an internal rotation AP, should be obtained before entering the OR. Daffner et al reported that in 11 of 20 cases of combined femoral shaft and neck fractures, the initial preoperative radiographs did not demonstrate the femoral neck fracture. Intraoperative fluoroscopy should also be used to evaluate for a femoral neck fracture both before (to evaluate for unrecognized fx) and after (to evaluate for iatrogenic fx) IM nailing. Tornetta et al also describe using preoperative CT scans to evaluate for a femoral neck fracture and found that they were able to reduce the number of missed ipsilateral femoral neck fractures.

Question 26

During the revision surgical procedure, thoracic pedicle screws are placed. Following placement, triggered electromyography (EMG) is performed by stimulating the pedicle screw heads. During testing the right T2 pedicle screw head returns a threshold of 2 mA. What does this reading indicate?

Explanation

DISCUSSION
This patient has developed a proximal junctional kyphosis following a long posterior fusion performed for treatment of degenerative lumbar scoliosis. Risk factors for proximal junctional kyphosis in the setting of instrumented fusions performed for degenerative scoliosis include advanced age, 360-
degree fusions, extension of fusion constructs to the sacrum, and upper instrumented vertebrae at the level of T1-3. The patient's junctional kyphosis is attributable to failure of the disk and ligamentous structures at T2-3 and would be graded as type I using the classification system of Yagi and associates. Most symptomatic proximal junctional kyphoses are treated with posterior extension of the fusion construct to a more proximal level spanning the kyphosed region. The use of orthoses or simple removal of instrumentation is unlikely to substantively impact symptoms or address the proximal kyphosis. Diabetes and obesity are known factors that increase risk for postsurgical infection following a spine fusion procedure. The most frequent complication following revision surgery for proximal junctional kyphosis, however, is the need for further surgery. In the study by Yagi and associates, 48% of patients who underwent revision surgery for proximal kyphosis developed further adjacent segment degeneration. In the proximal thoracic spine, where the pedicle may be narrow, triggered EMG testing of inserted pedicle screws may be used to assess for violation of the pedicle wall during insertion. In the setting of triggered EMG, thresholds exceeding 10 mA indicate a well-placed pedicle screw. Thresholds lower than 4 mA to 6 mA indicate that a screw is directly contacting a neural structure. Thresholds between 9 mA and 10 mA suggest that a breach of the pedicle may be present, but the screw is not contacting a neural structure.
RECOMMENDED READINGS
Yagi M, Rahm M, Gaines R, Maziad A, Ross T, Kim HJ, Kebaish K, Boachie-Adjei O; Complex Spine Study Group. Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity.Spine (Phila Pa 1976). 2014 May 1;39(10):E607-14. doi: 10.1097/BRS.0000000000000266. PubMed PMID: 24525992. View
Abstract at PubMed
Cammarata M, Aubin CÉ, Wang X, Mac-Thiong JM. Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976). 2014 Apr 15;39(8):E500-7. doi: 10.1097/BRS.0000000000000222. PubMed
PMID: 24480964. View Abstract at PubMed
Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012 Oct 15;37(22 Suppl):S144-64. doi: 10.1097/BRS.0b013e31826d611b. PubMed PMID: 22885829. View Abstract at PubMed Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 27

A 22-year-old ballet dancer undergoes hip arthroscopy for increasing hip pain and popping with activity. She experiences complete resolution of signs and symptoms post-operatively. Her pre- and post-operative magnetic resonance sagittal images shown in Figure A (left, pre-operative; right, post-operative). Which of the following pre-operative physical examination findings may have been positive? Review Topic

Explanation

This patient has internal snapping hip (coxa saltans), which is caused by the psoas tendon sliding over femoral head, iliopectineal ridge, lesser trochanter exostoses, or iliopsoas bursa.
Snapping hip exists in 3 forms: (1) external snapping hip, which is caused by the iliotibial band (ITB) sliding over the greater trochanter, (2) internal snapping hip, and
(3) intraarticular snapping hip, which is caused by loose bodies (traumatic, or from synovial chondromatoses) or labral tears. While painless snapping hip requires no treatment, painful snapping hip may be addressed with activity modification, physical therapy, steroid injections. Surgical release (ITB z-plasty or psoas tenotomy) is indicated if nonoperative management is unsuccessful.
Ilizaliturri et al. evaluated the results of endoscopic iliopsoas tendon release at the lesser trochanter (10 patients) vs endoscopic transcapsular psoas release from the peripheral compartment (9 patients). There were improvements in WOMAC scores in both groups, and no difference between groups. They conclude that both techniques are equally effective.
Marquez Arabia et al. evaluated if the psoas tendon regenerates after tenotomy in 27 patients. At 23 months, they found that tendon regeneration occurred in all patients, to
a mean circumference of 84% of the original. One patient had persistent pain, but all had 5/5 hip flexion strength. They hypothesize that the bulk of iliopsoas muscle fibers attaches directly to the proximal femoral shaft without a tendon, preventing retraction and allowing regeneration to occur easily.
Figure A shows pre- and post-operative arthroscopic psoas tenotomy magnetic resonance sagittal images. Illustration A shows the psoas tendon (white arrows) prior to transection. Illustration B shows the psoas tendon after transection (green arrows, proximal tendon segment; yellow arrows, distal segment). Illustration C and D are diagrams showing release at the level of the lesser trochanter and hip joint respectively.
Incorrect
90 degrees, but full external rotation. Answer 2: Decreased internal rotation and a positive impingement test (forced
flexion, adduction, femoroacetabular Answer 4: These
and internal
rotation) are classic findings
findings may
be found with intra-articular
for cam-type impingement loose bodies.

Question 28

An active 49-year-old woman who sustained a diaphyseal fracture of the clavicle 8 months ago now reports persistent shoulder pain with daily activities. An AP radiograph is shown in Figure 8. Management should consist of

Explanation

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have

shown some healing response with callus formation, but these techniques are not successful

in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions

of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson NS, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 29

What is the most common adverse postoperative complication of laminoplasty for multilevel cervical spondylotic myelopathy?

Explanation

DISCUSSION: A 30% to 50% loss of cervical range of motion is reported postoperatively in most patients following cervical laminoplasty. Inadvertent closure of the laminoplasty does occur but is rare. Laminoplasty is advocated in lieu of laminectomy to prevent progressive kyphosis and can effectively decompress the spinal cord. C5 nerve root palsies are a poorly understood but rare complication of surgical decompression for cervical spondylotic myelopathy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Edwards CC II, Riew KD, Anderson PA, et al: Cervical myelopathy: Current diagnostic and treatment strategies. Spine J 2003;3:68-81.

Question 30

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Explanation

DISCUSSION: The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot’s joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication.
REFERENCES: Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.
Kim YH, Kim JS, Oh SW: Total knee arthroplasty in neuropathic arthropathy. J Bone Joint

Surg Br 2002;84:216-219.

Question 31

A 63-year-old man with type I diabetes mellitus who underwent open forefoot amputation now has a high fever, and an elevated WBC count and blood glucose levels. Repeat laboratory studies the day after surgery show a WBC count of 9,500/mm 3 , a serum albumin level of 1.9 g/dL, and a total lymphocyte count of 1,900/mm 3 . Examination reveals that he is afebrile, and his blood glucose level is now normal. An ultrasound Doppler of the dorsalis pedis artery shows an ankle-brachial index of 0.6. A transcutaneous partial pressure measurement of oxygen at the ankle joint shows a level of 38 mm Hg. What is the best course of action?

Explanation

DISCUSSION: This patient appears to have adequate blood supply to heal a Syme’s ankle disarticulation but is currently malnourished because of the systemic infection, and is likely to progress to wound failure. Therefore, the initial management of choice is culture-specific antibiotic therapy, open wound management, and nutritional supplementation. If his serum albumin rises to a minimum of 2.5 gm/dL, he can undergo elective Syme’s ankle disarticulation. If the serum albumin does not rise within a short period of time, he should undergo transtibial amputation.
REFERENCE: Pinzur MS, Stuck RM, Sage R, et al: Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85:1667-1672.

Question 32

A 35-year-old man sustained a traumatic low ulnar nerve palsy 18 months ago. The extent of the clawing and intrinsic atrophy as well as the active radial deviation are seen in Figures 1 through 3. No hyperextensibility of any of the proximal interphalangeal (PIP) joints is observed. Preoperatively, the patient is not able to fully extend the PIP joints with the wrist in neutral position and the examiner holding the metacarpophalangeal (MCP) joints flexed. Figure 4 shows the intraoperative photograph obtained during the intrinsic reconstruction procedure that is performed. The tendon grafts were inserted distally into the

Explanation

EXPLANATION:
Originally, Burkhalter and Strait recommended bony insertion into the proximal phalanx through a drill hole. This procedure does require more surgical dissection and flexes only the MCP joints; thus it cannot extend the PIP joints directly. It does improve clawing in the fingers if the PIPs can extend with preoperative MCP flexion. The ability to extend the PIP joints is evaluated preoperatively using the Bouvier test. With the wrist in neutral position, the examiner holds the MCPs flexed and looks for the ability in that position to actively extend the PIPs. If the patient is able to do so, then the test is considered positive, and this describes "simple" clawing. In such cases, procedures that flex only the MCPs are appropriate. The insertion sites for these procedures include the proximal phalanx, the first annular pulley, and the second annular pulley. If the Bouvier test is negative, then it is best to insert the tendon grafts distally into the lateral bands. This technique has a low chance of leading to hyperextension of the PIP joints, particularly when performed with a wrist extensor motor (which leaves the flexor digitorum superficialis undisturbed) and with no preoperative hyperextensibility of the PIPs.

Question 33

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Explanation

DISCUSSION: The use of chemotherapy has dramatically improved survival rates of patients with Ewing’s sarcoma. Local disease is best handled with wide resection to decrease local recurrence and to avoid the complications of radiation therapy (ie, secondary sarcomas). Radiation therapy alone is reserved for unresectable lesions or poor surgical margins. Amputation generally is not necessary.
REFERENCES: Toni A, Neff JR, Sudanese A, et al: The role of surgical therapy in patients with non-metastatic Ewing’s sarcoma of the limbs. Clin Orthop 1991;286:225.
Picci P, Rougraff BT, Bacci G, et al: Prognostic significance of histopathologic response to chemotherapy in non-metastatic Ewing’s sarcoma of the extremities. J Clin Oncol 1993;11:1763.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant Bone Tumors. Instr Course Lect 2002;51:413-428.
FOR ALL MCQS CLICK THE LINK ORTHO MCQ BANK

Question 34

Which of the following is considered the lowest level that a standard thoracolumbosacral orthosis (TLSO) can immobilize?

Explanation

DISCUSSION: Without more distal immobilization such as a thigh extension, the lower two lumbar segments generally show the same or even increased mobility with a TLSO.
REFERENCES: White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, JB Lippincott, 1990, pp 475-509.
Norton PL, Brown T: The immobilizing efficiency of back braces. J Bone Joint Surg Am 1957;39:111-139.

Question 35

Figure 242 is the anteroposterior radiograph of a 28-year-old man who underwent resection and reconstruction for an Ewing sarcoma. What is the most common functional deficit encountered during rehabilitation?

Explanation

Question 36

A collegiate division I football player ruptures his anterior cruciate ligament (ACL). After counseling him, you agree to perform a double-bundle ACL reconstruction. Which of the following is a correct statement for this technique? Review Topic

Explanation

The ACL is composed of two anatomic bundles: the anteromedial (AM) and the posterolateral (PL). They are both considered important to the stability of the knee. Although they work in concert, the AM bundle controls translation, especially in flexion, whereas the PL bundle prevents rotation.

Question 37

What form of fixation is associated with the highest incidence of osseous union when using segmental allograft reconstruction following tumor resection?

Explanation

DISCUSSION: Plate and screw fixation of allograft is associated with the highest incidence of union but also the highest prevalence of allograft fracture. Conversely, intramedullary fixation is associated with a higher incidence of nonunion but fewer fractures. Step-cut osteotomies are not associated with a higher incidence of union.
REFERENCE: Vander Griend RA: The effect of internal fixation on the healing of large allografts. J Bone Joint Surg Am 1994;76:657-663.

Question 38

Which of the following drawbacks is associated with the Ganz periacetabular osteotomy?

Explanation

DISCUSSION: Although technically challenging, the Ganz periacetabular osteotomy offers advantages over other rotational pelvic osteotomies. Posterior column integrity is maintained, as is the acetabular vascular supply. Free mobility of the fragment makes large corrections in the center edge angle possible. Because of the asymmetric cuts and the need to restore anterior coverage, there is a tendency to anterior displacement of the joint while flexing the acetabulum. The procedure is commonly performed through a Smith-Petersen incision.
REFERENCES: Trousdale RT, Ganz R: Periacetabular osteotomy, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, Pa, Lippincott-Raven, 1998, pp 789-802.
Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.
MacDonald SJ, Hersche O, Ganz R: Periacetabular osteotomy in the treatment of neurogenic acetabular dysplasia. J Bone Joint Surg Br 1999;81:975-978.

Question 39

Which of the following results cannot be achieved with an in-shoe orthosis?

Explanation

DISCUSSION: Depending on the type of materials used, an orthotic can be fabricated to achieve a variety of results. While a rigid fixed deformity can be stabilized or cushioned, an orthotic will not correct a deformity that is not passively correctable.
REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 55-64.
Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.
Buonomo LJ, Klein JS, Keiper TL: Orthotic devices: Custom-made, prefabricated, and material selection. Foot Ankle Clin 2001;6:249-252.
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Question 40

Figures 1 through 3 show the radiographs obtained from a 40-year-old woman who injured her right index finger in a bicycle collision. Failure to restore sagittal plane alignment would likely result in

Explanation

EXPLANATION:
The radiographs reveal an extra-articular proximal phalanx fracture of the index finger. The fracture is comminuted with dorsal angulation of the distal fragment. The question specifically asks about the restoration of sagittal alignment. The fracture is comminuted with dorsal angulation of the distal fragment. The other options are incorrect, because overlapping of the digits occurs with rotational malalignment, the development of arthritis may occur with intra-articular fractures, and hyperextension would not occur with this type of deformity.

Question 41

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

Explanation

EXPLANATION:
Wall and Stern published a report on MCP joint pyrolytic carbon arthroplasty for osteoarthritis and another on PIP joint pyrolytic carbon resurfacing arthroplasty for osteoarthritis. They found different outcomes, and MCP joint implants outperformed PIP joint implants. Of eleven MCP joint arthroplasties, two produced asymptomatic squeaking and clicking, whereas eleven of 31 PIP joint implants produced this problem. No dislocations were reported among the MCP joint implants, but five PIP joint dislocations were observed. Outcomes were measured by the Michigan Hand Outcomes Questionnaire in both studies and were satisfactory for the MCP joint implants, with an average score of 80. The PIP implants did not fare as well, showing a higher degree of pain along with an average score of 53. The authors noted that, in the 15 patients in the PIP study who had unilateral surgery, the uninvolved, nonsurgical hand motion was actually statistically significantly (P<0.01) better than the surgical hand. MCP joint motion increased from 62º before surgery to 76º after surgery, whereas PIP joint motion got worse after surgery, with the average motion decreasing from 57º to 31º.

Question 42

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

Explanation

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

Question 43

A 10-year-old boy reports a gradual onset of weakness; however, he is fully ambulatory. History reveals that he has a 17-year-old brother who has just stopped walking because of a similar condition. Laboratory studies show a creatine kinase level of 5,480 IU/L (normal 25 to 232 IU/L), and examination shows a slightly positive Gower sign. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has Becker muscular dystrophy. Patients with this condition have a slower rate of progression of disease compared with patients who have Duchenne muscular dystrophy, and walking may continue into the late teens. The creatine kinase level is not as high as in Duchenne muscular dystrophy, which can range from 20,000 to 30,000 IU/L. Becker muscular dystrophy is allelic to Duchenne muscular dystrophy, resulting in a mutation in the dystrophin gene. Myotonic dystrophy is characterized by a progressive inability to relax the muscles after contracture. The Gower sign is not helpful in this disease. Patients with Charcot-Marie-Tooth disease, one type of which is also known as HMSN type II, do not have elevated creatine kinase levels and usually present with a foot deformity. Spinal muscular atrophy, type II, usually presents with severe weakness in the second year of life.
REFERENCES: Matsuo M: From molecular diagnosis to gene therapy. Brain Dev 1996;18:167-172.
Darras BT: Molecular genetics of Duchenne and Becker muscular dystrophy. J Pediatr 1990;117:1-15.
Gutmann DH, Fischbeck KH: Molecular biology of Duchenne and Becker’s muscular dystrophy: Clinical applications. Ann Neurol 1989;26:189-194.

Question 44

Figure 45 shows the radiograph of a 2-year-old patient who has progressive lumbar scoliosis as the result of hemivertebra. Examination reveals no associated cutaneous lesions, and an MRI scan shows no associated intraspinal anomalies. Treatment should consist of

Explanation

DISCUSSION: In a retrospective review of 10 patients treated with hemivertebra excision for hemivertebra in the levels of T12 to L3, the procedure was found to be safe and effective. The procedure provided an average curve correction of 67° and was greatest in patients who were younger than age 4 years at the time of surgery. Long anterior and posterior fusion with instrumentation is not the treatment of choice at this age. Either anterior hemiepiphyseodesis or posterior hemiarthrodesis in this isolated hemivertebra setting would be inadequate. Brace treatment is ineffective in management of the primary curvature.
REFERENCE: Callahan BC, Georgopoulos G, Eilert RE: Hemivertebral excision for congenital scoliosis. J Pediatr Orthop 1997;17:96-99.

Question 45

A 62-year-old man has had worsening pain in the left shoulder for the past 6 weeks without trauma. He participated in physical therapy to "strengthen" his shoulder; however, it failed to provide relief. On examination, his right shoulder motion is 180, 60, and T8 (forward flexion, external rotation, and internal rotation). His left shoulder motion, both active and passive, is 150, 40, and L1. T1- and T2-weighted MRI scans are shown in Figures 106a and 106b with an official diagnosis of partial supraspinatus tendon tear. What is the appropriate treatment? Review Topic

Explanation

The patient lacks both active and passive motion in all planes of shoulder motion; his primary pathology is adhesive capsulitis. Although the MRI scans reveal a partial-thickness rotator cuff tear, this is not uncommon in asymptomatic patients older than age 60 years. Physical therapy for patients with adhesive capulitis should stress shoulder motion rather than rotator cuff strengthening. Because most cases of adhesive capsulitis improve without surgical management, surgical treatment options are not appropriate at this time.

Question 46

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

Explanation

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

Question 47

If a surgeon inadvertently burrs through the midlateral wall of C5 during a anterior corpectomy, what structure is at greatest risk for injury?

Explanation

DISCUSSION: The vertebral artery is contained within the vertebral foramen and thus tethered alongside the vertebral body, making it vulnerable to injury if a drill penetrates the lateral wall. The C5 root passes over the C5 pedicle and is not in the vicinity. The C6 root passes under the C5 pedicle but is posterior to the vertebral artery and is only vulnerable at the very posterior-inferior corner. The carotid artery and the vagus nerve are both within the carotid sheath and well anterior.
REFERENCES: Pfeifer BA, Freidberg SR, Jewell ER: Repair of injured vertebral artery in anterior cervical procedures. Spine 1994;19:1471-1474.
Gerszten PC, Welch WC, King JT: Quality of life assessment in patients undergoing nucleoplasty-based percutaneous discectomy. J Neurosurg Spine 2006;4:36-42.

Question 48

Figures 1 and 2 are the MRI scans of a 57-year-old man who dislocated his left shoulder after a fall while playing tennis. On examination, he had full passive shoulder range of motion, but he was unable to actively elevate his injured shoulder. Sensation was intact to light touch over the lateral shoulder. What is the most likely etiology of his shoulder weakness?

Explanation

This patient has a massive rotator cuff tear resulting in disruption of the transverse force couple between the subscapularis anteriorly and the infraspinatus and teres minor posteriorly. These muscles provide dynamic shoulder stability throughout active elevation, and loss of the force couple produces a pathologic increase in translation of the humeral head and decreased active abduction. Active shoulder elevation <90 degrees in the presence of full passive motion is termed pseudoparalysis. The most common neurologic deficit after shoulder dislocation is isolated injury to the axillary nerve. This patient's sensory examination suggests that the axillary nerve is intact. Cervical radiculopathy is less common after shoulder dislocation but has been reported. Conflicting evidence exists regarding the contribution of the long head of the biceps tendon to glenohumeral stability. One study reported minimal electromyographic activity in the biceps during ten basic shoulder motions.

Question 49

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

Explanation

DISCUSSION: On T1-weighted images, the posterior cruciate ligament is a low-signal (black) structure that courses from the posterior aspect of the tibia to the medial femoral condyle. The posterior cruciate ligament can appear as arcuate, U-shaped, or kinked. The other structures have similar signal but different anatomic locations.
REFERENCES: Gross ML, Grover JS, Bassett LW, Seeger LL, Finerman GA: Magnetic resonance imaging of the posterior cruciate ligament: Clinical use to improve diagnostic accuracy. Am J Sports Med 1992;20:732-737.
Sonin AH, Fitzgerald SW, Friedman H, Hoff FL, Hendrix RW, Rogers LF: Posterior cruciate ligament injury: MR imaging diagnosis and patterns of injury. Radiology 1994;190:455-458.

Question 50

Duchenne’s muscular dystrophy is a genetic disorder that is transmitted by which of the following modes of inheritance?

Explanation

DISCUSSION: Patients with Duchenne’s muscular dystrophy show progressive muscular weakness because of the absence of dystrophin and have the clinical picture of progressive muscle weakness. The condition is an X-linked genetic disease.
REFERENCES: Fitzgerald RH, Kaufer H, Malkani AL: Orthopaedics. St Louis, MO, Mosby Year Book, 2002, pp 1573-1583.
Smith SA, Swaiman HF: Muscular dystrophies, in Swaiman KF, Ashwall S (eds): Pediatric Neurology Principles and Practice, ed 3. St Louis, MO, Mosby, 1999, pp 1235-1237.

Question 51

Figure 14 shows the AP radiograph of a patient who underwent prosthetic arthroplasty 8 years ago and has now become symptomatic again over the past 18 months. A WBC count and erythrocyte sedimentation rate are within normal limits, and aspiration of the glenohumeral joint yields a negative Gram stain and cultures. Which of the following procedures will most likely provide the best pain relief and function?

Explanation

DISCUSSION: Simple removal of the loose glenoid component or removal of the loose component followed by implantation of a new glenoid component are both appropriate treatment choices, depending on the remaining glenoid bone stock. However, removal and reimplantation appears to provide the most predictable pain relief and better function than removal alone.
REFERENCES: Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 2001;10:217-224.
Rodosky MW, Bigliani LU: Surgical treatment of non-constrained glenoid component failure. Oper Tech Orth 1994;4:226-236.

Question 52

Which of the following statements most accurately describes the risk of ileus following total joint arthroplasty?

Explanation

DISCUSSION: The risk of postoperative ileus is noted to be higher in patients undergoing THA than patients undergoing TKA. Older age, male gender, and a history of abdominal surgery have been identified as risk factors.
REFERENCE: Parvizi J, Han SB, Tarity TD, et al: Postoperative ileus after total joint arthroplasty. J Arthroplasty 2008;23:360-365.

Question 53

In the evaluation of Lisfranc injuries, which radiographic studies should routinely be obtained?

Explanation

DISCUSSION
It is estimated that as many as 20% of Lisfranc injuries are missed on initial radiographic examination. Weight-bearing bilateral radiographs should be performed routinely. CT scan, MRI, and stress radiographs performed under anesthesia may be needed in select cases. The Lisfranc ligament stabilizes the midfoot and consists of the dorsal and plantar oblique ligaments and the strong interosseous ligaments. All 3 extend from the base of the second metatarsal to the medial cuneiform. The “fleck sign" is a small avulsion fracture at the medial base of the second metatarsal, representing an avulsion of the Lisfranc ligament. The current treatment recommendation for displaced Lisfranc subluxations and dislocations is to perform ORIF with rigid fixation using either screws or plates and screws. Kirschner wire fixation may lead to recurrence after pin removal. Closed reduction and casting alone cannot permanently reduce the dislocation.
RECOMMENDED READINGS
Clanton TO, Waldrop III NE. Athletic injuries to the soft tissues of the foot and ankle. In: Coughlin MJ, Saltzman CL, Anderson RB, eds. Mann's Surgery of the Foot and Ankle. Vol 2. 9th ed. Philadelphia, PA: Elsevier-Saunders; 2014:1531-1687.
Karges DB. Foot trauma. In: Cannada LK, ed. Orthopaedic Knowledge Update 11. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2014:631-643.
CLINICAL SITUATION FOR QUESTIONS 5 THROUGH 8
A

Figures 5a and 5b are the clinical photograph and AP radiograph of a 55-year-old woman who has a painful right forefoot deformity. There is no history of antecedent trauma. The 1-2 intermetatarsal angle is 17 degrees, and the hallux valgus angle is 35 degrees.

Question 54

A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?

Explanation

DISCUSSION: The radiograph reveals a “bony mallet injury.” As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate.
REFERENCES: Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.
Bendre AA, Hartigan BJ, Kalainov DM: Mallet finger. J Am Acad Orthop Surg 2005;13:336-344.

Question 55

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Explanation

Advanced glycation end-products (AGEs) are found in aging and osteoarthritis (OA) and result in increased articular cartilage stiffness and increased brittleness.
AGEs are produced from spontaneous nonenzymatic glycation of proteins when sugars (glucose, fructose, ribose) react with lysine or arginine residues. Because of the low turnover, cartilage is susceptible to AGEs accumulation. The accumulation of AGEs has been thought to play a role in the development of OA of the knee and ankle.
Li et al. reviewed age-related changes in cartilage. They state that with aging, there is excessive collagen cross-linking increases cartilage stiffness, while shortening/degradation of aggrecan leads to loss of sugar side chains and water-binding ability, while increased levels of AGEs are associated with a decline in anabolic activity. There is also increased chondrocyte death and/or apoptosis.
Anderson et al. reviewed the relationship between osteoarthritis and aging. They state that knee cartilage thins with aging (especially on the femoral and patellar sides, suggesting a gradual loss of cartilage matrix. AGEs formation leads to modification of type II collagen by cross-linking of collagen molecules, increasing stiffness and brittleness and increasing susceptibility to fatigue failure.
Incorrect Answers:

Question 56

A 35-year-old recreational basketball player reports shoulder pain following a sprawl for a rebound. While examination reveals that he can actively elevate the arm with pain, a subacromial injection fails to provide relief. An MRI scan reveals medial subluxation of the long head of the biceps. Which of the following structures most likely has also been injured?

Explanation

DISCUSSION: Subscapularis tears can be associated with disruption of the transverse ligament supporting the biceps. The remaining aspects of the rotator cuff, superior labrum, and capsule can be intact with this injury.
REFERENCES: Petersson CJ: Spontaneous medial dislocation of the tendon of the long biceps brachii. Clin Orthop 1986;211:224-227.
Gerber C, Sebesta A: Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A preliminary report. J Shoulder Elbow Surg 2000;9:483-490.

Question 57

What part of the glenoid labrum has the least vascularity?

Explanation

DISCUSSION: The glenoid labrum receives its blood supply from the suprascapular, posterior humeral circumflex, and circumflex scapular arteries. The labral vessels arise from the capsular and periosteal vessels that penetrate the periphery of the labrum. The bone does not appear to be a source of vascularity. The posterior/superior and inferior labrum have a fairly robust vascular supply, whereas the anterior/superior labrum has relatively poor vascularity, which may influence the success of superior lateral repairs.
REFERENCE: Cooper DE, Arnoczky SP, O’Brien SJ, et al: Anatomy, histology and vascularity of the glenoid labrum: An anatomical study. J Bone Joint Surg Am 1992;74:46-52.

Question 58

.What is the most appropriate treatment if instability is present at the time of evaluation?

Explanation

Question 59

An otherwise healthy 37-year-old man fell off the flatbed of a delivery truck and landed directly on his dominant left hand. Surgical stabilization of a distal radius fracture is performed. An intraoperative radiograph is shown in Figure 22. What is the next most appropriate step in management?

Explanation

DISCUSSION: The intraoperative radiograph reveals a scapholunate ligament disruption. Repair of the stout dorsal scapholunate interosseous ligaments is required. Interestingly, the results of scapholunate ligament injuries associated with distal radius fractures appear to be superior to those of isolated ligament injuries.
REFERENCES: Smith DW, Henry MK: Comprehensive management of soft-tissue injuries associated with distal radius fractures. J ASSH 2002;3:153-164.
Fernandez DL, Wolfe SW: Distal radius fractures, in Green DP, Hotchkiss RN, Pederson WC,

et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 693.

Question 60

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Explanation

The complication rate with halo vest treatment in children is reported to be as high as 68% in contrast to a 36% complication rate in adults. These complications include not only pin tract infections, but also skull penetration. Multiple pins allow for the early removal of pins without fixation consequences should pin site infections begin to develop. Moreover, there is significant variability in the insertional torque applied by a variety halo pin torque wrenches, including those from the same manufacturer. Consequently, the use of a large number of pins (8 to 12) placed a very low insertional torque (1 to 5 in-lb) in children is recommended. A CT scan of the head should also be considered to assess for the thickest areas of the skull suitable for pin application.

Question 61

The posterior approach to the proximal radius uses what intermuscular interval?

Explanation

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 62

Figures 1 and 2 are the MR arthrogram images of a 16-year-old, right-hand-dominant baseball player who injured his left shoulder 4 weeks ago during a game. He now has pain, weakness, and the inability to swing a bat and can no longer do push-ups. He denies prior injury to his left shoulder. Radiographs are unremarkable. The patient fails an extensive course of physical therapy and is unable to return to baseball. He and his orthopaedic surgeon elect to proceed with surgery. During a repeat evaluation, he has negative sulcus and Beighton sign findings, and radiographs show 5° of glenoid retroversion. What is the most appropriate surgical plan?

Explanation

Posterior shoulder instability is a rare form of instability that often presents with pain rather than feelings of instability. It often occurs in young athletes during activities that put the shoulder in an “at-risk position” (flexion, adduction, internal rotation). Repetitive microtrauma can lead to posterior shoulder instability such as seen in football linemen. Swinging a bat or golf club places the lead arm in a flexed, adducted, and internally rotated position, which can lead to posterior translation of the humeral head that is forcibly reduced in follow-through, as seen in this patient. The glenohumeral joint relies on static and dynamic stabilizers. Static stabilizers help prevent instability at the end ranges of motion when the ligaments are taut. Dynamic stabilizers work to prevent subluxation at midranges of motion, at which the ligaments are lax. The rotator cuff is integral as a dynamic stabilizer of the shoulder. It works through a process called concavity compression. The four muscles of the rotator cuff compress the humeral head into the concavity of the glenoid-labrum. This prevents the humeral head from subluxing during the midranges of motion. Of the four rotator cuff muscles, the subscapularis is most important at preventing posterior subluxation. This patient has posterior instability, and various surgical techniques may be indicated depending on findings. Arthroscopic labral repair is indicated for anterior instability. Arthroscopic posterior labral repair is indicated for this patient because he has a posterior labral tear and posterior instability. If a patient has ligamentous laxity (not seen in this scenario because sulcus and Beighton sign findings would be negative), a posterior capsular shift with rotator interval closure is indicated. If a patient has excessive glenoid retroversion (not seen in this scenario with 5 degrees of retroversion), a posterior opening-wedge osteotomy is appropriate. The most common complication seen after arthroscopic posterior labral repair is stiffness, followed by recurrent instability
and degenerative joint disease.

Question 63

A 45-year-old man falls from a skateboard and dislocates his elbow. After a closed reduction in the emergency department, his elbow is carefully examined. He has positive valgus stress, moving valgus stress, and milking maneuver tests. His elbow appears stable to varus stress and lateral pivot shift tests. What is the most appropriate manner of immobilizing the elbow for this patient?

Explanation

Varus posteromedial rotatory instability occurs following a fall onto an outstretched hand with axial loading and a varus stress to the elbow. This injury can result in a rupture of the posterior band of the medial collateral ligament (MCL), fracture of the anteromedial facet of the coronoid, and avulsion of the lateral ulnar collateral ligament (LUCL). Based on the examination findings, this patient has an acute MCL rupture. Furthermore, the LUCL appears intact, as evidence by the stability with varus stress. To protect the reduction in the acute setting, posterior splinting is recommended, but placing the forearm in full supination tightens the structures medially where the MCL is deficient. Splinting in neutral is indicated for valgus posterolateral rotatory instability, where both the LUCL and MCL are ruptured. Splinting in full pronation is indicated for isolated LUCL ruptures. Early active range of motion is not recommended for adults immediately after an acute elbow dislocation, as ligamentous injury or fracture nearly always accompanies the dislocation. In this case, the
forearm should be splinted in full supination.

Question 64

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 65

When an adult hip is surgically dislocated for relief of femoro-acetabular impingment, what is the risk of postoperative iatrogenic osteonecrosis?

Explanation

DISCUSSION: In a report of more than 70 hips treated by surgical dislocation, iatrogenic osteonecrosis failed to develop in any of the hips.
REFERENCE: Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U: Surgical dislocation of the adult hip: A technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119-1124.

Question 66

Cortical bone demonstrates viscoelastic behavior as its mechanical properties are sensitive to strain rate and duration of applied load. Regarding longitudinal strain in cortical bone, which of the following statements regarding this characteristic is true?

Explanation

As strain rate increases, both elastic modulus and ultimate strength increase.
For LOW strain rates typical of normal activity (physiological strain rates of <0.1/s), bone is ELASTIC and DUCTILE (increasing ultimate strain with increasing strain rate). There is a ductile-to-brittle transition with increasing strain rate from normal to
supranormal rates. For EXTREMELY HIGH supranormal strain rates (>0.1/s, high impact trauma), bone is VISCOELASTIC and BRITTLE (low ultimate strain with increasing strain rate). Bone also becomes stronger and stiffer (higher modulus, steeper slope of stress-strain plot) as strain rate increases. This viscoelastic property helps in damping muscle contracture.
Natali and Meroi reviewed studies examining mechanical properties of bone. Mechanical properties are correlated with moisture, deformation rate, density and region of bone. Mechanical adaptation of bone is affected by strain rate (rate at which bone is deformed), strain mode (tension, compression, shear), strain direction (direction of strain relative to bone surface), strain frequency (cycles/second), stimulus duration (period over which deformation cycles are applied), strain distribution (pattern of strain magnitude across bone section) and strain energy (energy stored during deformation).
Illustration A shows the mechanical properties of bone with increasing strain rates. Incorrect Answers:
increase. During normal activity, as strain rate increases, bone is more ductile. With high impact trauma, bone is more brittle.

Question 67

A 7-year-old girl with a known diagnosis of neurofibromatosis has neck pain and deformity. She has been wearing a soft cervical collar for the past 2 months with mild relief of her symptoms. An MRI scan shows several small neurofibromas on the left side of the cervical spine near the foramina at C6 and 7. A lateral cervical spine radiograph is shown in Figure 34. What is the most appropriate management? Review Topic

Explanation

With a diagnosis of neurofibromatosis and severe kyphosis, anterior and posterior treatment is needed to achieve correction and fusion. In situ fusion has a high failure rate with the kyphotic deformity and even with traction, correction of the kyphosis is not expected. Anterior treatment alone may achieve correction, but in neurofibromatosis only circumferential treatment has been shown to provide longterm stability.

Question 68

A football lineman who sustained a traumatic injury while blocking during a game now reports that his shoulder is slipping while pass blocking. Examination reveals no apprehension in abduction and external rotation; however, he reports pain with posterior translation of the shoulder. He has full strength in external rotation, internal rotation, and supraspinatus testing. What is the pathology most likely responsible for his symptoms? Review Topic

Explanation

Traumatic posterior instability is a common finding in football players, especially in the blocking positions as well as in the defensive linemen and linebackers. A traumatic blow to the outstretched arm results in posterior glenohumeral forces. Labral detachment at the glenoid rim is common. Patients report slipping or pain with posteriorly directed pressure. Rarely do these patients have true dislocations that require reduction; however, recurrent episodes of subluxation or pain are not uncommon. Posterior repair has been shown to be successful in the treatment of traumatic instability.

Question 69

A 47-year-old obese man with a body mass index of 42 comes into the office with left knee pain 1 year after undergoing an uncomplicated left medial unicompartmental knee arthroplasty (UKA). Radiographs show a loose tibial component in varus. What is the most appropriate next step to treat this failed construct?

Explanation

DISCUSSION:
This patient likely is experiencing failure of the UKA secondary to poor patient selection. In this young, heavy man, the component likely loosened due to the ongoing varus alignment of the knee and his elevated
weight. Despite this likely scenario, the next step is determining whether an infection is the cause of his pain. Prior to obtaining an aspiration, the surgeon can order ESR and CRP studies to determine whether aspiration is warranted. If the laboratory studies are unremarkable, the surgeon likely can forgo the aspiration and proceed to a revision TKA with possible augments on standby.

Question 70

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Explanation

DISCUSSION: An isolated avulsion of the lesser tuberosity occurs very rarely and usually is found in 12- and 13-year-old adolescents. The MRI scans reveal a tear of the humeral attachment of the inferior glenohumeral ligament, a so-called HAGL lesion. This injury to the inferior glenohumeral ligament occurs much less commonly than the classic Bankart lesion (anterior inferior labral tear). A tear of the subscapularis occurs with a similar mechanism of injury but generally occurs in older individuals.
REFERENCES: Bokor DJ, Conboy VB, Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br 1999;81:93-96.
Wolf EM, Cheng JC, Dickson K: Humeral avulsion of the inferior glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.

Question 71

Figures 39a and 39b show the current radiographs of an 8-year-old girl who has had pain in the left thigh for the past 3 months. She was recently diagnosed with hypothyroidism and started treatment 1 week ago. Examination reveals a mild abductor deficiency limp on the left side. She lacks 30 degrees internal rotation on the left hip compared with the right hip. Management should consist of

Explanation

DISCUSSION: The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip

“pre-slip.” Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Aronson DD, Carlson WE: Slipped capital femoral epiphysis: A prospective study of fixation with a single screw. J Bone Joint Surg Am 1992;74:810-819.

Question 72

A 30-year-old man who participates in recreational sports reports the spontaneous onset of intermittent pain and swelling about the right knee. Examination reveals a 3+ effusion, with a range of motion of 10° to 60°. He has mild diffuse tenderness but no instability. MRI scans and an arthroscopic view are shown in Figures 39a through 39c. Management should consist of

Explanation

DISCUSSION: The patient has synovial chondromatosis. The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies. The arthroscopic view shows the classic appearance of multiple small chondral loose bodies. Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify. The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods.
REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br

1989;71:498-500.
Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison

of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy

1994;10:166-170.

Question 73

Figure 1 shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be perfomed

Explanation

DISCUSSION: Very large corrections of tibial deformity can be achieved at or just below the tibial tubercle. This level of osteotomy maintains the relationship between the tubercle and the rest of the joint, does not alter patellofemoral mechanics, and avoids complicating possible future conversion to total knee arthroplasty. High tibial osteotomy is contraindicated for large corrections because of excessive elevation of the tibial tubercle and overhang of the lateral plateau. Correction in the tibial diaphysis creates a zig zag pattern in the tibia by correcting below the deformity and risks nonunion in cortical bone. There is no evidence that the femur is deformed; therefore, femoral osteotomy is not indicated.
REFERENCE: Murphy SB: Tibial osteotomy for genu varum: Indications, preoperative planning, and technique. Orthop Clin North Am 1994;25:477-482.

Question 74

A 46-year-old man reports occasional squeaking of his hip 2 years after undergoing an uneventful total hip arthroplasty. History reveals no pain, physical examination cannot reproduce audible squeaking, and radiographs show appropriate implant position. What is the most appropriate management?

Explanation

DISCUSSION: In the absence of component malpositioning, hip pain, or other compelling reasons to reoperate, a squeaking ceramic bearing is not an indication for revision surgery. The patient can be reassured and observed.
Hopefully, with a better understanding of acoustic phenomena following ceramic total hip arthroplasty, this complication can be minimized.
REFERENCES: Yang CC, Kim RH, Dennis DA: The squeaking hip: A cause for concem-disagrees. Orthopedics
2007;30:739-742.
Walter WL, O’Toole GC, Walter WK, et al: Squeaking in ceramic-on-ceramic hips: The importance of acetabular component orientation. J Arthroplasty 2007;22:496-503.

Figure 80a Figure 80b

Question 75

A 27-year-old male competitive soccer player reports a 1-year history of pain in the adductor region that has prevented him from playing. Examination reveals tenderness about the adductor attachment to the pelvis, and pain at the same site with resisted contraction of the adductors. There is no tenderness over the hip joint and no signs of a sports hernia. Radiographs are normal. MRI does not show any evidence of enthesopathy. What is the next best step in management?

Explanation

DISCUSSION: Schilders and associates reported their results of treating adductor-related groin pain in competitive athletes. They reported that a single corticosteroid injection into the pubic cleft can be expected to provide at least 1 year of relief of adductor-related groin pain in a competitive athlete with normal findings on MRI. In contrast, when there is evidence of enthesopathy on MRI in this competitive- athlete population, these injections are not therapeutic and are associated with a high likelihood of recurrence of symptoms. Hip arthroscopy is generally reserved for intra-articular problems. Percutaneous adductor tenotomy is not indicated for this condition. A bone scan is unlikely to provide any useful information for clinical decision-making. Rheumatology consultation is also not indicated in the absence of any evidence of inflammatory arthropathy.
REFERENCES: Schilders E, Bismil Q, Robinson P, et al: Adductor-related groin pain in competitive athletes: Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. J Bone Joint Surg Am 2007;89:2173-2178.
Robinson P, Barron DA, Parsons W, et al: Adductor-related groin pain in athletes: Correlation of MR imaging with clinical findings. Skelet Radiol 2004;33:451-457.

Question 76

What is the standard interval for placement of an anterolateral portal in ankle arthroscopy?

Explanation

As with arthroscopy of the knee, the anterolateral (AL) portal is the primary diagnostic portal used for initial placement of the arthroscope. The AL portal is made 5 mm below the joint line just lateral to the extensor tendons. The lateral cutaneous branch of the superficial peroneal nerve lies near this portal region. From this approach, one can visualize the anteromedial (AM), anterocentral (AC), and most of the AL areas of the tibiotalar joint. With the addition of laterally based external distraction instrumentation, the surgeon can usually advance the arthroscope posterocentrally and posterolaterally to visualize most of the articulation and the structures in the central and posterior compartments: the intraarticular aspects and synovium of the distal tibiofibular syndesmosis, the posterior tibiofibular ligament, the transverse ligament, and the synovial plicae that overlie the transverse ligament.

Question 77

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Explanation

The MRI scan clearly reveals bone bruises in the mid lateral femoral condyle and posterior tibial plateau. These MRI findings are commonly associated with acute anterior cruciate ligament injuries. Therefore, the preferred answer would be a positive pivot shift examination. A positive posterior drawer and positive quad active test are associated with posterior cruciate ligament injuries. A positive dial test would be suggestive of a posterolateral instability of the knee.

Question 78

Radiographs of the cervical spine of a 73-year-old man who fell down stairs reveal cervical spondylosis without evidence of fracture or dislocation. MRI and CT scans are consistent with the plain radiographs. After 72 hours, neurologic evaluation reveals intact sensation; however, weakness of the upper extremities is greater than that of the lower extremities. What is the most likely diagnosis?

Explanation

Central cord syndrome is the correct answer. Common in the older patient, sacral sparing, upper extremity involvement greater than the lower extremity. Functional recovery expected in 75% of patients. 2-Anterior cord syndrome complete motor deficit; trunk and lower
extremity deep pressure and proprioceptive preserved. 3-Posterior cord syndrome is rare with loss of deep pressure, deep pain, and proprioception. 4-Brown-Sequard syndrome-Uncommon-Ipsilateral motor deficit, contralateral pain and temperature deficit. 5-Cervical nerve root injury- functional impairment of the cervical spine. Symptoms are often acute and severe, dependent on the level of the lesion. An infraforaminal protrusion may compress only the spinal root ganglion resulting in severe brachialgia with paresthesia and numbness but with little or no motor involvement.

Question 79

An 18-year-old high school football player sustains a thigh injury that results in the findings shown in Figure 1. Initial management should consist of

Explanation

DISCUSSION: The radiograph shows myositis ossificans within the quadriceps muscle. This condition occurs as a complication of muscle injury. Initial treatment should include rest, ice, compression, and elevation. While gentle active range of motion is encouraged in the functional recovery from this injury, passive stretching is contraindicated as it can enhance hemorrhage and accentuate the development of myositis ossificans. Ultrasound is similarly contraindicated because it can enhance the development of myositis ossificans and has no proven efficacy in this patient; electrical stimulation also has no proven benefits. Massage is contraindicated in the initial management of this injury because of its influence on increasing local blood flow.
REFERENCES: Anderson JE (ed): Grant’s Atlas of Anatomy. Baltimore, MD, Williams & Wilkins, 1978, pp 4.39-4.49.
Brumet ME, Hontas RB: The thigh, in DeLee JC, Drez D Jr (eds): Orthopaedic Sports Medicine. Philadelphia, PA, WB Saunders, 1994, pp 1086-1112.
Antao NA: Myositis of the hip in a professional soccer player: A case report. Am J Sports Med 1988;16:82-83.
Jackson DW, Feagin JA: Quadriceps contusions in young athletes: Relation of severity of injury to treatment and prognosis. J Bone Joint Surg Am 1973;55:95-105.

Question 80

A 74-year-old patient is seen for follow-up 6 weeks after undergoing a total shoulder arthroplasty for glenohumeral osteoarthritis. The patient missed the 2-week follow-up appointment and is currently wearing a sling. The incision is well healed with no signs of breakdown. Examination reveals that passive range of motion is forward elevation of 90 degrees, external rotation at the side 0 degrees, and internal rotation up the back is to the level of the greater trochanter. A radiograph shows no signs of fracture or dislocation. What is the next most appropriate management for this patient? Review Topic

Explanation

The patient has a postoperative stiff shoulder. The patient missed follow-up appointments and has not been participating in physical therapy for stretching. Based on normal radiographic findings, the shoulder is not dislocated; therefore, physical therapy should begin immediately. Continued sling immobilization will further worsen the stiffness. There is no indication of an infection or rotator cuff tear. Deep venous thrombosis would present with abnormal swelling and pain.

Question 81

When compared with patients having a body mass index (BMI) lower than 35, patients with a BMI above 40 who undergo primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) are likely to have

Explanation

DISCUSSION:
The obesity epidemic is increasing, and the number of patients with a BMI higher than 35 undergoing THA and TKA also is growing. Controversy exists over the optimal BMI cutoff and the ability to perform joint replacements safely in patients who are morbidly obese. Several clinical series and national database analyses have shown that morbidly obese patients undergoing THA or TKA are at increased risk for wound complications as well as 30-day and 90-day readmissions. These patients’ incisions are typically larger because of the size of the soft-tissue envelope. Although the clinical scores following successful THA or TKA often are lower than the scores of controls, the overall changes in clinical function and satisfaction are equivalent in nonobese and obese patients.

Question 82

Figures 111a and 111b show axial MRI scans of a 24-year-old man who injured his right shoulder several years ago and now reports continued difficulty with the shoulder and has pain with activity. He reports that when the injury occurred, he felt that his shoulder "popped" but he never required closed reduction. He wore a

Explanation

Performing a bench press with large amounts of weight is most likely to cause pain for a patient with a posterior labral tear. A patient who sustains a first-time posterior dislocation is less likely to have recurrent dislocations compared with first-time anterior dislocations. Patients often do have problems with loading the shoulder in a forward flexed position, such as during a bench press. The other activities listed here might be difficult, but are not as likely to be problematic. A biceps curl might bother a person with a SLAP tear. The late cocking/early acceleration phase of throwing, the overhead portion of a tennis serve, and spiking a volleyball places the shoulder in an abduction/external rotation position, which is likely to be problematic for a person with anterior instability.

Question 83

What is the best indication for prosthetic radial head arthroplasty following fracture?

Explanation

The Mason classification differentiates the degree of displacement, angulation, and mechanical block to motion. Most nondisplaced radial head fractures (Mason I) in which there is no block to motion can be treated nonsurgically. Mason type III injuries are severely comminuted radial head fractures. Fragment excision can be considered in unreconstructable fractures in which the interosseous membrane is intact. However, if the interosseous membrane has been disrupted, fragment excision can lead to proximal migration of the radius with associated wrist problems. In this case, radial head arthroplasty is indicated. Radial head arthroplasty may also be required when the radial head fracture is associated with other ligamentous injuries as seen following an elbow dislocation, or with an associated unstable coronoid fracture.

Question 84

A 22-year-old man sustained a stable pelvic fracture, bilateral femur fractures, and a left closed humeral shaft fracture in a motor vehicle accident. Examination 24 hours after injury reveals that the patient is confused and has shortness of breath. A clinical photograph of his conjunctiva is shown in Figure 44. He has a temperature of 101 degrees F (38.3 degrees C) and a pulse rate of 120/min. Laboratory studies show a hemoglobin level of 8 g/dL, a platelet count of 50,000/mm3, and a PaO2 of 57 mm Hg on 2L of oxygen. What is the most likely diagnosis?

Explanation

DISCUSSION: The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia.
REFERENCE: 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 308-316.

Question 85

A 9-year-old boy has lateral right knee pain. An MRI scan shows a discoid lateral meniscus with a partial tear in its central portion. Treatment should consist of Review Topic

Explanation

A tear of the mid portion of a stable discoid lateral meniscus should be treated with a partial menisectomy with saucerization. Lateral total menisectomy is contraindicated because of the poor long-term results following this procedure. Meniscal transplant and casting do not have a role in this scenario, although meniscal repairs may be needed for peripheral meniscal instability.

Question 86

Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic

Explanation

Thyroid dysfunction is not one of the clinical entities included in the female athlete triad.
The female athlete triad was coined in 1992 by the American College of Sports Medicine as a complex disorder more prevalent in the adolescent and young female
athlete population including decreased bone mineral density (BMD), menstrual dysfunction, and low energy availability with or without a concomitant eating disorder. Treatment should involve a multidisciplinary approach, including psychological and nutritional counseling for eating behaviors and dietary management, reduction of training intensity to decrease risk of stress fractures, and initiating calcium and vitamin D supplements for osteoporosis.
Nazem et al performed a systematic review of articles containing the female athlete triad, reviewing diagnosis via screening during physical examinations as well as laboratory and imaging evaluation for menstrual dysfunction, low energy availability, and low bone mineral density. They state that potential complications including possible infertility, decreased immune function, cardiovascular disease, and irreversible loss of bone mineral density. They concluded that prevention, early recognition, and a multidisciplinary treatment team with a focus on proper nutrition and natural return of menses is vital.
Nattiv et al review the position of the American College of Sports Medicine regarding the female athlete triad, including screening for the triad at the pre-participation physical, discouragement of unhealthy weight loss practices. Essential members of the multidisciplinary treatment team include a health-care professional, a registered dietitian, and a mental health practitioner. They endorse that the first aim of treatment for any triad component is to increase energy availability by increasing energy intake and reducing exercise energy expenditure.

Question 87

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Explanation

EXPLANATION:
Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.

Question 88

During excision of a Baker cyst, the base or stalk is usually found between the

Explanation

DISCUSSION: Although there are several bursae in the posterior portion of the knee, the most prevalent one with a connection to the knee joint is the one in the interval between the semimembranosus and the medial head of the gastrocnemius muscle. The popliteus muscle and posterior cruciate ligament, the posterior cruciate ligament and lateral gastrocnemius muscle, and the medial gastrocnemius muscle and posterior cruciate ligament are all too lateral and uncommon. The semitendinosus and medial head of the gastrocnemius muscles do not come in contact in the posterior aspect of the knee.
REFERENCES: Resnick D: Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia, PA,

WB Saunders, 1995, p 379.
Justis EJ Jr: Nontraumatic disorders, in Crenshaw AH (ed): Campbell’s Operative Orthopaedics, ed 7. Philadelphia, PA, Lippincott, 1987, vol 3, p 2257.

Question 89

Figures 3a and 3b show the finger deformity that a 13-year-old girl has had since birth. What is the most likely diagnosis?

Explanation

The figures show a little finger to be incurving towards the ring finger (3a) and no flexion deformity (3b). This in itself is the definition of Clinodactyly. In addition to this curvature in the radioulnar/frontal plane, the deformity is one that affects the middle phalanx, usually bilateral, and autosomal dominant. The
definitions of the other distracters are self-explanatory (Staheli, Fundamental of Pediatric Orthopedics, 1998): Camptodactyly: non-painful flexion deformity of the PIP joint (i.e. AP Plane); abnormality of the insertions of the intrinsics and extrinsics flexor tendons; both hereditary and non-hereditary forms. Symbrachydactyly: digital absence in the form of transverse efficiency; teratogenic etiology resulting in absence distal metacarpals with finger nubbins. Kirner’s deformity: rare progressive deformity of the terminal phalanx of the small fingers with fingernails a curved and clubbed appearance; usually bilateral and appears during adolescence. Digiti minimi adductus: no such deformity found mention in the literature.

Question 90

A 12-month-old boy has right congenital fibular intercalary hemimelia with a normal contralateral limb. A radiograph of the lower extremities shows a limb-length discrepancy of 2 cm. All of the shortening is in the right tibia. Assuming that no treatment is rendered prior to skeletal maturity, the limb-length discrepancy will most likely

Explanation

DISCUSSION: Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a “multiplier method,” as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements.
REFERENCES: Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting

limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446.
Moseley CF: A straight-line graph for leg length discrepancies. Clin Orthop 1978;136:33-40.

Question 91

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?

Explanation

DISCUSSION: Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve which lies inferior to the teres minor in the quadrilateral space.
REFERENCES: Dreese J, D’Alessandro D: Posterior capsulorrhaphy through infraspinatus split for posterior instability. Tech Shoulder Elbow Surg 2005;6:199-207.
Shaffer BS, Conway J, Jobe FW, et al: Infraspinatus muscle-splitting incision in posterior shoulder surgery: An anatomic and electromyographic study. Am J Sports Med 1994;22:113-120.
Fuchs B, Jost B, Gerber C: Posterior-inferior capsular shift for the treatment of recurrent voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25.

Question 92

A 25-year-old woman has lower leg pain during exercise without numbness, tingling, or weakness. The symptoms resolve by the following day. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19a (Table 1). She undergoes anterior compartment fasciotomy with complete resolution of symptoms. Two years later, she has recurrent pain and tightness with exercise. Radiographs, a technetium bone scan, and noninvasive vascular study findings are normal. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19b (Table 2). What is the most likely etiology for her recurrent symptoms?

Explanation

DISCUSSION
Exertional compartment syndrome involves an increase in compartment pressure caused by exercise or sports activity that restricts blood flow in the compartment, resulting in pain with continued activity. Compartment pressures of at least 15 mm Hg measured at rest, at least 30 mm Hg measured 1 minute after exercise, and at least 20 mm Hg measured 5 minutes after exercise are diagnostic. Surgical fasciotomy for exertional compartment syndrome is successful for the majority of patients, but recurrence rates as high as 20% have been reported. Scar formation within the fascial defect can result in recurrent symptoms and/or nerve entrapment, and recurrence is typically observed after an initial symptom-free period. In a series of 18 patients, recurrent symptoms occurred at a mean of 23.5 months after the index procedure. Other potential causes of recurrence include inadequate fascial release, failure to recognize involvement of other compartments, nerve compression, and misdiagnosis. Surgical complications after fasciotomy include hemorrhage leading to excessive fibrosis, neurovascular injury, and hematoma or seroma formation.

Question 93

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Explanation

DISCUSSION: In the normal adult, the distance between the basion and the tip of the dens is 4 mm to 5 mm. Any distance greater than 5 mm is considered abnormal. This is one way to detect occipitocervical dissociation other than using the Power’s ratio, which relies on an anterior dislocation.
REFERENCES: Wiesel SW, Rothman RH: Occipitoatlantal hypermobility. Spine 1979;4:187-191.
Wholey MH, Browner AJ, Baker HL Jr: The lateral roentgenogram of the neck: With comments on the atlanto odontoid-basion relationship. Radiol 1958;71:350-356.

Question 94

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

Explanation

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

Question 95

Figures below depict the radiographs obtained from a 60-year-old man with instability and pain 1 year after primary right total knee arthroplasty. He states that he had surgery on two occasions for a tendon rupture that was repaired with sutures but that his knee popped again, and now the leg is unable to hold his weight. On examination, he is in no acute distress. His height is 6'3", and he weighs 240 pounds. He is ambulatory with crutches. Range of motion of the right knee is 50° to 120° actively and 0° to 120° passively. More than 10° of varus/valgus laxity and more than 5 mm of anteroposterior drawer are present. A palpable defect is observed in the tissue just proximal to the patella. The incision is well healed. The erythrocyte sedimentation rate is 46 mm/h (reference range 0 to 20 mm/h) and the C-reactive protein level is 2.04 mg/L (reference range 0.08 to 3.1 mg/L). Aspiration of the right knee reveals hazy yellow fluid with a white blood cell count of 120 and 1% neutrophils. No growth of organisms is seen on routine culture. What is the best next step?

Explanation

DISCUSSION:
This patient has a chronic quadriceps tendon rupture after total knee arthroplasty. Two previous primary repair attempts have failed, which is not surprising based on the poor results of primary repair reported in the literature. The patient also has an unstable knee and will require revision of some or all of the prosthesis to achieve a stable knee. Revision total knee arthroplasty with extensor mechanism allograft allows an allograft reconstruction of the ruptured quadriceps tendon. The other option is to utilize a synthetic mesh extensor mechanism reconstruction. These are likely to have the best result in this situation. Revision total knee arthroplasty with liner change and primary quadriceps repair is not the best form of management, because it involves a third attempt at primary tendon repair, which will likely fail again. Resection knee arthroplasty and arthrodesis with antegrade nail is a possible option but is not the best, because it would likely make driving and other daily activities difficult. Two-stage revision total
knee arthroplasty with extensor mechanism allograft is not the best option because the laboratory results show no signs of infection, so a single-stage procedure is preferred.

Question 96

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

Explanation

Question 97

A 17-year-old high school football player is seen for follow-up after sustaining an injury 3 days ago. He reports that he tackled a player, felt numbness throughout his body, and could not move for approximately 15 seconds. A spinal cord injury protocol was initiated on the field. Evaluation in the emergency department revealed a normal neurologic examination and full painless neck motion. He states that he has no history of a similar injury. An MRI scan of the cervical spine is normal. During counseling, the patient and his family should be informed that he has sustained

Explanation

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro AR, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 98

Immediately after undergoing lumbar instrumentation, a patient reports severe right leg pain and has 4+/5 weakness. Figure 24 shows an axial CT scan of L5. Exploratory surgery will most likely reveal

Explanation

DISCUSSION: The most common finding at exploration of an inappropriately placed pedicle screw is displacement of the nerve. Pedicle breach is common, ranging from 2% to 20%, but most are asymptomatic. All of the choices are possible, but in a large series conducted by Lonstein and associates, the authors reported that displacement of the root, most often medial, was the most common finding. Laceration, contusion, or transfixion usually was not seen. Spinal fluid leakage occurs less frequently and is not expected in the minimal broach illustrated.
REFERENCES: Esses SI, Sachs BL, Dreyzin V: Complications associated with the technique of pedicle screw fixation: A selected survey of ABS members. Spine 1993;18:2231-2238.
Laine T, Lund T, Ylikoski M, et al: Accuracy of pedicle screw insertion with and without computer assistance: A randomised controlled clinical study in 100 consecutive patients. Eur Spine J 2000;9:235-240.
Lonstein JE, Denis F, Perra JH, et al: Complications associated with pedicle screws. J Bone Joint Surg Am 1999;81:1519-1528.

Question 99

A 51-year-old woman is seen for evaluation of chronic supraspinatus and infraspinatus tendon tears. Three years ago, in an attempted repair the surgeon was unable to repair the supraspinatus and infraspinatus tendon tears. Currently she has a marked amount of pain, reduced range of motion, and weakness. Examination reveals anterosuperior escape. Radiographs show no signs of arthritic changes. You are considering a latissimus dorsi tendon transfer. During the discussion, you mention that

Explanation

DISCUSSION: Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively.
REFERENCES: Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears: Factors affecting outcome. J Bone Joint Surg Am

2006;88:113-120.
Iannotti JP, Hennigan S, Herzog R, et al: Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. J Bone Joint Surg Am 2006;88:342-348.

Question 100

Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?

Explanation

DISCUSSION
The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609. View Abstract at PubMed
Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211. View Abstract at PubMed
Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13. View Abstract at PubMed
Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496. View Abstract at PubMed
Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070. View Abstract at PubMed
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.View Abstract at PubMed
Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258. View Abstract at PubMed

Full Question & Answer Text (for Search Engines)

Question 1:

Which laboratory findings would most support a diagnosis of prosthetic joint infection (PJI) in a hip or knee arthroplasty performed 3 weeks ago?

Options:

Erythrocyte sedimentation rate (ESR) higher than 30 mm/h
C-reactive protein (CRP) level higher than 10 mg/L
Synovial white blood cell count higher than 10000 cells/µL
Synovial percentage of polymorphonuclear (PMN) leukocytes higher than 60%

Correct Answer: Synovial white blood cell count higher than 10000 cells/µL

Explanation:

Question 2:

What is an example of cognitive rest after concussion? Review Topic

Options:

Playing chess
Increasing reading
Working online
Limiting video games

Correct Answer: Limiting video games

Explanation:

Question 3:

Which of the following structures is predominantly composed of Type 1 collagen? Review Topic

Options:

Epithelial Basement Membrane
L4 disc nucleus pulposus
Anterior cruciate ligament
Medial femoral condyle articular cartilage
Dupuytren's contracture tissue

Correct Answer: Epithelial Basement Membrane

Explanation:

Question 4:

An injury to the axillary nerve would result in deltoid muscle weakness. 5 . An injury to the thoracodorsal nerve would result in latissimus dorsi weakness and would not cause scapular winging.

Options:

A 31-year-old right handed pitcher felt a pop in his throwing elbow during a game. He is diagnosed with a rupture to the medial ulnar collateral ligament complex of the elbow. During which phase of the overhead throwing cycle did this pitcher most likely sustain his injury? Wind-up
Early cocking Early acceleration Ball release Follow-through

Correct Answer: A 31-year-old right handed pitcher felt a pop in his throwing elbow during a game. He is diagnosed with a rupture to the medial ulnar collateral ligament complex of the elbow. During which phase of the overhead throwing cycle did this pitcher most likely sustain his injury? Wind-up

Explanation:

The medial ulnar collateral ligament is subjected to the greatest tensile stress during the late cocking/early acceleration phase of throwing.
The medial ulnar collateral ligament, or medial collateral ligament of the elbow, is composed of three bundles: an anterior bundle, a posterior bundle, and a variable
transverse oblique bundle. During late cocking and early acceleration phases of the overhead throw, the medial UCL is subjected to the greatest amount of valgus stress to the elbow. During this phase, the forearm lags behind the upper arm and generates valgus stress while the elbow is primarily dependent on the anterior band of the UCL for stability. This puts the ligament at greatest risk of injury during this phase.
Fleisig et al. examined the kinetics of baseball pitching and the implications on injury mechanisms. They showed that the UCL contributes to 54% of the varus torque that is generated during the early acceleration of throwing. The position of greatest load occurred when the arm was flexed to 95 +/14 degrees with an applied valgus load.
Illustration A shows a diagram of the medial ulnar collateral ligament ligament bundles. Incorrect Answers:
A 14-year-old elite basketball player develops acute medial elbow pain after a fall. Physical examination reveals medial elbow tenderness over the submlime tubercle, but full range of motion. The provocative tests seen in Figure A exacerbate his elbow pain. Radiographs of the elbow are normal. What would be the next best step in treatment?
Supervised elbow stretching program Therapeutic elbow arthroscopy
Static elbow external fixation for 3 to 6 weeks, then MR arthrography if pain continues Activity avoidance for 6 weeks
Serial inflammatory markers and rheumatology referral
Figure A shows a moving valgus stress, which is a provocative test for ulnar collateral ligament (UCL) injury and elbow valgus instability. The initial treatment would be a short period of immobilization, rest and flexor pronator strengthening in this patient population.
Adolescent UCL injuries can be effectively treated with a short period of rest and NSAIDs to control pain. As the acute inflammation resolves, the patient can be started on a supervised therapy program. This should target flexor pronator muscles, as they are important secondary dynamic stabilizers of valgus stress. Once symptoms have improved and the athlete has regained full range of motion and strength, a mediated throwing program may be initiated. Throwing athletes should be educated to avoid provocative activities during this period.
Chen et al. wrote a JAAOS article on shoulder and elbow injuries in the skeletally immature athlete. They state that surgery is reserved for older athletes with persistent valgus instability despite > 6 months of non-surgical management.
Murthi et al. reviewed recurrent elbow instability. They state the anterior bundle of the medial ulnar collateral ligament complex is the primary valgus stabilizer of the elbow. The anterior band is taut for the first 60° of elbow flexion, and the posterior band is taut from 60° to 120° of flexion. The secondary valgus stabilizers of the elbow joint include the radial head, the anterior and posterior aspects of the capsule, and the muscular forces around the joint.
Figure A is showing a moving valgus stress. Illustration A shows provocative tests for valgus instability of the elbow. The image on the left shows a valgus stress test. This assesses the anterior bundle of the medial ulnar collateral ligament complex by flexing the elbow to 25-30 degrees and applying a valgus load across the elbow. The image on the right shows milking maneuver. This assesses the posterior bundle of the medial ulnar collateral ligament complex by pulling on the
beyond 90°. Incorrect Answers:
A young, healthy male undergoes a distal biceps repair and sustains an iatrogenic nerve injury during the procedure. Which of the following clinical findings are most likely to be seen in this circumstance?
Inability to extend the thumb
Lateral volar forearm numbness Inability to flex the middle finger Medial volar forearm numbness Dorsal thumb numbness
The most commonly injured nerve during a distal biceps repair is the lateral antebrachial cutaneous nerve (LABCN). Injury to this nerve would result in lateral volar forearm numbness.
Distal biceps avulsions can be partial or complete. Indications for surgical management include young, healthy patients who do not wish to sacrifice function, as well as partial biceps avulsions that do not respond to conservative management. Repair of a distal biceps avulsion can be approached through either an anterior one-incision technique or a two-incision technique (BoydAnderson). The one-incision technique uses the interval between the brachioradialis (radial nerve) and pronator teres (median nerve), while the two-incision technique uses this same interval in addition to a second posterolateral elbow incision. The lateral antebrachial cutaneous nerve is the most common nerve injured during either approach.
Kelly et al. retrospectively reviewed 74 distal biceps tendon repairs, and found five sensory nerve paresthesias. The lateral antebrachial cutaneous nerve was most commonly injured, followed by the superficial radial nerve.
Cain et al. retrospectively reviewed 198 distal biceps tendon repairs, and found a 36% complication rate. Lateral antebrachial cutaneous nerve paresthesias were found in 26%, while radial sensory nerve paresthesias were found in 6%, and posterior interosseous nerve (PIN) injury in 4%.
Illustration A shows the close relationship between the lateral antebrachial cutaneous nerve (LABCN) and the distal biceps. Illustration B shows the sensory nerves of the upper extremity and their respective areas of innervation.
Incorrect Answers:
A 33-year-old female presents with left shoulder weakness. Two weeks prior to presentation, the patient experienced sudden-onset, left shoulder pain, which occurred a few days after receiving the influenza vaccine. The pain subsided over the next day, followed by gradual weakness of her shoulder and eventual general disuse of her left upper extremity. An initial visit to her primary care provider resulted in the recommendation of observation. On physical exam, there is weakness and gross atrophy of the shoulder girdle. Figures A & exhibit T2-weighted MRI images of her left shoulder. To further confirm her suspected diagnosis, she is sent for electromyography.
What is the expected result?
Normal results
Fibrillation potentials consistent with compression at the spinoglenoid notch 3 . Sharp waves and fibrillations potentials associated with the deltoid and biceps
Acute denervation of both peripheral nerve and nerve root distribution with sharp waves and fibrillation potentials
Early reinnervation with polyphasic motor unit potentials
This patient has Parsonage-Turner Syndrome, which, when tested on EMG during the first 3 weeks, exhibits acute denervation of both peripheral nerve and nerve root distributions with positive sharp waves and fibrillation potentials.
Parsonage-Turner Syndrome is an idiopathic disorder with an etiology that is still unknown. Typical antecedent events can involve a viral illness, recent immunization, or elective surgery. Clinical presentation is usually initiated by acute onset shoulder pain, which quickly subsides and is followed by gradual weakness. Early MRI exhibits edema in the effected muscles, and fatty infiltration in later stages. Treatment is typically non-operative, and resolution can be seen as early as 6 weeks from onset.
Tjoumakaris et al. provide a thorough review of the diagnosis and management of ParsonageTurner Syndrome. The authors report the usefulness of MRI, which exhibits early edema and later fatty infiltration in the affected muscles, and urge the use of EMG as a confirmatory diagnostic measure as well as a monitoring tool to track resolution. Early identification and diagnosis may be treated with a short course of steroids, which may help shorten symptoms.
Stutz et al. concisely summarize Parsonage-Turner Syndrome and provide typical presentation, diagnosis and management principles. The authors note the common association with viral illness and/or recent immunization along with the importance of obtaining a baseline chest radiograph to rule out a compressive Pancoast tumor. Management is typically supportive with eventual resolution.
Figures A, B, and C are T2-weighted coronal, sagittal, and axial cuts of the shoulder girdle with associated edema in the supraspinatus and infraspinatus typically seen in Parsonage-Turner Syndrome.
Incorrect answers:
A total shoulder arthroplasty (TSA) would be the most appropriate treatment in which of the following arthritic patients?

Question 5:

A B

Options:

in her first interspace and an inability to dorsiflex her toes.
over her lateral forefoot and an inability to evert her foot.
over her medial forefoot and an inability to invert her foot.
over her lateral forefoot and an inability to plantar flex her first metatarsal.

Correct Answer: in her first interspace and an inability to dorsiflex her toes.

Explanation:

Question 6:

Options:

Medical management with intravenous (IV) antibiotics and observation
CT-guided aspiration of the abscess before initiating antibiotics
Surgical decompression and IV antibiotics
Blood cultures and re-evaluation in 24 hours

Correct Answer: Surgical decompression and IV antibiotics

Explanation:

DISCUSSION
Epidural abscess is a serious and potentially disastrous condition. Although medical management is effective in some situations, surgical decompression is considered urgent with the presence of a neurological deficit. Medical management can be considered in the case of a neurologically intact patient, particularly when the microorganism has been identified. If medical management is chosen, careful observation and serial examination for neurologic deterioration is required. Surgical decompression is indicated if a patient's neurologic status worsens or if medical management failure is noted. Additionally, diabetes, a CRP level higher than 115 mg/L, WBC higher than 12500/µL , and bacteremia have proven predictive of medical treatment failure. This patient would be a better candidate for urgent surgical decompression and subsequent IV antibiotics than for medical management.
RECOMMENDED READINGS
Patel AR, Alton TB, Bransford RJ, Lee MJ, Bellabarba CB, Chapman JR. Spinal epidural abscesses: risk factors, medical versus surgical management, a retrospective review of 128 cases. Spine J. 2014 Feb 1;14(2):326-30. doi: 10.1016/j.spinee.2013.10.046. Epub 2013 Nov 12. PubMed PMID: 24231778.
View
Abstract at PubMed
Kim SD, Melikian R, Ju KL, Zurakowski D, Wood KB, Bono CM, Harris MB. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9. doi: 10.1016/j.spinee.2013.10.011. Epub 2013 Oct 30. PubMed PMID:

Question 7:

Options:

arthroscopic rotator cuff repair.
arthroscopic anterior capsulorrhaphy.
arthroscopic selective posterior capsular release.
selective posterior rotator cuff strengthening.
posterior capsular stretching with scapular stabilization.

Correct Answer: posterior capsular stretching with scapular stabilization.

Question 8:

Options:

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

Correct Answer: Decreased risk of sacral fractures

Explanation:

Question 9:

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 10:

- A high school distance runner reports a 3-week history of heel pain while running. Examination elicits no pain with dorsiflexion or with palpitation of the plantar fascia; however, pain is evident with palpitation over the muscular origin of the abductor hallucis. What is the most likely etiology of the pain?

Options:

Heel spur
Plantar fascitis
Dysfunction of the tibialis posterior tendon
Compression of the first branch of the lateral plantar nerve
Compression of the calcaneal nerve

Correct Answer: Compression of the first branch of the lateral plantar nerve

Explanation:

Question 11:

Options:

Revision repair of subscapularis
Revision repair of infraspinatus
Latissimus dorsi transfer
Rotator interval release
Total shoulder arthroplasty

Correct Answer: Revision repair of subscapularis

Explanation:

Question 12:

Options:

Continued nonsurgical management to include long-acting narcotic analgesics
Referral for vertebral axial decompression
Referral to interventional pain management for a spinal cord stimulator
Intradiskal electrothermal therapy (IDET) at L5-S1
Lumbar spinal fusion at L5-S1

Correct Answer: Lumbar spinal fusion at L5-S1

Explanation:

DISCUSSION: The MRI scans reveal advanced degenerative disk disease at L5-S1. Nonsurgical management has failed to provide relief and the patient is quite debilitated as a result of her back pain. Fritzell and associates demonstrated that in a well-informed and selected group of patients with severe low back pain, lumbar fusion can diminish pain and decrease disability more efficiently than commonly used nonsurgical treatments. In a recent updated Cochrane Review of surgery for degenerative lumbar spondylosis, it was noted that while Fritzell and associates appeared to provide strong evidence in favor of fusion, a more recent trial by Brox and associates demonstrated no difference between those patients undergoing lumbar fusion compared to those receiving cognitive intervention and exercise. The Cochrane Review suggests that this may reflect a difference between the control groups. Fritzell and associates compared lumbar fusion to standard 1990s “usual care,” whereas Brox and associates compared lumbar fusion to a “modern rehabilitation program.” Bear in mind that this patient is a certified athletic trainer and runs a hospital health fitness department; therefore, at least for purposes of this question, it can be assumed that she has participated in a “modern rehabilitation program.” The Cochrane Review goes on to state that preliminary results of three small trials of intradiskal electrotherapy suggest that it is ineffective and that preliminary data from three trials of disk arthroplasty do not permit firm conclusions.
REFERENCES: Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: Updated Cochrane Review. Spine 2005;30:2312-2320.
Fritzell P, Hagg O, Wessberg P, et al: 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001;26:2521-2532.
Brox JI, Sorensen R, Friis A, et al: Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913-1921.

Question 13:

Options:

Inlet and outlet views of the pelvis to better delineate the injury
Angiography
Laparotomy
Open reduction and internal fixation of the pelvis
Placement of a pelvic binder around the patient

Correct Answer: Placement of a pelvic binder around the patient

Explanation:

Question 14:

Options:

repeat aspiration to rule out culture contamination.
IV administration of kanamycin for 6 weeks, followed by suppressive oral antibiotics.
removal of the implant and 6 weeks of antibiotics, followed by reimplantation.
removal of the implant, followed by knee fusion.
open irrigation of the implant and intraoperative cultures, followed by 6 weeks of antibiotics.

Correct Answer: removal of the implant and 6 weeks of antibiotics, followed by reimplantation.

Explanation:

Question 15:

In a patient with a C5-6 herniation, the most likely sensory deficit will be in the

Options:

lateral shoulder.
radial forearm, thumb, and index finger.
dorsal forearm and middle finger.
ulnar forearm, ring finger, and little finger.
volar forearm and palm.

Correct Answer: radial forearm, thumb, and index finger.

Explanation:

Question 16:

Options:

Bed rest for 6 weeks, followed by a thoracolumbosacral orthosis (TLSO) until the fracture is healed
TLSO and or body cast for 3 to 6 months with mobilization when comfortable
Posterior spinal fusion and instrumentation
Anterior decompression with spinal fusion and instrumentation
Anterior decompression and anterior-posterior spinal fusion and instrumentation

Correct Answer: TLSO and or body cast for 3 to 6 months with mobilization when comfortable

Explanation:

Question 17:

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

Options:

Loose body
Plica
Displaced meniscus tear
Torn retinaculum
Osteochondral defect

Correct Answer: Plica

Explanation:

Question 18:

Options:

Deep periprosthetic joint infection
Deep vein thrombosis
Hemarthrosis
Extensor mechanism disruption

Correct Answer: Hemarthrosis

Explanation:

Question 19:

Acute redislocation of the glenohumeral joint is a complication that occurs following a first-time dislocation. This is most often seen with

Options:

subglenoid dislocation.
subcoracoid dislocation.
fracture of the greater tuberosity.
fracture of the greater tuberosity and glenoid rim.
pediatric-age patients.

Correct Answer: fracture of the greater tuberosity and glenoid rim.

Explanation:

DISCUSSION: Redislocation following acute dislocation occurs in approximately 3% of patients. This redislocation tends to occur in middle-aged and elderly patients. A higher incidence of redislocation occurs when there are accompanying fractures of the glenoid rim and the greater tuberosity.
REFERENCES: Robinson CM, Kelly M, Wakefield AE: Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment.
J Bone Joint Surg Am 2002;84:1552-1559.
Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. J Sports Med 1998;26:41-45.

Question 20:

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

Options:

Oxycodone hydrochloride
Hydrocodone/acetaminophen
Tramadol
Imipramine
Ketorolac

Correct Answer: Ketorolac

Explanation:

Question 21:

Options:

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

Correct Answer: Medial-displacing calcaneal osteotomy

Explanation:

Question 22:

Options:

Intraoperative damage to the medial femoral circumflex artery
Intraoperative damage to the lateral femoral circumflex artery
Excessive pressure on the femoral head after reduction
Incarceration of the acetabular labrum in the reduction

Correct Answer: Excessive pressure on the femoral head after reduction

Explanation:

DISCUSSION
The incidence of pediatric hip dysplasia is approximately 1 per 100 live births, with hip dislocation present in 1 in 1000 births. Two surgical approaches primarily are used for surgical reduction in the dislocated pediatric hip: the modified medial approach as described by Weinstein and the
anterior Smith-Peterson approach. The Weinstein modification of the Ludloff approach exploits the interval between the pectineus muscle and the femoral neurovascular bundles rather than the interval between the pectineus and the adductor longus and brevis. The modified “bikini” anterior Smith-Peterson approach passes between the sartorius and tensor fascia lata superficially and between the rectus and gluteus medius during deep dissection.
When using the medial approach, the neurovascular bundle is particularly at risk, including the medial circumflex femoral vessels that supply blood to the femoral head ossific nucleus. Damage to this structure increases risk for osteonecrosis of the femoral head. Unlike the anterior approach, the medial approach does not allow for the performance of a capsulorrhaphy, poses higher risk for postprocedure redislocation, and is less useful in children of walking age. Identification of the ligamentum teres during deep dissection assists in localization of the true bony acetabulum.
The anatomic structure primarily at risk during the anterior approach is the lateral femoral cutaneous nerve. Excessive traction or transection of this structure will result in numbness in the proximal lateral thigh. This surgical approach allows for identifying and addressing all potential impediments to reduction: the redundant capsule, hypertrophic labrum, hypertrophic ligamentum teres, pulvinar, iliopsoas tendon, and transverse acetabular ligament. In older children who undergo open reduction with periacetabular osteotomy without a concomitant proximal femoral shortening osteotomy, reduction may be accompanied by increased pressure on the femoral head which, in turn, may result in secondary osteonecrosis of the femoral head.
RECOMMENDED READINGS
Karol LA. Developmental dysplasia of the hip. In: Song KM, ed.
Orthopaedic Knowledge Update: Pediatrics 4
. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:159-167.
Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg. 2001 Nov-Dec;9(6):401-11. Review. PubMed PMID: 11730331.
View Abstract at
PubMed
Weinstein SL, Ponseti IV. Congenital dislocation of the hip. J Bone Joint Surg Am. 1979 Jan;61(1):119-

Question 23:

What structure is most at risk for injury from a retractor against the tracheoesophageal junction during an anterior approach to the cervical spine?

Options:

Esophagus
Trachea
Superior laryngeal nerve
Recurrent laryngeal nerve
Sympathetic chain

Correct Answer: Recurrent laryngeal nerve

Explanation:

DISCUSSION: Although any of these structures can be injured by pressure from the medial blade of a self-retaining retractor, the recurrent laryngeal nerve runs cephalad in the interval between the esophagus and trachea and is vulnerable to pressure if caught between the retractor and an inflated endotracheal tube balloon.
REFERENCES: Ebraheim NA, Lu J, Skie M, et al: Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine 1997;22:2664-2667.
Kilburg C, Sullivan HG, Mathiason MA: Effect of approach side during anterior cervical discectomy and fusion on the incidence of recurrent laryngeal nerve injury. J Neurosurg Spine 2006;4:273-277.

Question 24:

The standard Bankart lesion involves detachment of the labrum along with which of the following capsular ligaments? Review Topic

Options:

Superior glenohumeral ligament and coracohumeral ligament
Superior glenohumeral ligament and middle glenohumeral ligament
Middle glenohumeral ligament and inferior glenohumeral ligament
Inferior glenohumeral ligament
Superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament

Correct Answer: Middle glenohumeral ligament and inferior glenohumeral ligament

Explanation:

Question 25:

Options:

ipsilateral foot/calcaneus
ipsilateral hip
contralateral hip
ipsilateral tibia/fibula
thoracic spine

Correct Answer: ipsilateral foot/calcaneus

Explanation:

Question 26:

Options:

The right T2 pedicle screw is well seated within the pedicle.
The right T2 pedicle screw has breached the pedicle wall and has violated the costovertebral junction.
There is a breach in the right T2 pedicle wall, but the screw is not in contact with a neural structure.
There is a breach in the right T2 pedicle and the screw is in contact with a neural structure.

Correct Answer: There is a breach in the right T2 pedicle and the screw is in contact with a neural structure.

Explanation:

DISCUSSION
This patient has developed a proximal junctional kyphosis following a long posterior fusion performed for treatment of degenerative lumbar scoliosis. Risk factors for proximal junctional kyphosis in the setting of instrumented fusions performed for degenerative scoliosis include advanced age, 360-
degree fusions, extension of fusion constructs to the sacrum, and upper instrumented vertebrae at the level of T1-3. The patient's junctional kyphosis is attributable to failure of the disk and ligamentous structures at T2-3 and would be graded as type I using the classification system of Yagi and associates. Most symptomatic proximal junctional kyphoses are treated with posterior extension of the fusion construct to a more proximal level spanning the kyphosed region. The use of orthoses or simple removal of instrumentation is unlikely to substantively impact symptoms or address the proximal kyphosis. Diabetes and obesity are known factors that increase risk for postsurgical infection following a spine fusion procedure. The most frequent complication following revision surgery for proximal junctional kyphosis, however, is the need for further surgery. In the study by Yagi and associates, 48% of patients who underwent revision surgery for proximal kyphosis developed further adjacent segment degeneration. In the proximal thoracic spine, where the pedicle may be narrow, triggered EMG testing of inserted pedicle screws may be used to assess for violation of the pedicle wall during insertion. In the setting of triggered EMG, thresholds exceeding 10 mA indicate a well-placed pedicle screw. Thresholds lower than 4 mA to 6 mA indicate that a screw is directly contacting a neural structure. Thresholds between 9 mA and 10 mA suggest that a breach of the pedicle may be present, but the screw is not contacting a neural structure.
RECOMMENDED READINGS
Yagi M, Rahm M, Gaines R, Maziad A, Ross T, Kim HJ, Kebaish K, Boachie-Adjei O; Complex Spine Study Group. Characterization and surgical outcomes of proximal junctional failure in surgically treated patients with adult spinal deformity.Spine (Phila Pa 1976). 2014 May 1;39(10):E607-14. doi: 10.1097/BRS.0000000000000266. PubMed PMID: 24525992.
View
Abstract at PubMed
Cammarata M, Aubin CÉ, Wang X, Mac-Thiong JM. Biomechanical risk factors for proximal junctional kyphosis: a detailed numerical analysis of surgical instrumentation variables. Spine (Phila Pa 1976). 2014 Apr 15;39(8):E500-7. doi: 10.1097/BRS.0000000000000222. PubMed
PMID: 24480964.
View Abstract at PubMed
Kim HJ, Lenke LG, Shaffrey CI, Van Alstyne EM, Skelly AC. Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review. Spine (Phila Pa 1976). 2012 Oct 15;37(22 Suppl):S144-64. doi: 10.1097/BRS.0b013e31826d611b. PubMed PMID: 22885829.
View Abstract at PubMed
Schoenfeld AJ, Carey PA, Cleveland AW 3rd, Bader JO, Bono CM. Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients. Spine J. 2013 Oct;13(10):1171-9. doi: 10.1016/j.spinee.2013.02.071. Epub 2013 Apr 9. PubMed PMID:

Question 27:

Options:

Pain with internal and external rotation of her hip with her hip and knee in an extended position
Limited motion when moving the hip from flexion-abduction-external rotation to flexion-adduction-internal rotation
Moving from hip flexion-abduction-external rotation to neutral triggers a popping sensation
Limitation in active hip range of motion with catching, locking and grinding noted on passive motion
Pain with a half sit-up and tenderness at the pubic ramus

Correct Answer: Pain with a half sit-up and tenderness at the pubic ramus

Explanation:

Question 28:

Options:

external electrical stimulation.
external ultrasound stimulation.
implanted electrical stimulation.
closed reduction and percutaneous fixation.
open reduction and internal fixation with bone graft.

Correct Answer: open reduction and internal fixation with bone graft.

Explanation:

DISCUSSION: The radiograph reveals an atrophic nonunion of the diaphysis of the clavicle. Electrical or ultrasound stimulation may be an option in diaphyseal nonunions that have
shown some healing response with callus formation, but these techniques are not successful
in an atrophic nonunion. The preferred technique for achieving union is open reduction and internal fixation with bone graft. Percutaneous fixation has no role in treatment of nonunions
of the clavicle.
REFERENCES: Boyer MI, Axelrod TS: Atrophic nonunion of the clavicle: Treatment by compression plating, lag-screw fixation and bone graft. J Bone Joint Surg Br 1997;79:301-303.
Simpson
NS
, Jupiter JB: Clavicular nonunion and malunion: Evaluation and surgical management. J Am Acad Orthop Surg 1996;4:1-8.

Question 29:

What is the most common adverse postoperative complication of laminoplasty for multilevel cervical spondylotic myelopathy?

Options:

Loss of cervical range of motion
Inadvertent closure of the laminoplasty postoperatively
Progressive cervical kyphosis
C5 nerve root palsy
Inadequate decompression of the spinal cord

Correct Answer: Loss of cervical range of motion

Explanation:

Question 30:

Figure 3 shows the AP radiograph of a patient with diabetes mellitus who has knee pain. A semiconstrained knee prosthesis was used in this patient to prevent which of the following complications?

Options:

Infection
Instability
Stiffness
Bone loss
Malalignment

Correct Answer: Instability

Explanation:

DISCUSSION: The radiographic appearance of the joint is highly suspicious for neuropathic joint (Charcot’s joint). Evidence of bone loss on both the tibial and the femoral sides may necessitate the use of metal and/or bone augments. Patients with a neuropathic joint often have excellent range of motion, and postoperative stiffness is not a problem. The main problem with these patients is instability that occurs secondary to ligamentous laxity. Use of a semiconstrained prosthesis prevents the latter complication.
REFERENCES: Parvizi J, Marrs J, Morrey BF: Total knee arthroplasty for neuropathic (Charcot) joints. Clin Orthop 2003;416:145-150.
Kim YH, Kim JS, Oh SW: Total knee arthroplasty in neuropathic arthropathy. J Bone Joint
Surg Br 2002;84:216-219.

Question 31:

Options:

Guillotine transtibial amputation
Standard transtibial amputation with a posterior myocutaneous flap and immediate prosthetic limb fitting
Culture-specific antibiotic therapy, open wound management, and metabolic/nutritional therapy
Culture-specific antibiotic therapy and Syme ankle disarticulation
Two-stage Syme ankle disarticulation

Correct Answer: Culture-specific antibiotic therapy, open wound management, and metabolic/nutritional therapy

Explanation:

Question 32:

Options:

proximal phalanx.
radial lateral bands.
first annular pulley.
second annular pulley.

Correct Answer: radial lateral bands.

Explanation:

Question 33:

An 11-year-old child has Ewing’s sarcoma of the femoral diaphysis with a small soft-tissue mass. Staging studies show no evidence of metastases. Treatment should consist of

Options:

chemotherapy and radiation therapy to the femur.
chemotherapy and wide resection.
chemotherapy and above-knee amputation.
hip disarticulation.
wide resection.

Correct Answer: chemotherapy and wide resection.

Explanation:

Question 34:

Which of the following is considered the lowest level that a standard thoracolumbosacral orthosis (TLSO) can immobilize?

Options:

L1-2
L3-4
L5-S1
T9-10
T11-12

Correct Answer: L3-4

Explanation:

DISCUSSION: Without more distal immobilization such as a thigh extension, the lower two lumbar segments generally show the same or even increased mobility with a TLSO.
REFERENCES: White AA, Panjabi MM: Clinical Biomechanics of the Spine, ed 2. Philadelphia, PA, JB Lippincott, 1990, pp 475-509.
Norton PL
, Brown T: The immobilizing efficiency of back braces. J Bone Joint Surg Am 1957;39:111-139.

Question 35:

Options:

Hip instability
Abductor weakness
Adductor weakness
Quadriceps weakness
Leg-length discrepancy

Correct Answer: Abductor weakness

Question 36:

Options:

The anteromedial (AM) bundle limits translation and the posterolateral (PL) bundle controls rotation.
The PL bundle limits translation and the AM bundle controls rotation.
The anterolateral (AL) bundle limits translation and the posteromedial (PM) bundle controls rotation.
Both the AL and the PM control rotation equally.
The AL bundle controls rotation and the PM bundle limits translation.

Correct Answer: The anteromedial (AM) bundle limits translation and the posterolateral (PL) bundle controls rotation.

Explanation:

Question 37:

What form of fixation is associated with the highest incidence of osseous union when using segmental allograft reconstruction following tumor resection?

Options:

Plate and screw fixation
Fluted intramedullary rods
Interlocking intramedullary rods
Cemented intramedullary rods
Step-cut osteotomies and interlocking intramedullary rods

Correct Answer: Plate and screw fixation

Explanation:

Question 38:

Which of the following drawbacks is associated with the Ganz periacetabular osteotomy?

Options:

The tendency to anterior displacement of the hip joint
The need for two incisions
Limited potential for acetabular reorientation
Posterior column disruption
Devascularization of the acetabulum

Correct Answer: The tendency to anterior displacement of the hip joint

Explanation:

Question 39:

Which of the following results cannot be achieved with an in-shoe orthosis?

Options:

Correction of rigid deformity
Increased cushion
Diminished shear forces
Metatarsal head relief
Redistribution of plantar forces

Correct Answer: Correction of rigid deformity

Explanation:

Question 40:

Options:

overlapping of the digits.
index finger proximal interphalangeal (PIP) joint arthritis.
extensor lag at the PIP joint.
hyperextension at the PIP joint.

Correct Answer: extensor lag at the PIP joint.

Explanation:

Question 41:

At a minimum 2-year follow-up and compared with the metacarpophalangeal (MCP) joint, pyrolytic carbon resurfacing arthroplasties of the proximal interphalangeal (PIP) joint

Options:

produce less squeaking or clicking.
result in more dislocations.
provide superior pain relief.
result in better motion compared with the preoperative status.

Correct Answer: result in more dislocations.

Explanation:

EXPLANATION:
Wall and Stern published a report on MCP joint pyrolytic carbon arthroplasty for osteoarthritis and another on PIP joint pyrolytic carbon resurfacing arthroplasty for osteoarthritis. They found different outcomes, and MCP joint implants outperformed PIP joint implants. Of eleven MCP joint arthroplasties, two produced asymptomatic squeaking and clicking, whereas eleven of 31 PIP joint implants produced this problem. No dislocations were reported among the MCP joint implants, but five PIP joint dislocations were observed. Outcomes were measured by the Michigan Hand Outcomes Questionnaire in both studies and were satisfactory for the MCP joint implants, with an average score of 80. The PIP implants did not fare as well, showing a higher degree of pain along with an average score of 53. The authors noted that, in the 15 patients in the PIP study who had unilateral surgery, the uninvolved, nonsurgical hand motion was actually statistically significantly (
P
<0.01) better than the surgical hand. MCP joint motion increased from 62º before surgery to 76º after surgery, whereas PIP joint motion got worse after surgery, with the average motion decreasing from 57º to 31º.

Question 42:

Options:

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

Correct Answer: Hip MRI arthrogram

Explanation:

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

Question 43:

Options:

Spinal muscular atrophy, type II
Myotonic dystrophy
Duchenne muscular dystrophy
Becker muscular dystrophy
Hereditary motor sensory neuropathy, type II (HMSN)

Correct Answer: Becker muscular dystrophy

Explanation:

Question 44:

Options:

hemivertebra excision.
anterior and posterior spinal fusion with instrumentation from T4 to L4.
convex anterior hemiepiphyseodesis.
convex posterior hemiarthrodesis.
an orthosis.

Correct Answer: hemivertebra excision.

Explanation:

Question 45:

Options:

Physical therapy for rotator cuff strengthening and scapula stabilization
Regimen of stretching exercises for motion
Arthroscopic acromioplasty
Arthroscopic acromioplasty and rotator cuff repair
Open rotator cuff repair

Correct Answer: Regimen of stretching exercises for motion

Explanation:

Question 46:

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

Options:

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

Correct Answer: Milking maneuver

Explanation:

Question 47:

If a surgeon inadvertently burrs through the midlateral wall of C5 during a anterior corpectomy, what structure is at greatest risk for injury?

Options:

C5 root
C6 root
Internal carotid artery
Vertebral artery
Vagus nerve

Correct Answer: Vertebral artery

Explanation:

DISCUSSION: The vertebral artery is contained within the vertebral foramen and thus tethered alongside the vertebral body, making it vulnerable to injury if a drill penetrates the lateral wall. The C5 root passes over the C5 pedicle and is not in the vicinity. The C6 root passes under the C5 pedicle but is posterior to the vertebral artery and is only vulnerable at the very posterior-inferior corner. The carotid artery and the vagus nerve are both within the carotid sheath and well anterior.
REFERENCES: Pfeifer BA, Freidberg SR, Jewell ER: Repair of injured vertebral artery in anterior cervical procedures. Spine 1994;19:1471-1474.
Gerszten PC, Welch WC, King JT: Quality of life assessment in patients undergoing nucleoplasty-based percutaneous discectomy. J Neurosurg Spine 2006;4:36-42.

Question 48:

Options:

Axillary nerve injury
Cervical radiculopathy involving the C6 nerve root
Massive rotator cuff tear with loss of the transverse force couple
Long head of the biceps tendon rupture with loss of superior stabilizing effect

Correct Answer: Massive rotator cuff tear with loss of the transverse force couple

Explanation:

Question 49:

A sagittal T1-weighted MRI scan of the knee joint is shown in Figure 23. What structure is identified by the arrow?

Options:

Popliteal tendon
Ligament of Humphrey
Anterior cruciate ligament
Posterior cruciate ligament
Lateral gastrocnemius tendon

Correct Answer: Posterior cruciate ligament

Explanation:

Question 50:

Duchenne’s muscular dystrophy is a genetic disorder that is transmitted by which of the following modes of inheritance?

Options:

X-linked
Autosomal-dominant
Autosomal-recessive
Chromosomal duplication
Chromosomal deletion

Correct Answer: X-linked

Explanation:

DISCUSSION: Patients with Duchenne’s muscular dystrophy show progressive muscular weakness because of the absence of dystrophin and have the clinical picture of progressive muscle weakness. The condition is an X-linked genetic disease.
REFERENCES: Fitzgerald RH, Kaufer H, Malkani AL: Orthopaedics. St Louis, MO, Mosby Year Book, 2002, pp 1573-1583.
Smith SA, Swaiman HF: Muscular dystrophies, in Swaiman KF, Ashwall S (eds): Pediatric Neurology Principles and Practice, ed 3. St Louis, MO, Mosby, 1999, pp 1235-1237.

Question 51:

Options:

Removal of the humeral and glenoid components
Removal of the glenoid component
Removal of the loose glenoid component and reimplantation of a new glenoid component
Removal of the glenoid component followed by biologic resurfacing of the glenoid
Arthrodesis after removal of both components

Correct Answer: Removal of the loose glenoid component and reimplantation of a new glenoid component

Explanation:

Question 52:

Which of the following statements most accurately describes the risk of ileus following total joint arthroplasty?

Options:

Older age decreases risk.
Male gender decreases risk.
The risk is roughly 1% in total joint arthroplasty patients.
The risk more commonly occurs in total knee arthroplasty (TKA) patients than in total hip arthroplasty (THA) patients.
A history of abdominal surgery has no effect on risk.

Correct Answer: The risk is roughly 1% in total joint arthroplasty patients.

Explanation:

Question 53:

In the evaluation of Lisfranc injuries, which radiographic studies should routinely be obtained?

Options:

MRI
Bilateral weight-bearing anteroposterior and lateral views of the foot with obliques
Stress radiographs under anesthesia
CT scan with 3-dimensional images

Correct Answer: Bilateral weight-bearing anteroposterior and lateral views of the foot with obliques

Explanation:

Question 54:

Options:

Extension splinting of the proximal interphalangeal and distal interphalangeal joints
Extension splinting of the distal interphalangeal joint
Transarticular pinning of the distal interphalangeal joint
Extension block pinning of the distal interphalangeal joint
Open reduction and internal fixation of the distal phalanx

Correct Answer: Extension splinting of the distal interphalangeal joint

Explanation:

DISCUSSION: The radiograph reveals a “bony mallet injury.” As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate.
REFERENCES: Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.
Bendre AA, Hartigan BJ, Kalainov DM: Mallet finger. J Am Acad Orthop Surg 2005;13:336-344.

Question 55:

An increase in advanced glycation end-products (AGEs) is characteristic of which of the following clinical conditions and results in which pathologic process?

Options:

Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness
Increased AGES is characteristic of osteoarthritis and results in increased articular cartilage stiffness
Increased AGES is characteristic of unresurfaced patellar cartilage after total knee arthroplasty and results in articular cartilage thinning
Increased AGES is characteristic of rheumatoid arthritis and results in synovial thickening
Increased AGES is characteristic hemarthrosis and results in articular cartilage staining

Correct Answer: Increased AGES is characteristic of aging articular cartilage and results in decreased articular cartilage stiffness

Explanation:

Question 56:

Options:

Inferior glenohumeral ligament
Middle glenohumeral ligament
Superior labrum
Subscapularis tendon
Supraspinatus tendon

Correct Answer: Subscapularis tendon

Explanation:

Question 57:

What part of the glenoid labrum has the least vascularity?

Options:

Midanterior
Anterior/inferior
Anterior/superior
Posterior/superior
Posterior/inferior

Correct Answer: Anterior/superior

Explanation:

Question 58:

.What is the most appropriate treatment if instability is present at the time of evaluation?

Options:

TEA
Distal humeral replacement arthroplasty
Arthroscopic release with debridement
Soft-tissue interposition arthroplasty DISCUSSION.. The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

Correct Answer: Soft-tissue interposition arthroplasty DISCUSSION.. The radiographs reveal ulnohumeral arthrosis with relative sparing of the radiocapitellar articulation secondary to underlying osteoarthritis. Arthrosis of the elbow joint in this young and active patient presents a treatment dilemma for the surgeon. Interposition arthroplasty allows for improved function with pain relief and no weight-lifting restrictions, as required with TEA. This option is an intermediate procedure that preserves bone stock and allows for conversion to a TEA if necessary. Conventional TEA would provide pain relief with improved range of motion, but activity limitation and lifetime weight restrictions make this an undesirable option. Arthroscopic debridement is not an option, considering the previous failure from this modality. Contraindications for soft-tissue interposition arthroplasty include elbow instability, active infection, and pain without motion loss. Common complications associated with this procedure include instability, infection, ulnar neuropathy, bone resorption, and heterotopic bone formation.

Question 59:

Options:

Immobilization of the wrist in ulnar deviation for 4 weeks before starting range-of-motion exercises
In situ Kirschner wire fixation of the carpal bones for 6 weeks
Extending the volar incision used for fracture fixation and repairing the injured structures in addition to percutaneous Kirschner wire fixation
Performing a separate dorsal incision and repairing the injured structures in addition to percutaneous Kirschner wire fixation
Arthroscopic repair of the injured structures and percutaneous Kirschner wire fixation

Correct Answer: Performing a separate dorsal incision and repairing the injured structures in addition to percutaneous Kirschner wire fixation

Explanation:

DISCUSSION: The intraoperative radiograph reveals a scapholunate ligament disruption. Repair of the stout dorsal scapholunate interosseous ligaments is required. Interestingly, the results of scapholunate ligament injuries associated with distal radius fractures appear to be superior to those of isolated ligament injuries.
REFERENCES: Smith DW, Henry MK: Comprehensive management of soft-tissue injuries associated with distal radius fractures. J ASSH 2002;3:153-164.
Fernandez DL, Wolfe SW: Distal radius fractures, in Green DP, Hotchkiss RN, Pederson WC,
et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 693.

Question 60:

Halo treatment for preadolescent children typically requires the use of which of the following? Review Topic

Options:

4 to 6 pins with an insertional torque of 1 to 5 in-lb
4 to 6 pins with an insertional torque of 4 to 6 in-lb
4 to 6 pins with an insertional torque of 6 to 8 in-lb
8 to 12 pins with an insertional torque of 1 to 5 in-lb
8 to 12 pins with an insertional torque of 4 to 6 in-lb

Correct Answer: 8 to 12 pins with an insertional torque of 1 to 5 in-lb

Explanation:

Question 61:

The posterior approach to the proximal radius uses what intermuscular interval?

Options:

Extensor carpi radialis brevis and extensor digitorum communis
Extensor carpi radialis longus and extensor digitorum communis
Extensor digitorum communis and extensor pollicis brevis
Brachioradialis and flexor carpi radialis
Anconeus and extensor carpi ulnaris

Correct Answer: Extensor carpi radialis brevis and extensor digitorum communis

Explanation:

DISCUSSION: Knowledge of intermuscular and internervous planes allows safe exposures throughout the body. The posterior (Thompson) approach to the proximal forearm uses the interval between the extensor carpi radialis brevis and extensor digitorum communis. The anterior (Henry) approach to the proximal forearm uses the interval between the brachioradialis and the flexor carpi radialis.
REFERENCES: Spinner M: Injuries to the Major Branches of Peripheral Nerves of the Forearm, ed 2. Philadelphia, PA, WB Saunders, 1978, pp 66-77.
Henry AK: Extensile Exposure, ed 3. New York, NY, Churchill Livingstone, 1995.

Question 62:

Options:

Arthroscopic infraspinatus tenodesis
Arthroscopic posterior labral repair
Arthroscopic capsular shift and rotator interval closure
Posterior glenoid opening-wedge osteotomy

Correct Answer: Arthroscopic posterior labral repair

Explanation:

Question 63:

Options:

Sling for 3 days, with early active range of motion
Posterior splint for 5 to 7 days, forearm in full pronation
Posterior splint for 5 to 7 days, forearm in neutral
Posterior splint for 5 to 7 days, forearm in full supination

Correct Answer: Posterior splint for 5 to 7 days, forearm in full supination

Explanation:

Question 64:

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 65:

When an adult hip is surgically dislocated for relief of femoro-acetabular impingment, what is the risk of postoperative iatrogenic osteonecrosis?

Options:

Less than 2%
2% to 4%
5% to 10%
11% to 20%
More than 20%

Correct Answer: Less than 2%

Explanation:

Question 66:

Options:

As strain rate increases, both elastic modulus and ultimate strength increase
As strain rate increases, elastic modulus remains unchanged but ultimate strength increases
As strain rate increases, elastic modulus increases but ultimate strength decreases
As strain rate increases, both elastic modulus and ultimate strength decrease
As strain rate increases, elastic modulus increases but ultimate strength remains unchanged

Correct Answer: As strain rate increases, both elastic modulus and ultimate strength increase

Explanation:

Question 67:

Options:

Anterior and posterior spinal fusion
Anterior spinal fusion
In situ posterior fusion
Halo traction correction and posterior fusion
Continued soft cervical collar treatment

Correct Answer: Anterior and posterior spinal fusion

Explanation:

Question 68:

Options:

Anterior glenoid rim fracture tear
Anterior inferior labral tear
Posterior labral tear
Total capsular laxity
Osteochondral defect of the humeral head

Correct Answer: Posterior labral tear

Explanation:

Question 69:

Options:

Aspiration of joint fluid to obtain a cell count
Revision of the UKA using primary total knee arthroplasty (TKA) components
Revision of the UKA using a revision TKA with augments
Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Correct Answer: Procurement of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level

Explanation:

Question 70:

A 15-year-old wrestler sustains an abduction, hyperextension, and external rotation injury to his right shoulder. The MRI scan findings shown in Figures 27a and 27b are most consistent with

Options:

an avulsion of the lesser tuberosity.
a midsubstance tear of the capsule.
a tear of the anterior inferior labrum.
a tear of the subscapularis.
a tear of the humeral insertion of the inferior glenohumeral ligament.

Correct Answer: a tear of the humeral insertion of the inferior glenohumeral ligament.

Explanation:

Question 71:

Options:

abductor muscle strengthening.
a left 1-½ hip spica cast.
closed reduction and pinning of the left hip.
symptomatic treatment with crutch walking and nonsteroidal anti-inflammatory drugs.
in situ pinning of both hips.

Correct Answer: in situ pinning of both hips.

Explanation:

DISCUSSION: The radiographs confirm a slipped capital femoral epiphysis of the left hip, as well as a widened growth plate on the contralateral hip. This is considered a stable slip because the patient is able to walk. Treatment options for stable slips include in situ pinning, bone graft epiphysiodesis, and in some centers severe slips are treated with primary osteotomy and epiphyseal fixation. Percutaneous in situ fixation is the most popular and widely used method of treatment. This juvenile patient has an endocrine condition and a widened growth plate on the right side; therefore, strong consideration should be given to pinning the contralateral hip
“pre-slip.” Muscle strengthening, hip spica casting, and closed reduction have no place in the primary treatment of a stable slipped capital femoral epiphysis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Loder R, Wittenberg B, DeSilva G: Slipped capital femoral epiphysis associated with endocrine disorders. J Pediatr Orthop 1995;15:349-356.
Aronson DD, Carlson WE: Slipped capital femoral epiphysis: A prospective study of fixation with a single screw. J Bone Joint Surg Am 1992;74:810-819.

Question 72:

Options:

arthroscopic debridement of the articular lesion and resurfacing.
knee aspiration and an intra-articular cortisone injection.
rheumatologic evaluation.
infectious disease evaluation for possible Lyme disease.
arthroscopic synovectomy.

Correct Answer: arthroscopic synovectomy.

Explanation:

DISCUSSION: The patient has synovial chondromatosis. The MRI scans show multiple small proscribed areas of signal intensity in the gutters and suprapatellar pouch, suggesting very small loose bodies. The arthroscopic view shows the classic appearance of multiple small chondral loose bodies. Synovial chondromatosis is a condition in which the synovium undergoes metaplasia, producing multiple chondral loose bodies that can subsequently ossify. The treatment of choice, removal of the loose bodies and arthroscopic synovectomy, results in a lower incidence of recurrence than other treatment methods.
REFERENCES: Coolican MR, Dandy DJ: Arthroscopic management of synovial chondromatosis of the knee: findings and results in 18 cases. J Bone Joint Surg Br
1989;71:498-500.
Ogilvie-Harris DJ, Saleh K: Generalized synovial chondromatosis of the knee: A comparison
of removal of the loose bodies alone with arthroscopic synovectomy. Arthroscopy
1994;10:166-170.

Question 73:

Figure 1 shows the radiograph of an 18-year-old patient who has severe knee pain. Treatment consisting of osteotomy should be perfomed

Options:

above the tibial tubercle.
at or just below the tibial tubercle.
in the tibial diaphysis.
on both the femur and tibia.
on the femur alone.

Correct Answer: at or just below the tibial tubercle.

Explanation:

Question 74:

Options:

Revise the cup bearing to polyethylene
Revise the cup bearing to polyethylene and replace the femoral head with a metal design
Increase the cup abduction angle
Decrease the cup abduction angle
Continue routine follow-up and observation

Correct Answer: Continue routine follow-up and observation

Explanation:

Question 75:

Options:

Hip arthroscopy
Corticosteroid injection
Percutaneous adductor tenotomy
Bone scan
Rheumatology consultation

Correct Answer: Corticosteroid injection

Explanation:

Question 76:

What is the standard interval for placement of an anterolateral portal in ankle arthroscopy?

Options:

Peroneus brevis to peroneus longus
Peroneus tertius to extensor hallucis longus
Peroneus tertius to superficial peroneal nerve
Extensor hallucis longus to deep peroneal nerve
Extensor hallucis longus to extensor digitorum longus

Correct Answer: Peroneus tertius to superficial peroneal nerve

Explanation:

Question 77:

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Options:

grade 2 pivot shift.
positive Thessaly test.
positive quadriceps active test.
positive dial test at 30°.

Correct Answer: grade 2 pivot shift.

Explanation:

Question 78:

- Radiographs of the cervical spine of a 73-year-old man who fell down stairs reveal cervical spondylosis without evidence of fracture or dislocation. MRI and CT scans are consistent with the plain radiographs. After 72 hours, neurologic evaluation reveals intact sensation; however, weakness of the upper extremities is greater than that of the lower extremities. What is the most likely diagnosis?

Options:

Central cord syndrome
Anterior cord syndrome
Posterior cord syndrome
Brown-Sequard syndrome
Cervical nerve root injury

Correct Answer: Central cord syndrome

Explanation:

Question 79:

An 18-year-old high school football player sustains a thigh injury that results in the findings shown in Figure 1. Initial management should consist of

Options:

gentle passive stretching.
pulsed therapeutic ultrasonography.
interferential electrical stimulation.
cross-fiber friction massage.
resting the muscle group.

Correct Answer: resting the muscle group.

Explanation:

Question 80:

Options:

Physical therapy for range-of-motion exercises
Aspiration for possible infection
MRI to evaluate for possible rotator cuff tear
Sling immobilization and reevaluation in 4 weeks
Duplex ultrasound for possible upper extremity deep venous thrombosis

Correct Answer: Physical therapy for range-of-motion exercises

Explanation:

Question 81:

Options:

smaller incisions.
more wound complications.
fewer 30-day and 90-day readmissions.
lower rates of patient satisfaction.

Correct Answer: more wound complications.

Explanation:

Question 82:

Options:

Reaching back to hit a forehand in tennis
External rotating the shoulder to spike a volleyball
Performing a bench press with large amounts of weight
Performing a biceps curl with large amounts of weights
Throwing a baseball at the point of late cocking/early acceleration

Correct Answer: Performing a bench press with large amounts of weight

Explanation:

Question 83:

What is the best indication for prosthetic radial head arthroplasty following fracture?

Options:

Mason type I fracture with full range of motion
Mason type I fracture with decreased supination
Mason type I fracture with decreased pronation
Mason type III fracture with associated interosseous membrane injury
Mason type III fracture without associated interosseous membrane disruption

Correct Answer: Mason type III fracture with associated interosseous membrane injury

Explanation:

Question 84:

Options:

Pulmonary embolism
Fat embolism syndrome
Sepsis
Pneumonia
Pneumothorax

Correct Answer: Fat embolism syndrome

Explanation:

Question 85:

A 9-year-old boy has lateral right knee pain. An MRI scan shows a discoid lateral meniscus with a partial tear in its central portion. Treatment should consist of Review Topic

Options:

arthroscopic saucerization of the meniscus.
lateral total menisectomy.
meniscal transplant.
arthroscopy and repair of the central tear.
casting for 6 weeks followed by physical therapy.

Correct Answer: arthroscopic saucerization of the meniscus.

Explanation:

Question 86:

Which of the following is not considered to be a part of the constellation of the clinical entities known as the female athlete triad? Review Topic

Options:

Decreased bone mineral density
Menstrual dysfunction
Low energy availability with an eating disorder
Low energy availability without an eating disorder
Thyroid dysfunction

Correct Answer: Decreased bone mineral density

Explanation:

Question 87:

Figures 1 and 2 are the radiographs of a 17-year-old man who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?

Options:

Long-arm thumb spica casting
Bracing and bone stimulation
Scaphoid excision with intercarpal fusion
Bone grafting with screw placement

Correct Answer: Bone grafting with screw placement

Explanation:

Question 88:

During excision of a Baker cyst, the base or stalk is usually found between the

Options:

popliteus muscle and posterior cruciate ligament.
posterior cruciate ligament and lateral gastrocnemius muscle.
medial gastrocnemius muscle and posterior cruciate ligament.
semimembranosus and medial head of the gastrocnemius muscles.
semitendinosus and medial head of the gastrocnemius muscles.

Correct Answer: semimembranosus and medial head of the gastrocnemius muscles.

Explanation:

DISCUSSION: Although there are several bursae in the posterior portion of the knee, the most prevalent one with a connection to the knee joint is the one in the interval between the semimembranosus and the medial head of the gastrocnemius muscle. The popliteus muscle and posterior cruciate ligament, the posterior cruciate ligament and lateral gastrocnemius muscle, and the medial gastrocnemius muscle and posterior cruciate ligament are all too lateral and uncommon. The semitendinosus and medial head of the gastrocnemius muscles do not come in contact in the posterior aspect of the knee.
REFERENCES: Resnick D: Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia, PA,
WB Saunders, 1995, p 379.
Justis EJ Jr: Nontraumatic disorders, in Crenshaw AH (ed): Campbell’s Operative Orthopaedics, ed 7. Philadelphia, PA, Lippincott, 1987, vol 3, p 2257.

Question 89:

- Figures 3a and 3b show the finger deformity that a 13-year-old girl has had since birth. What is the most likely diagnosis?

Options:

Clinodactyly
Camptodactyly
Symbrachtyly
Kirner’s deformity
Digiti minimi adductus

Correct Answer: Clinodactyly

Explanation:

Question 90:

Options:

remain 2 cm at maturity.
decrease slowly until the limb lengths equalize.
increase at a constant rate of 2 cm per year.
increase markedly because of complete failure of tibial growth.
increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Correct Answer: increase slowly, with the right lower extremity remaining in proportion to the left lower extremity.

Explanation:

DISCUSSION: Many congenital limb deficiencies and bowing deformities result in growth retardation. If unilateral, a gradually progressive limb-length discrepancy will result; however, the proportional lengths of the lower extremities will remain at a relatively constant ratio. For example, if the right foot is at the level of the left knee at birth, this will still be true at maturity. This concept can be useful for early prediction of limb-length discrepancy by using a “multiplier method,” as described by Paley and associates. This method can facilitate early treatment decisions, such as the need for amputation, without having to wait for serial scanography measurements.
REFERENCES: Paley D, Bhave A, Herzenberg JE, et al: Multiplier method for predicting
limb-length discrepancy. J Bone Joint Surg Am 2000;82:1432-1446.
Moseley CF: A straight-line graph for leg length discrepancies. Clin Orthop 1978;136:33-40.

Question 91:

In recurrent posterior shoulder instability, what is the recommended approach to the posterior capsule?

Options:

A teres minor-splitting approach
An infraspinatus-splitting approach
Between the infraspinatus and teres minor
Between the supraspinatus and infraspinatus
In the rotator interval

Correct Answer: An infraspinatus-splitting approach

Explanation:

DISCUSSION: Using an infraspinatus-splitting incision allows for excellent exposure of the posterior capsule and minimizes the risk of injury to the axillary nerve which lies inferior to the teres minor in the quadrilateral space.
REFERENCES: Dreese J, D’Alessandro D: Posterior capsulorrhaphy through infraspinatus split for posterior instability. Tech Shoulder Elbow Surg 2005;6:199-207.
Shaffer BS, Conway J, Jobe FW, et al: Infraspinatus muscle-splitting incision in posterior shoulder surgery: An anatomic and electromyographic study. Am J Sports Med 1994;22:113-120.
Fuchs B, Jost B, Gerber C: Posterior-inferior capsular shift for the treatment of recurrent voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25.

Question 92:

Options:

Misdiagnosis
Hematoma formation
Postsurgical fibrosis
Failure to recognize involvement of other compartments

Correct Answer: Postsurgical fibrosis

Explanation:

Question 93:

In the normal adult, the distance between the basion and the tip of the dens with the head in neutral position is how many millimeters?

Options:

2 to 3
4 to 5
6 to 7
7 to 8
9 to 10

Correct Answer: 4 to 5

Explanation:

Question 94:

Options:

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

Correct Answer: Malignant peripheral nerve sheath tumor

Explanation:

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

Question 95:

Options:

Revision total knee arthroplasty with extensor mechanism allograft
Revision total knee arthroplasty with liner change and primary quadriceps repair
Resection knee arthroplasty and arthrodesis with antegrade nail
Two-stage revision total knee arthroplasty with extensor mechanism allograft

Correct Answer: Revision total knee arthroplasty with extensor mechanism allograft

Explanation:

Question 96:

Options:

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

Correct Answer: Medial and anterolateral nonlocked plates

Question 97:

Options:

a spinal cord injury and he cannot participate in contact sports.
no obvious injury and can return to all sports without risk of recurrence.
no obvious injury, but he is at a high risk for breaking his neck in athletic competition.
transient quadriplegia only, but this places him at greater risk for future spinal cord injury and he should refrain from all contact sports.
transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Correct Answer: transient quadriplegia and that there is no evidence of increased risk of permanent spinal cord injury should he return to contact sports.

Explanation:

DISCUSSION: The long-term effect of transient quadriplegia is unknown. Based on a history of one brief episode of transient quadriplegia and normal examination and MRI findings, the risk of permanent spinal cord injury with a return to play is low. There is a risk of recurrent episodes of transient quadriplegia after the initial episode.
REFERENCES: Morganti C, Sweeney CA, Albanese SA, et al: Return to play after cervical spine injury. Spine 2001;26:1131-1136.
Odor JM, Watkins RG, Dillin WH, et al: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990;18:507-509.
Torg JS, Naranja RJ Jr, Palov H, et al: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 1996;78:1308-1314.
Vaccaro
AR
, Watkins B, Albert TJ, et al: Cervical spine injuries in athletes: Current return-to-play criteria. Orthopedics 2001;24:699-703.

Question 98:

Immediately after undergoing lumbar instrumentation, a patient reports severe right leg pain and has 4+/5 weakness. Figure 24 shows an axial CT scan of L5. Exploratory surgery will most likely reveal

Options:

transection of the L5 root.
displacement of the L5 root.
partial laceration of the L5 root.
segmental artery injury.
spinal fluid leakage.

Correct Answer: displacement of the L5 root.

Explanation:

Question 99:

Options:

she can expect to have good pain relief following surgery.
active forward elevation and external rotation are reliably obtained postoperatively.
with her current anterosuperior escape, she is likely to have a poor surgical result.
postoperatively, significant muscular atrophy in the latissimus dorsi commonly occurs.
no advancement in glenohumeral arthritic changes should occur following surgery.

Correct Answer: with her current anterosuperior escape, she is likely to have a poor surgical result.

Explanation:

DISCUSSION: Latissimus dorsi tendon transfer is considered a surgical option for treatment in patients with chronic supraspinatus and infraspinatus tendon tears. Preoperative subscapularis function is necessary for good clinical results. Additionally, men with active elevation to shoulder level and active external rotation to 20 degrees have predictably good results. Women with active shoulder elevation limited to below chest level have poor results from this procedure and should not be considered candidates. Postoperatively they lack pain control, active elevation, and active external rotation. Muscular atrophy in the latissimus dorsi does not occur, and glenohumeral arthritic changes frequently develop postoperatively.
REFERENCES: Gerber C, Maquieira G, Espinosa N: Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears: Factors affecting outcome. J Bone Joint Surg Am
2006;88:113-120.
Iannotti JP, Hennigan S, Herzog R, et al: Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. J Bone Joint Surg Am 2006;88:342-348.

Question 100:

Intraoperative frozen section analysis reveals 10 neutrophils per high-power field and a positive gram stain result. What is the best next step?

Options:

Implant removal, irrigation and debridement, and resection arthroplasty
Implant removal, irrigation and debridement, and rTSA
Implant removal, irrigation and debridement, and revision hemiarthroplasty
Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Correct Answer: Implant removal, irrigation and debridement, and antibiotic cement spacer placement

Explanation:

DISCUSSION
The radiograph reveals a rotator cuff dysfunction secondary to malpositioning of the humeral stem and a nonanatomic humeral head. Glenohumeral kinematics have been altered, resulting in damage to the rotator cuff, which in turn has led to impingement with the coracoacromial arch. This single radiograph reveals excessive humeral head height, “overstuffing” of the joint, and severe narrowing of the acromiohumeral interval. Osteolysis and implant loosening are not radiographically apparent. An orthogonal view (axillary lateral) would be necessary to evaluate for shoulder instability. A CT arthrogram is the most appropriate advanced imaging test in the setting of a retained shoulder arthroplasty to evaluate the integrity of the rotator cuff. An MRI evaluation would be obfuscated by artifact. Three-phase and indium-tagged white blood cell scans may be appropriate in the setting of an occult infection evaluation, but not as a test to evaluate rotator cuff injury.
In the absence of infection with rotator cuff compromise, the most appropriate procedure(s) during revision would involve humeral component explantation and conversion to rTSA Revision anatomic hemiarthroplasty may provide pain relief, but function may not appreciably change because of the unbalanced forced couples of the rotator cuff complex. Placement of a glenoid component in the setting of an irreparable rotator cuff tear is contraindicated because rapid glenoid loosening will occur due to eccentric loading during active shoulder motion. Resection arthroplasty should be reserved for recalcitrant cases of infection because this procedure does not provide functional improvement.
In the event that frozen section analysis and positive gram stain results indicate an infection, the treating surgeon should remove all components, perform a thorough debridement and irrigation of suspect tissue, implant an antibiotic spacer, and perform a second-stage reconstruction when deemed appropriate (in light of laboratory studies, repeat shoulder aspiration, frozen section analysis, and arthroscopic soft-tissue biopsy findings). Irrigation and debridement with primary exchange/conversion of components remains inferior to 2-stage reconstruction for infection eradication. Resection arthroplasty remains a salvage procedure for resistant cases that preclude reimplantation and generally is performed for symptom control and sepsis prevention.
RECOMMENDED READINGS
Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92. Review. PubMed PMID: 17015609.
View Abstract at PubMed
Florschütz AV, Lane PD, Crosby LA. Infection after primary anatomic versus primary reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2015 Aug;24(8):1296-301. doi: 10.1016/j.jse.2014.12.036. Epub 2015 Feb 19. PubMed PMID: 25704211.
View Abstract at PubMed
Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg. 2015 May;24(5):741-6. doi: 10.1016/j.jse.2014.11.044. Epub 2015 Jan 13.
View Abstract at PubMed
Leung B, Horodyski M, Struk AM, Wright TW. Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy. J Shoulder Elbow Surg. 2012 Mar;21(3):319-23. doi: 10.1016/j.jse.2011.05.023. Epub 2011 Aug 26. PubMed PMID: 21872496.
View Abstract at PubMed
Iannotti JP, Spencer EE, Winter U, Deffenbaugh D, Williams G. Prosthetic positioning in total shoulder arthroplasty. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):111S-121S. PubMed PMID: 15726070.
View Abstract at PubMed
Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992 Apr;74(4):491-500. PubMed PMID: 1583043.
View Abstract at PubMed
Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. doi: 10.2106/JBJS.M.00258.
View Abstract at PubMed

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

Orthopedic Board Prep MCQs: Arthroplasty, Infection & Nerve | Part 170

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 170

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index