Orthopedic Board Review MCQs: Trauma & Deformity | OITE

About This Board Review Set

This is Part 182 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 182

This module focuses heavily on: Ankle, Arthroplasty, Deformity, Fracture, Hip, Ligament, Nerve.

Sample Questions from This Set

Sample Question 1: As an orthopaedic surgery resident, you arrive late to a medial patellofemoral ligament reconstruction procedure in your institution's outpatient surgical center. It is standard practice in your residency program to miss the start of the fi...

Sample Question 2: -Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?...

Sample Question 3: Figures 16a and 16b show the radiographs of an otherwise healthy 3 1/2-year-old boy who has an isolated deformity of the left leg. Definitive primary treatment of this condition should consist of...

Sample Question 4: Figures 245a through 245e are the radiographs and MRI scans of a 50-year-old ice hockey referee with a 3-year history of progressive anterolateral ankle pain, a history of multiple ankle sprains, and a fibular fracture he sustained 30 years...

Sample Question 5: A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now reports pain in his hips and difficulty with ambulation to the point where he now uses crutches. A radiograph of the hip and pelvis is shown in Figure 26. What ...

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

As an orthopaedic surgery resident, you arrive late to a medial patellofemoral ligament reconstruction procedure in your institution's outpatient surgical center. It is standard practice in your residency program to miss the start of the first case because of didactic requirements on Tuesdays. The surgical team has your gown and gloves ready, and following scrubbing and gowning, you join the surgical team and assist the attending with the procedure. Which of the following represents a violation of standard surgical safety checklists?

Explanation

When a surgeon arrives late to the operating room, the timeout should be repeated to confirm the patient and procedure as well as introduce all members of the team and their respective roles.
The World Health Organization and nearly every professional surgical subspecialty group advocates for safety checklists prior to operations. Although there are institutional variations to individual items on the checklists, it is important to include a system for marking the surgical site, verifying the patient's identity and procedure planned, identifying all team members in the room and agreement regarding the type of anesthesia, antibiotic prophylaxis, instrumentation used. Simply put, safety checklists have been shown to drastically reduce costly errors in other high-risk
industries, and they have been universally adopted by hospitals and surgery centers and the organizations that inspect and validate healthcare settings.
The Joint Commission Guidelines and the WHO surgical safety checklists are examples of governing bodies of healthcare implementing safety checklists in procedural settings.
Illustration A is the WHO surgical safety checklist. Incorrect Answers:

Question 2

Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?

Explanation

Femoral nerve is located in the anterior neurovascular bundle which does not lie between the gluteus medius minimus. Obturator arises from lumbar plexus supplies and runs with the adductor muscles. Inferior gluteal runs with the posterior neurovascular bundle which do not lie between these muscles. The lateral femoral cutaneous arises inferior and medial to the ASIS which is anterior and medial to this area as well.
The direct lateral approach (Transgluteal approach). No true intervenous plane (“split the fibers” of the gluteus medius “distal to the point where the superior gluteal nerve supplies the muscle”). “Do not (split) more than 3 cm above the upper boarder of the trochanter.”

Question 3

Figures 16a and 16b show the radiographs of an otherwise healthy 3 1/2-year-old boy who has an isolated deformity of the left leg. Definitive primary treatment of this condition should consist of

Explanation

DISCUSSION: Treatment of congenital pseudarthrosis of the tibia is problematic. To achieve union, a resection of the pseudarthrosis, stabilization, and bone grafting must be performed. Simple cast immobilization does not yield union. There are various options for the resection, immobilization, and grafting. On the first surgical attempt, retrograde intramedullary nailing offers the best chance for success by transfixing the ankle and subtalar joints with abundant autogenous bone grafting. Distraction osteogenesis and vascularized free fibular graft are reserved as salvage procedures.
REFERENCES: Gilbert A, Brockman R: Congenital pseudarthrosis of the tibia: Long-term follow-up of 29 cases treated by microvascular bone transfer. Clin Orthop 1995;314:37-44.
Boero S, Catagni M, Donzelli O, Facchini R, Frediani PV: Congenital pseudarthrosis of the tibia associated with neurofibromatosis - 1: Treatment with Ilizarov’s device. J Pediatr Orthop 1997;17:675-684.
Anderson DJ, Schoenecker PL, Sheridan JJ, Rich MM: Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am 1992;74:161-168.

Question 4

Figures 245a through 245e are the radiographs and MRI scans of a 50-year-old ice hockey referee with a 3-year history of progressive anterolateral ankle pain, a history of multiple ankle sprains, and a fibular fracture he sustained 30 years ago. Examination reveals mild bilateral pes planovalgus feet with passive ankle joint dorsiflexion range of motion of 10 degrees and plantar flexion of 45 degrees without pain. The physician should recommend

Explanation

Question 5

A 58-year-old patient who underwent bilateral hip arthroplasty 12 years ago now reports pain in his hips and difficulty with ambulation to the point where he now uses crutches. A radiograph of the hip and pelvis is shown in Figure 26. What is the best treatment option for this patient?

Explanation

DISCUSSION: The radiographs reveal acetabular component failure with bone loss. There

are several treatment options available. The best option for survivorship is a cementless

porous-coated acetabular component. This patient may or may not require structural bone graft, which may need to be determined at the time of surgery. Bipolar implants and cemented acetabular components for revision surgery have not demonstrated long-term success. The use of a protrusio ring is reserved primarily for massive bone loss such as a Paprosky type III bone loss with significant superior migration of the acetabular component. The best clinical results for acetabular component revision have been achieved with cementless porous-coated implants.
REFERENCES: Haddad FS, Masri BA, Garbuz DS, et al: Acetabulum, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 923-936.
D’Antonio JA: Periprosthetic bone loss of the acetabulum: Classification and management. Orthop Clin North Am 1992;23:279-290.
Rubash HE, Sinha RK, Paprosky W, et al: A new classification system for the management of acetabular osteolysis after total hip arthroplasty. Instr Course Lect 1999;48:37-42.

Question 6

An year-old African American woman who lives in a large city is scheduled for total hip arthroplasty to address primary osteoarthritis. Part of the presurgical protocol includes nasal swab screening to assess for methicillin-resistant Staphylococcus aureus (MRSA) colonization. Which demographic factor places this patient at highest risk for a positive result?

Explanation

DISCUSSION:
Demographic factors are associated with increased risk for MRSA colonization, so it is important to identify vulnerable patients. Female gender and advanced age reduce the risk for colonization, whereas African American race increases this risk. Urban environments do not influence MRSA colonization.

Question 7

An 11-year-old girl sustained an injury to her right foot when a 500-lb headstone fell on it. The headstone was removed after 3 minutes. Radiographs show multiple midfoot fractures. Examination reveals severe pain that is worse with passive toe motion. Clinical photographs are shown in Figure 28. Management should consist of

Explanation

DISCUSSION: The patient has a classic history and examination for an acute compartment syndrome of the foot. CT, MRI, or stress radiographs are not necessary prior to emergent fasciotomies of the foot. These studies can be performed after the initial fasciotomies to determine the best long-term management of the fractures. There are nine compartments in the foot. These are decompressed through three incisions (two on the dorsal foot and one medially). A short leg cast does not address the compartment syndrome and could be limb threatening with excessive swelling in a circumferential cast. It is preferable to splint severe crush injuries rather than apply a cast.
REFERENCES: Fulkerson E, Razi A, Tejwani N: Review: Acute compartment syndrome of the foot. Foot Ankle Int 2003;24:180-187.
Weber TG, Manoli A II: Compartment syndromes of the foot. Foot Ankle Clin 1999;4:473-486.

Question 8

Figure 32 shows the radiograph of a laborer who jammed his thumb in a fall. Examination reveals pain at the base of the thumb and proximal thenar eminence region. Management should consist of

Explanation

DISCUSSION: The radiographs are classic for a Bennett’s fracture, which involves a fracture of the palmar ulnar aspect of the proximal phalanx. This fracture fragment is still attached to the anterior oblique ligament. The deforming forces that cause subluxation of the base of the proximal phalanx include the pull of the abductor pollicis longus as well as the adductor pollicis. Adequate reduction can be achieved by closed reduction, percutaneous pin fixation, and casting. The fragment is too small for secure internal fixation.
REFERENCES: Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green’s Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Howard FM: Fracture of the basal joint of the thumb. Clin Orthop 1987;220:46-51.

Question 9

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Explanation

DISCUSSION
Gamma irradiation produces free radicals. Although these free radicals can form cross-links with other polyethylene chains, the free radicals can also form a bond with oxygen, resulting in early oxidation. Gamma irradiation in air produces the highest risk for oxidized polyethylene, resulting in the highest risk for wear, delamination, and subsequent osteolysis.
This patient demonstrates severe periarticular osteolysis. When she is asymptomatic, this suggests the acetabular and femoral components remain well fixed to the bone. Consequently, she can be treated by removing the wear generator (polyethylene exchange), along with bone grafting of the osteolytic defect. Considering the extensive amount of osteolysis, observation for 1 year would not be appropriate.
The psoas is the anatomic structure that runs anterior to the acetabulum. The femoral neurovascular structures are at risk if the retractor is placed anterior and inferior to the psoas tendon.
The patient develops a foot drop 2 days after surgery. As a result, it can be assumed that the nerve was not injured directly during the surgical procedure. Although MR imaging or a CT scan may be indicated to identify an evolving hematoma, the immediate concern is to minimize pressure on the sciatic nerve. Tension on the nerve can be decreased by flexing the surgical knee and positioning the bed flat.

Question 10

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 11

Iliosacral screws placed for stabilization of posterior pelvic ring injuries (eg, sacroiliac dislocation) that exit the sacrum anteriorly are most likely to injure which of the following structures?

Explanation

DISCUSSION: Iliosacral screws have gained popularity for posterior stabilization of pelvic ring disruptions, but complications attributed to incorrect placement are a clinical problem. The L5 nerve root is at greatest risk and is in closest proximity to a malpositioned screw (exiting the sacrum). The L4 root is more anterior at this level. The S1 root is still intraosseous at this level and is at risk but not from the screw exiting anteriorly at this level. The arteries are at risk but are more anterior and are at less risk than the L5 nerve root.
REFERENCE: Ebraheim NA, Haman SP, Xu R, Stanescu S, Yeasting RA: The lumbosacral nerves in relation to dorsal SI screw placement and their locations on plain radiographs. Orthopedics 2000;23:245-247.

Question 12

Figures 44a through 44c show the radiographs of an 18-year-old female soccer player who fell on her outstretched hand 1 day ago. She denies any history of wrist pain. Examination reveals tenderness at the anatomic snuffbox. Management should consist of

Explanation

DISCUSSION: The treatment of choice for proximal pole scaphoid fractures is open reduction and internal fixation with a differential pitch screw via a dorsal approach. Healing rates of 100% have been reported for these acute fractures. Casting results in slow healing, with recommendations including 16 weeks or more in a cast. Vascularized bone grafts are not indicated for acute fractures.
REFERENCES: Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg 1999;24:1206-1210.
Raskin KB, Parisi D, Baker J, et al: Dorsal open repair of proximal pole scaphoid fractures. Hand Clin 2001;17:601-610.

Question 13

The sartorius muscle is innervated by which of the following nerves?

Explanation

DISCUSSION: The femoral nerve enters the thigh behind the inguinal ligament, lying on the surface of the iliopsoas muscle lateral to the femoral artery and vein. The nerve divides into numerous muscular and cutaneous branches in the femoral triangle. The first motor branch (sometimes two branches) is to the sartorius. There is a variable branch to the pectineus. Subsequent branches go to the rectus femoris and then the vastus muscles in variable order. The last motor branch is to the articularis genu. The muscular branches can be injured in anterior approaches to the hip, especially the middle window of the ilioinguinal approach.
REFERENCES: Hollinshead WH: Textbook of Anatomy, ed 3. Hagerstown, MD, Harper and Row, 1974, p 404.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, p 139.

Question 14

Based on the type of articulation shown in Figure 32, wear is not affected by which of the following factors?

Explanation

DISCUSSION: Wear in total hip arthroplasty is a very complex phenomenon. The radial mismatch of the femoral head to the acetabular component has been shown in multiple studies to be a significant factor in wear. The mismatch can neither be too small nor too large. When the mismatch is too small, seizing of the implants can occur. When the mismatch is too large, contact stresses increase and produce exceptionally high wear. The ideal radial mismatch should be approximately 50 microns. Surface roughness and ball sphericity are two items that are extremely important with respect to wear. High carbon content has been shown to decrease wear. This device has a very large head-to-neck ratio, so impingement-related wear is unlikely.
REFERENCES: Amstutz HC, Grigoris P: Metal on metal bearings in hip arthroplasty. Clin Orthop 1996;329:S11-S34.
Amstutz HC, Campbell P, McKellop H, et al: Metal on metal total hip replacement workshop consensus document. Clin Orthop 1996;329:S297-S303.
McKellop H, Park SH, Chiesa R, et al: In vivo wear of three types of metal on metal hip prostheses during two decades of use. Clin Orthop 1996;329:S128-S140.

Question 15

Figures 38a and 38b show the CT scans of a 64-year-old woman. What is the most likely diagnosis?

Explanation

DISCUSSION: The CT scans show large cystic lesions in the talus and calcaneus with complete subluxation of the subtalar joint, allowing the calcaneus to slide laterally until it becomes blocked by the fibula. The cause of this subluxation is severe posterior tibial tendon dysfunction. Although no fibular fracture has yet appeared, it can occur with continued stress from the calcaneus. There is, however, a pathologic fracture in the medial calcaneus through a medial degenerative cyst. The joint space is irregular and not symmetrical as would be seen in an inflammatory arthropathy. Cystic lesions are not present in the tibia. No stress fracture is seen in the talus.
REFERENCES: Coughlin MJ: Sesamoids and accessory bones of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 437-499.
Anderson RB, Davis WH: Management of the adult flatfoot deformity, in Myerson M (ed):

Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1017-1039.

Question 16

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Explanation

DISCUSSION: Insufficient caloric intake caused by either a poor diet or an eating disorder is the most common cause for the loss of menses in a female athlete. In the face of adequate caloric intake, stress is unlikely to cause amenorrhea. Oral contraceptives control menses but do not eliminate it. Diabetes mellitus does not cause the new onset of amenorrhea. Pregnancy can be a cause in a sexually active athlete. Chromosomal abnormalities can result in delayed or absent menarche but not the onset of amenorrhea in a postmenarchal female.
REFERENCES: Constantini NW: Clinical consequences of amenorrhea. Sports Med 1994;17:213-223.
Bennell KL, Malcolm SA, Thomas SA, et al: Risk factors for stress fractures in track and field athletes: A twelve-month prospective study. Am J Sports Med 1996;24:810-818.

Question 17

During fracture healing, granulation tissue tolerates the greatest strain before failure so that mature bone can eventually bridge the fracture gap during healing. What is the definition of strain?

Explanation

Strain is defined as the change in length/original length (L) and is created by a deformation of a material from an applied force.
The mechanical environment at the fracture site has a major influence on fracture healing. Granulation tissue can withstand higher strain, which stabilizes the mechanical environment and forms a scaffold on which cartilage and bone eventually form; this occurs after strain decreases incrementally. Optimal healing, however, depends on duration, rate, timing and type of mechanical influence. Bone is formed by osteoblasts that are adapted to the very low strains of over 1% change in length. Osteoblast synthesis and proliferation is stimulated at uniaxial strain of between 0.3% and 2.8%. It is known that limited inter-fragmentary movement of 0.2 mm to 1 mm is optimal for fracture healing, resulting in promotion of callus and increase in rigidity. Excessive movement, on the other hand, prolongs fracture healing. Researchers have identified that tissue strain of 2% is suitable for primary bone healing and secondary bone healing takes place at tissue strain of 2-10%. Strain of 10-100% results in fibrous tissue formation and 100% strain to non-union. This is known as Perren's theory.
Stokes published a review article on the effects of stress on bone healing and growth, and notes the importance of the 'Hueter-Volkmann Law' (growth is retarded by increased mechanical compression, and accelerated by reduced loading in comparison with normal values) in bone growth. Stokes also notes that sustained compression of physiological magnitude inhibits growth by 40% or more, while distraction increases growth rate by a much smaller amount.
Illustration A shows an example of a stress-strain curve, with several key definitions labeled on the diagram.
Incorrect Answers:

Question 18

A researcher experimenting with limb patterning removes some tissue from 1 part of the limb bud (which we shall call Site A) and transplants it along the anteroposterior (AP) axis to create a mirror-hand duplication. Which of the following is true?

Explanation

The ZPA is located on the posterior (ulnar) margin of the limb bud. It expresses Shh protein. When tissue from ZPA is added to the anterior (radial) margin of the limb bud, ulnar dimelia, or mirror hand duplication, occurs.
The ZPA controls AP (radioulnar) growth. The signaling molecule is Shh, which is dose dependent. Higher Shh doses lead to posterior (ulnar) digits ulnar sided polydactyly. The extent of duplication is dose dependent (higher dose = more replication). Reduced Shh leads to loss of digits. Posterior elements (little finger/ulna) are formed EARLY prior to anterior elements which are formed LATE (radius/thumb). Disruption of AP patterning will result in loss of later forming elements (radius/thumb).
Al-Qattan et al. reviewed embryology of the upper limb. They summarized that embryology of the upper limb can be viewed in 2 distinct ways: the steps of limb development and the way that the limb is patterned along its 3 spatial axes. Cell signaling plays a major role in regulating growth and patterning of the vertebrate limbs. Signaling cell dysfunction results in congenital differences according to the affected signaling axis.
Illustration A shows an experiment to create ulnar dimelia by adding ZPA tissue to the anterior limb bud. The video shows development of the limb.
Incorrect Answers:

Question 19

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

Explanation

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

Question 20

A 35-year-old woman states that she stepped on a piece of glass 6 months ago and reports numbness and shooting pain along the plantar lateral forefoot. She had previously received steroid injections in the 3 to 4 webspace. Examination reveals mild tenderness along the plantar fascia; no Tinel’s sign is noted plantar medially and no Mulder’s click is noted distally. An MRI scan is shown in Figure 7. What is the most likely cause of the numbness?

Explanation

DISCUSSION: The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter’s nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel’s sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder’s click. A digital nerve laceration would exhibit isolated numbness more distally.
REFERENCES: Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992;279:229-236.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA, JB Lippincott, 1983.

Question 21

Figures 1 through 4 are selected sagittal MR images of an otherwise healthy 20-year-old collegiate football running back who was tackled during a game and has immediate onset of right knee pain. Video analysis of the injury shows that his flexed knee impacted the field. He is not able to return to play. On examination in the training room the following morning, he has a moderate effusion, no patellar instability, minimal joint line tenderness, and is stable to varus and valgus stress at 30° of knee flexion. A dial test is also negative. He has increased laxity in the anterior to posterior direction. What is the most appropriate next step in treatment?

Explanation

DISCUSSION:
This athlete sustained an isolated PCL injury. The mechanism of injury is typical for a PCL injury. When a PCL injury is identified, one must rule out other ligamentous injuries to the knee. The patient has a stable examination to varus and valgus and a negative dial test, so the lateral collateral, medial collateral, and posterolateral corner (respectively) are intact. It is common to have increased anterior to posterior translation in isolated PCL injuries, even with an intact ACL, as the tibia will rest posterior to the medial femoral condyle. Treatment of isolated PCL injuries is typically nonoperative, with an initial focus on quadriceps strengthening. Hamstring strengthening and rehabilitation is added at a later time, as this places increased stress on the healing PCL. The images reveal an isolated PCL injury with intact menisci and ACL, ruling out ACL reconstruction using autograft tissue and PCL reconstruction using autograft tissue.

Question 22

A patient undergoing joint arthroplasty is put on a drug that competitively inhibits the activation of an enzyme that breaks down Factor Ia. The drug is

Explanation

Factor Ia is fibrin. The enzyme that breaks down fibrin is plasmin. Tranexamic acid (TXA) is an antifibrinolytic that prevents the activation of plasmin from the inactive zymogen plasminogen.
Tranexamic acid competitively inhibits the activation of plasminogen to plasmin by binding to specific sites on both plasminogen and plasmin. Tranexamic acid has roughly eight times the antifibrinolytic activity of an older analogue, e-aminocaproic acid. It is used during joint replacement surgery to reduce blood loss and the need for transfusion.
Watts et al. review strategies for minimizing blood loss and transfusion. They recommend 1g of TXA prior to incision, and 1g at wound closure. They also recommend giving fluids for symptoms of anemia, rather than transfusion, as even high risk patients do well with sufficient intravascular volume even with low hemoglobin levels.
Imai et al. evaluated TXA in 107 patients undergoing THA. They found that intraoperative blood loss after preoperative TXA administration was lower than both control and postoperative TXA administration groups. They recommend using 1 g of TXA 10 minutes before surgery and 6 hours after the first administration to best reduce blood loss during THA.
Gillette et al. retrospectively reviewed 2046 patients receiving TXA for THA or TKA together with either aspirin, warfarin or dalteparin. They found that the rates of symptomatic DVT (0.35%, 0.15%, and 0.52%, respectively) and nonfatal PE were similar (0.17%, 0.43%, and 0.26%, respectively) for the 3 drugs respectively. They recommend TXA to decrease blood loss and transfusion.
Illustration A shows the role of tranexamic acid in the fibrinolytic cycle and the
clotting cascade.
Incorrect Answers:

Question 23

A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?

Explanation

DISCUSSION: The radiographic findings are consistent with a type II Hangman’s fracture or traumatic spondylolisthesis of C2. This occurs with more than 3 mm of displacement according to the classification of Levine and Edwards. Even though the radiograph reveals significant displacement, the overall space available for the neural elements is increased, therefore minimizing the risk of neural compromise. Neurologic injury is most frequently encountered in type III injuries that are associated with bilateral facet dislocations of C2 on C3 but is infrequent in type I (less than 3 mm displacement) and type II traumatic spondylolisthesis. When neurologic deficits are associated with type II injuries, it is usually the result of an associated head injury. Cruciate paralysis occurs as a result of the crossover of the motor and sensory tracts at different levels of the cord at the C1-C2 junction. This results in normal sensation but complete loss of motor function.
REFERENCES: Levine AM: Traumatic spondylolisthesis of the axis (Hangman’s fracture), in Levine AM, Eismont FJ, Garfin S, Zigler JE (eds): Spine Trauma. Philadelphia, PA, WB Saunders, 1998, pp 287-288.
Francis WR, Fielding JW, Hawkins RJ, Pepin J, Hensinger R: Traumatic spondylolisthesis of the axis. J Bone Joint Surg Br 1981;63:313-318.

Question 24

A 72-year-old woman who is right hand-dominant has severe pain in the right shoulder that has failed to respond to nonsurgical management. She reports night pain and significant disability. Examination reveals 30 degrees of active forward elevation. An AP radiograph is shown in Figure 27. Which of the following treatment options will provide the best functional improvement?

Explanation

DISCUSSION: The patient has end-stage rotator cuff tear arthropathy. The radiograph shows complete proximal humeral migration (acromiohumeral interval of 0 mm), severe glenohumeral arthritis, and acetabularization of the acromion. In addition, she has "pseudoparalysis" with active elevation of only 30 degrees. Reverse shoulder arthroplasty affords her the best opportunity for pain relief and functional improvement. The other procedures have mixed results but typically are better for pain relief than they are for functional gains.
REFERENCES: Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-1705.
Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-1486.

Question 25

Which of the following statements best describes the relationship between tissue response to thermal capsulorrhaphy and the type of device used?

Explanation

DISCUSSION: Although radiofrequency devices and lasers differ fundamentally in the way they generate heat within a tissue, both classes of devices are capable of producing temperatures within the critical temperature range (65 to 75 degrees C) for collagen denaturation and subsequent tissue shrinkage. When it comes to cell viability and tissue response, heat is heat. Once critical temperatures are reached, cells will die at 45 degrees C, collagen will become denatured at 60 degrees C, and tissue ablation will occur at 100 degrees C no matter what the source of thermal energy. Therefore, claims of a better or different type of heat have little bearing on the biologic response of the tissue. Histologic, ultrastructural, and biomaterial alterations induced by laser and radiofrequency energy have been shown to be similar.
REFERENCES: Arnoczky SP, Aksan A: Thermal modification of connective tissues: Basic science considerations and clinical implications. J Am Acad Orthop Surg 2000;8:305-313.
Hayashi K, Markel MD: Thermal modification of joint capsule and ligamentous tissues: The use of thermal energy in sports medicine. Operative Techniques Sports Med 1998;6:120-125.
Naseef GS III, Foster TE, Trauner K, et al: The thermal properties of bovine joint capsule: The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med 1997;25:670-674.

Question 26

A 35-year-old man has profound deltoid weakness after sustaining a traumatic anterior shoulder dislocation 6 weeks ago. Electromyographic (EMG) studies confirm an axillary nerve injury. Follow-up examination at 3 months reveals no recovery of function. What is the best course of action?

Explanation

DISCUSSION: Documenting the status of recovery at this time is appropriate; therefore, repeat EMG studies should be conducted to check for early signs of reinnervation. Timing of nerve exploration in this setting is debated, with authors suggesting exploration if there is no sign of recovery at 6 to 9 months.
REFERENCES: Perlmutter GS: Axillary nerve injury. Clin Orthop 1999;368:28-36.
Artico M, Salvati M, D’Andrea V, et al: Isolated lesions of the axillary nerves: Surgical treatment and outcome in twelve cases. Neurosurgery 1991;29:697-700.
Vissar CP, Coene LN, Brand R, et al: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery: A prospective clinical and EMG study. J Bone Joint Surg Br 1999;81:679-685.
Pasila M, Jarma H, Kiviluoto O, et al: Early complications of primary shoulder dislocations. Acta Orthop Scand 1978;49:260-263.

Question 27

Figures 63a and 63b show the radiographs of an 11-year-old girl who sustained a twisting injury of the knee playing soccer. She is now asymptomatic. What is the appropriate treatment of the lesion?

Explanation

DISCUSSION: This is a nonossifying fibroma of the proximal tibia. The lesion is eccentric, cortically based, with sclerotic margins and no evidence of a soft-tissue mass. Nonossifying fibromas are benign lesions that need no biopsy or surgical treatment when classic findings appear on radiographs. A follow-up radiograph should be performed 2 to 3 months after the initial presentation to ensure that the lesion is not progressive. Surgery is reserved for large lesions with risk of pathologic fracture or for cases where a displaced pathologic fracture has occurred and internal fixation is needed for fracture treatment. Nondisplaced pathologic fractures through nonossifying fibromas are best treated by allowing the fracture to heal and observation of the lesion.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 77-85.

Question 28

Figures A and B show the six-month follow-up radiographs of a 62-year-old woman who sustained a hip fracture in a fall. Prior to the fall, the patient was active and had no difficulty with ambulation. The patient underwent open reduction and internal fixation with a sliding hip screw device. She has difficulty with ambulation, continues to walk with a walker, and reports startup pain. What is the most appropriate management at this time? Review Topic

Explanation

The radiographs demonstrate a healed fracture with penetration of the screw through the femoral head into the acetabulum as well as osteonecrosis and collapse of the femoral head (Figure 129b). Conversion to total hip arthroplasty with a long stem is necessary to bypass the femoral cortical defects from the screw holes. A primary tapered stem is not appropriate because of the proximal femoral deformity and the stress risers associated with the screw holes. Removal of hardware, valgus osteotomy, and revision of the internal fixation are not appropriate in the presence of the femoral head collapse and acetabular penetration.

Question 29

Figures 23a and 23b show the radiograph and clinical photograph of a patient who reports a reduced ability to flex the interphalangeal joint of her great toe after undergoing a Chevron-Akin bunionectomy. What is the most likely cause?

Explanation

DISCUSSION: The flexor hallucis longus tendon is at risk during a Chevron-Akin osteotomy because of its close relationship to the base of the proximal phalanx. The radiograph reveals a reduced ability to flex the interphalangeal joint secondary to the flexor hallucis longus laceration. The other complications are not supported by the radiograph.
REFERENCES: Tollison ME, Baxter DE: Combination chevron plus Akin osteotomy for hallux valgus: Should age be a limiting factor? Foot Ankle Int 1997;18:477-481.
Scaduto AA, Cracchiolo A III: Lacerations and ruptures of the flexor or extensor hallucis longus tendons. Foot Ankle Clin 2000;5:725-736.

Question 30

A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient’s desire to return to sport? Review Topic

Explanation

Injuries to the MCL usually result from repetitive high valgus stress on the medial aspect of the elbow joint due to overhead throwing or racquet sports. Excessive
stresses during the late cocking and acceleration phase of throwing can injure the anterior band of the MCL. Clinically, the injuries may present as chronic or acute, and a pop may be noted in the latter. Associated ulnar nerve involvement is common. Valgus instability is present in about 25% of patients. Patients typically are athletes who participate in throwing and have localized medial elbow pain and tenderness along the course of a ligament that extends from the medial epicondyle of the distal humerus to the sublime tubercle of the ulna. Surgical reconstruction is the procedure of choice in an athlete desiring a return to a high level of throwing.

Question 31

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 32

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future? Review Topic

Explanation

For the parachute test, the examiner holds the child prone and then lowers the child rapidly toward the floor. The parachute reaction is normal or positive if the child reaches toward the floor. The Moro or startle reflex should not be present beyond age 6 months. Asymmetric tonic neck reflex, extensor thrust, and absent foot placement are abnormal findings at any age.

Question 33

Figures 124a and 124b are the radiographs of a 30-year-old man who sustained an ankle injury and has swelling with lateral tenderness. The patient denies any previous ankle injuries. After 6 weeks of rest and use of a removable ankle brace, he continues to have swelling, lateral pain, and popping. An anterior drawer test reveals a solid end point. Recommended treatment should include which of the following?

Explanation

The radiographs and examination reveal peroneal tendon instability requiring surgical treatment for persistent symptoms and tendon instability. The radiographs demonstrate the "fleck sign," which is an avulsion of the posterior distal fibular ridge, and represents an injury to the superior peroneal retinaculum and probable peroneal dislocation. Peroneal tendon dislocations are typically present with vague lateral ankle findings associated with swelling and tenderness over the distal fibula. The tendons may be palpated as a ridge over the lateral fibula distally. Initial management of the acute injury with cast immobilization in plantar flexion/inversion with the use of a pad in the shape of a "U" or "J" is effective in 50% of patients; the rest will require surgical treatment. The indications for surgical treatment of peroneal dislocation/subluxation include continued pain and failure of nonsurgical management. Associated peroneal tendon tears can be found when performing retinacular reconstruction. Many techniques have been described including soft-tissue reconstructions, bone block procedures as well as fibular groove-deepening procedures. Radiographs do not reveal an osteochondral lesion. There is no evidence
of lateral ankle ligament instability. Ankle rehabilitation and physical therapy may further damage the unstable tendons.

Question 34

-A 32-year-old man who is a smoker sustained an open tibial fracture and underwent a staged treatment with placement of an intramedullary nail. Four weeks after surgery, he developed a pseudomonas deepwound infection. What is the strongest predictor of persistent infection if implants are retained until fracture union?

Explanation

Question 35

A 45-year-old man feels a pop in the anterior aspect of his elbow while lifting furniture. He denies any antecedent pain or injury. Which examination method is best for diagnosing a distal biceps rupture?

Explanation

EXPLANATION:

Question 36

A 30-year-old man reports pain and weakness in his right arm. Examination reveals grade 4 strength in wrist flexion and elbow extension, decreased sensation over the middle finger, and decreased triceps reflex. These symptoms are most compatible with impingement on what spinal nerve root?

Explanation

DISCUSSION: Motor impulses to the triceps, wrist flexion and elbow extension, and sensation to the middle finger are associated most commonly with the C7 root.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Upper Saddle River, NJ, Prentice Hall, 1976, p 125.
Lauerman WC, Goldsmith ME: Spine, in Miller MD (ed): Review of Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2000, pp 353-378.

Question 37

What nerve is at greatest risk of harm from the portal shown in Figure 36?

Explanation

DISCUSSION: The figure shows the anterolateral portal for elbow arthroscopy, and injury to the radial nerve has been reported in conjunction with this portal site. Studies have shown that closer proximity to the radial nerve is associated with more distal portal sites. The lateral and posterior antebrachial cutaneous nerves are both at less risk of injury. The ulnar and median nerves are both fairly remote to this location.
REFERENCES: Field LD, Altchek DW, Warren RF, O’Brien SJ, Skyhar MJ, Wickiewicz TL: Arthroscopic anatomy of the lateral elbow: A comparison of three portals. Arthroscopy 1994;10:602-607.
Papilion JD, Neff RS, Shall LM: Compression neuropathy of the radial nerve as a complication of elbow arthroscopy: A case report and review of the literature. Arthroscopy 1988;4:284-286.
Poehling GG, Whipple TL, Sisco L, Goldman B: Elbow arthroscopy: A new technique. Arthroscopy 1989;5:222-224.

Question 38

A 29-year-old man reports severe knee instability and popliteal pain. History reveals that he had polio of the left lower extremity as a child and has been brace-free his entire life. Examination reveals that he walks with 40° of knee hyperextension and has a fixed ankle equinus deformity of 30° . He has no active motors about the knee or ankle. Which of the following methods will provide knee stability and pain relief?

Explanation

DISCUSSION: The ankle equinus allows the patient to keep his weight-bearing line anterior to the axis of the hyperextended knee joint. With time, pain has developed because of continued stretching and now incompetence of the posterior capsule of the knee joint. Several soft-tissue and bony procedures have been designed to provide knee stability in this situation; however, the results have been either short-lived or inconsistent. Tenodeses, capsular plications, and bony blocks have had limited success and generally fail over time. Current orthotic technology makes soft-tissue release and orthotic control the most predictable option. To decrease the hyperextension moment on the knee joint, the ankle deformity also must be corrected. The most predictable method of achieving stability and diminished pain during walking is with soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint.
REFERENCE: Michael JW: Lower limb orthoses, in Goldberg B, Hsu JD (eds): Atlas of Orthoses and Assistive Devices. St Louis, MO, Mosby, 1997, pp 209-224.

Question 39

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

Explanation

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

Question 40

In addition to pain, which of the following factors are considered most predictive of the risk of pathologic fracture?

Explanation

DISCUSSION: While guidelines for predicting fracture risk are at best imprecise, the scoring system by Mirels (pain, anatomic location, and pattern of bony destruction) has been shown to be most predictive of fracture risk. Functional pain, peritrochanteric location, and lytic bone destruction are the greatest risk factors for pathologic fracture. The factors of patient weight, age, soft-tissue mass, and location within bone are all of lesser importance.
REFERENCES: Frassica FJ, Frassica DA, McCarthy EF, Riley LH III: Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. Instr Course Lect 2000;49:453-459.
Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 1989;249:256-264.

Question 41

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Explanation

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.

High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 42

A 36-year-old woman is brought to the emergency department intubated and sedated following a motor vehicle accident. She is moving her upper and lower extremities spontaneously. She cannot follow commands. CT scans are shown in Figures 7a through 7c. The initial survey does not reveal any other injuries. Initial management of the cervical injury should consist of immediate

Explanation

DISCUSSION: The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.
Kwon BK, Vaccaro AR, Grauer JN, et al: Subaxial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78-89.

Question 43

An active 65-year-old man has pain in the left shoulder 5 years after undergoing a hemiarthroplasty. He has a remote history of two previous instability operations. Examination reveals that forward elevation is 140 degrees and external rotation is 40 degrees. Serologic studies for infection are negative. AP and axillary radiographs are shown in Figures 7a and 7b. What surgical procedure will provide the most predictable pain relief and function? Review Topic

Explanation

The radiographs show glenoid arthrosis, which is common after a hemiarthroplasty. Conversion to a conventional total shoulder arthroplasty with placement of a glenoid component predictably decreases pain and improves function. There is no indication for a reverse total shoulder arthroplasty because the patient has 140 degrees of elevation with an intact rotator cuff. Biologic resurfacing has more unpredictable results and is usually reserved for younger patients in whom a prosthetic glenoid component might not be desired. Both resection arthroplasty and arthrodesis are associated with poor function.

Question 44

A skeletally mature 15-year-old girl who was thrown from the car in a rollover accident sustained the injuries shown in Figures 23a through 23d. Examination reveals no neurologic deficit, but the patient has moderate posterior spinal tenderness at the level of the injury. What is the most appropriate treatment?

Explanation

DISCUSSION: The majority of patients with thoracolumbar burst fractures without neurologic deficit can be effectively treated with a TLSO or a hyperextension body cast. Indications for surgery are neurologic deficit and/or significant deformity (greater than 50% loss of anterior vertebral body height or marked kyphosis).
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 197-217.
Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH: Functional outcome of thoracolumbar burst fractures managed with hyperextension casting or bracing and early mobilization. Spine 1996;21:2170-2175.

Question 45

What is the most common presenting sign or symptom in an adult with lumbar pyogenic infection?

Explanation

DISCUSSION: Pain is very common but is often nonspecific; therefore, the diagnosis of spinal infection is often delayed. Fever and sepsis can occur but are not common. Neurologic manifestations also can occur but are absent in most patients. In findings reported by Carragee, the urinary tract is a common source for hematogenous spinal infection, but the source was found in only 27% of 111 patients. Direct inoculation during spinal surgery is uncommon.
REFERENCES: Carragee EJ: Pyogenic vertebral osteomyelitis. J Bone Joint Surg Am 1997;79:874-880.
Frazier DD, Campbell DR, Garvey TA, et al: Fungal infections of the spine: Report of eleven patients with long-term follow-up. J Bone Joint Surg Am 2001;83:560-565.
Hadjipavlou AG, Mader JT, Necessary JT, et al: Hematogenous pyogenic spinal infections and their surgical management. Spine 2000;25:1668-1679.

Question 46

A 52-year-old man sustained the left elbow injury shown in Figure A while playing basketball 2.5 months ago. He underwent the procedure shown in Figure B. Post-operatively he was mobilized in a hinged brace. On examination today, his arc of elbow flexion is 75 degrees with loss of 45 degrees of full extension. His Disabilities of the Arm, Shoulder and Hand (DASH) Outcome Measure score is 45 points. What initial treatment option will likely provide the greatest improvement in this patients DASH score and functional range of motion? Review Topic

Explanation

The clinical presentation is consistent with post-traumatic elbow stiffness following an elbow fracture-dislocation. Supervised exercise therapy with static elbow splinting over a 6 month period has shown to have a significant improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.
Post-traumatic elbow stiffness is often difficult to manage. The ultimate goal of treatment is to restore a functional range of elbow motion (30° to 130°). Nonoperative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static progressive elbow splinting with a turnbuckle, alongside aggressive physical therapy, has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
Doornberg et al. looked at a retrospective case series of 29 patients with posttraumatic elbow stiffness. They showed that static progressive splinting can help gain additional motion when standard exercises fail to produce additional improvements.
Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12 month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.
Figure A shows a posterior elbow dislocation with an associated medial epicondyle fracture. Figure B shows ORIF of the fracture seen in Figure A. Illustration A shows a static progressive turnbuckle elbow splint used for post-traumatic elbow stiffness.
Incorrect Answers:

Question 47

A 22-year-old man who plays recreational soccer (Figure 41)

Explanation

Question 48

A 68-year-old woman with serologically proven rheumatoid arthritis underwent an open synovectomy and radial head resection 10 years ago. She now has severe pain that has failed to respond to nonsurgical management. Examination reveals a flexion arc of greater than 90 degrees. Radiographs are shown in Figures 15a and 15b. What is the most appropriate management?

Explanation

DISCUSSION: The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states.
REFERENCES: Whaley A, Morrey BF, Adams R: Total elbow arthroplasty after previous resection of the radial head and synovectomy. J Bone Joint Surg Br 2005;87:47-53.
Maenpaa HM, Kuusela PP, Kaarela KK, et al: Reoperation rate after elbow synovectomy in rheumatoid arthritis. J Shoulder Elbow Surg 2003;12:480-483.
Schemitsch EH, Ewald FC, Thornhill TS: Results of total elbow arthroplasty after excision of the radial head and synovectomy in patients who had rheumatoid arthritis. J Bone Joint Surg Am 1996;78:1541-1547.

Question 49

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 50

A 29-year-old woman reports dysesthesias and burning after undergoing bunion surgery that consisted of a proximal crescentic first metatarsal osteotomy 6 months ago. Examination reveals a positive Tinel’s sign at the proximal aspect of the healed incision. What injured nerve is responsible for her continued symptoms?

Explanation

DISCUSSION: Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.
REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 51

Figure 21 shows the AP radiograph of a 41-year-old patient who sustained a closed bicolumnar fracture of the distal humerus that resulted in a painful nonunion. What is the best initial construct for rigid stabilization of this fracture pattern?

Explanation

DISCUSSION: The dual plate fixation construct is significantly stronger than single plate or “Y” plate fixation. Two-plate constructs at right angles, the ulnar plate medially and the lateral plate posteriorly, would appear to be biomechanically optimal. This approach usually is feasible at the time of surgery. Clinically, dual 3.5-mm reconstruction or dynamic compression plates are superior to one third tubular plate fixation. Supplementary external fixation is not considered a better treatment option. Failure of fixation and nonunion are often the result of inadequate fixation and osteoporosis.
REFERENCES: Helfet DL, Hotchkiss RN: Internal fixation of the distal humerus: A biomechanical comparison of methods. J Orthop Trauma 1990;4:260-264.
Sodergard J, Sandelin J, Bostman O: Mechanical failures of internal fixation in T and Y fractures of the distal humerus. J Trauma 1992;33:687-690.

Question 52

A 30-year-old firefighter sustained a longitudinal pulling injury to the arm while attempting to move a heavy object during a fire. Figure 45 shows an MRI scan of the elbow. Initial management should consist of

Explanation

DISCUSSION: Because the MRI scan shows a complete rupture of the distal biceps tendon, the preferred treatment is anatomic repair of the tendon to the radial tuberosity either with the use of suture anchors or transosseous sutures through a two-incision technique. Several studies have documented superior results with anatomic repair of the distal biceps tendon when compared with results of nonsurgical management or repair of the tendon by attachment to the brachialis muscle. Patients undergoing anatomic repair of the distal biceps tendon through a two-incision technique typically regain a functional range of motion and nearly normal strength.
REFERENCES: D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW: Repair of distal biceps tendon ruptures in athletes. Am J Sports Med 1993;21:114-119.
Boyd JB, Anderson LD: A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg Am 1961;43:1041-1043.
Morrey BF, Askew LJ, An KN, Dobyns JH: Rupture of the distal tendon of the biceps brachii: A biomechanical study. J Bone Joint Surg Am 1985;67:418-421.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 53

A right-hand-dominant 45-year-old man sustains an injury to the anterior aspect of his right elbow while trying to lift a heavy load 3 days ago. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made and surgical treatment is chosen. The anatomic relationship of the distal biceps tendon to the median nerve and recurrent radial artery within the antecubital fossa is such that the biceps tendon travels

Explanation

During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on
the radial tuberosity.

Question 54

A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

Explanation

The most commonly seen deformity in subtrochanteric femur fractures is abduction and flexion of the proximal fragment. Subtrochanteric fractures can pose challenges in reduction because of the muscle attachments proximal and distal to the fragment. The gluteus medius and gluteus minimus attach to the greater trochanter and abduct the proximal fragment. The iliopsoas attaches to the lesser trochanter, flexing and externally rotating the proximal fragment. The short external rotators (piriformis, superior and inferior gamellus) and the obturator internus also cause external rotation of the proximal fragment.

Question 55

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Explanation

DISCUSSION: All of the answers are possible complications of meniscal repair. There are large volumes of literature evaluating the results of meniscal repair, both for the all-inside technique, as well as the inside-out technique. Failure rates are similar. Intra-articular synovitis occurs with absorbable sutures and absorbable implants. Peroneal nerve injuries are more common with the lateral-sided repairs. Saphenous nerve injuries are more common with medial-sided tears. Because of the incision required and the technique of tying over soft tissue, the risk of a saphenous nerve injury is greater with an inside-out technique than with an all-inside technique.
REFERENCES: Farng E, Sherman O: Meniscal repair devices: A clinical and biomechanical literature review. Arthroscopy 2004;20:273-286.
Jones HP, Lemos MJ, Wilk RM, et al: Two-year follow-up of meniscal repair using a bioabsorbable arrow. Arthroscopy 2002;18:64-69.

Question 56

A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?

Explanation

DISCUSSION: Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon’s canal must be protected during the surgical approach.
REFERENCES: Kulund DN, McCue FC III, Rockwell DA, et al: Tennis injuries: Prevention and treatment: A review. Am J Sports Med 1979;7:249-253.
Morgan WJ, Slowman LS: Acute hand and wrist injuries in athletes: Evaluation and management. J Am Acad Orthop Surg 2001;9:389-400.

Question 57

A 71-year-old woman reports the insidious onset of shoulder pain at night and when moving her shoulder. She cannot raise her arm above shoulder level. Physical therapy has failed to provide pain relief or improve function. An injection relieved her pain in the office, but she could not raise her arm above shoulder level. A radiograph is shown in Figure 21. What surgical procedure will provide the best chance of restoring above shoulder function and pain relief? Review Topic

Explanation

The radiograph shows complete loss of the acromiohumeral space. The glenohumeral joint space is also severely narrowed, which is consistent with rotator cuff tear arthropathy. In patients who have pain that limits elevation, pain-reducing procedures such as biceps tenolysis, open debridement, or hemiarthroplasty may allow the patient to regain the shoulder function. If the patient cannot elevate the arm after a successful local anesthetic injection, then pain is not the reason for the patient's loss of elevation. In this situation, a reverse total shoulder arthroplasty will most reliably restore function and provide pain relief.

Question 58

Figures 38a and 38b

Explanation

DISCUSSION
Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.
RECOMMENDED READINGS
Schepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013 Sep;37(9):1833-8. PubMed PMID: 23959223. View Abstract at PubMed
Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516. View Abstract at PubMed
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165. View Abstract at PubMed
Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511. View Abstract at PubMed

Question 59

A 24-year-old professional basketball player reports the gradual onset of pain that is poorly localized to the left midfoot for the past 2 months. Examination reveals diffuse tenderness to palpation, full range of motion of the ankle and subtalar joint, and a normal neurovascular examination to the foot. An AP radiograph is shown in Figure 10. Definitive treatment should include

Explanation

DISCUSSION: The imaging studies reveal a navicular stress fracture. This condition is secondary to chronic overuse (often running on hard surfaces) and results in vague, ill-defined pain in the midfoot. These fractures can be missed on radiographs but are well-defined on CT or MRI. Tarsal navicular fractures are typically oriented in the sagittal plane. Surgery is typically indicated for the high-level athlete because of the high risk for nonunion and persistent symptoms following nonsurgical management. Internal fixation is the treatment of choice.
REFERENCES: Torg JS, Pavlov H, Cooley JH, et al: Stress fractures of the tarsal navicular.
J Bone Joint Surg Am 1982;64:700-712.
Brodsky JW, Krause JO: Stress fractures of the foot and ankle, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2391-2409.

Question 60

Figures 1 through 5 are the MR images of a 12-year-old boy with left lateral-sided knee pain following a football injury. He has a several-year history of recurrent knee pain that improves with rest. An examination reveals a moderate effusion. Range of motion is 0° to 90° and is limited by pain in deep flexion. He has tenderness to palpation along the lateral joint line, and no instability is noted. What other finding may be noted in patients with this diagnosis?

Explanation

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral
discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatment of a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

Question 61

A 35-year-old woman is involved in a head-on collision while driving. Initial radiographs are shown in Figures 8a and 8b. Injury to what vessel increases the risk for osteonecrosis of the injured bone?

Explanation

The patient has a Hawkins type III talar neck fracture-dislocation with a risk of osteonecrosis ranging from 69% to 100%. Anatomic studies have shown that the artery of the tarsal canal supplies the lateral two thirds of the talar body. The other vessels listed provide no significant contribution to the talus.

Question 62

A 60-year-old woman reports a painful hip arthroplasty after undergoing surgery 18 months ago. Radiographs show stable cementless implants without signs of ingrowth. Laboratory studies show an erythrocyte sedimentation rate of 50 mm/h. Management should now consist of

Explanation

DISCUSSION: Significant elevation of the erythrocyte sedimentation rate in a patient with a painful hip arthroplasty mandates a complete work-up for infection prior to considering revision surgery. Reproducibility and reliability of ultrasonography as a diagnostic test still needs clarification. Aspiration is the easiest and most cost-effective test and should be performed prior to nuclear imaging. The latter is most valuable if the results are negative, strongly predicting the absence of infection.
REFERENCES: Barrack RL, Harris WH: The value of aspiration of the hip joint before revision total hip arthroplasty. J Bone Joint Surg Am 1993;75:66-76.
McAuley JP, Moreau G: Sepsis: Etiology, prophylaxis, and diagnosis, in Callaghan JJ, Rosenberg AG, Rubash HE (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 1295-1306.

Question 63

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 64

What are the four most common soft-tissue sarcomas to spread via the lymph node system?

Explanation

DISCUSSION: Soft-tissue sarcomas most frequently metastasize to the lung, but certain histologic types have a predilection for the lymph node system as well. Rhabdomyosarcoma, clear cell sarcoma, epithelioid sarcoma, and synovial sarcoma are four of the most common types to spread in this fashion. Careful evaluation and/or sentinel lymph node biopsy plays a role in disease staging and prognosis.
REFERENCES: Riad S, Griffin AM, Liberman B, et al: Lymph node metastasis in soft-tissue sarcoma in an extremity. Clin Orthop Relat Res 2004;426:129-134.
Blazer DG III, Sabel MS, Sondak VK: Is there a role for sentinel lymph node biopsy in the management of sarcoma? Surg Oncol 2003;12:201-206.

Question 65

Which of the following statements best describes synovial fluid?

Explanation

DISCUSSION: Synovial tissue is composed of vascularized connective tissue that lacks a basement membrane. Two cell types (type A and type B) are present: type B cells produce synovial fluid. Synovial fluid is made of hyaluronic acid and lubricin, proteinases,and collagenases. It is an ultrafiltrate of blood plasma added to fluid produced by the synovial membrane. It does not contain erythrocytes, clotting factors, or hemoglobin. It lubricates articular cartilage and provides nourishment via diffusion. Synovial fluid exhibits non-Newtonian flow characteristics. The viscosity coefficient is not a constant, the fluid is not linearly viscous, and its viscosity increases as the shear rate decreases.
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 443-470.

Question 66

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

Explanation

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

Question 67

A 45-year-old man who has had recurrent pain and swelling of the left Achilles tendon insertion for the past 10 years reports that physical therapy and activity modification have provided relief in the past. He now has continued pain despite these efforts. He also reports occasional bouts of dysuria that he attributes to a history of prostatitis. He also notes recent eye irritation that he attributes to allergies. A lateral heel radiograph is shown in Figure 33. Which of the following laboratory studies would best aid in diagnosis?

Explanation

DISCUSSION: Reiter’s syndrome is a seronegative spondyloarthropathy characterized most commonly by a triad of asymmetric arthritis, urethritis, and uveitis. Tendon ensethopathies can also be present. It is most often seen in men and is associated with a positive HLA-B27 marker. Rheumatoid arthritis does not usually present with these features; more commonly it causes forefoot pain and synovitis of the metatarsophalangeal joints. A CBC count with differential would be helpful in a situation of possible infection. The urethral swab would help to diagnose a gonococcal infection which can cause a monoarticular septic arthritis. Antiphospholipid antibody is associated with a hypercoaguable state and increased risk of deep venous thrombosis.
REFERENCE: Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, vol 1, pp 560-650.

Question 68

A 28-year-old professional football player reports painless loss of ankle motion after sustaining a “severe” ankle sprain 12 months ago. A mortise radiograph is shown in Figure 1. Surgical treatment should be reserved for which of the following conditions?

Explanation

DISCUSSION: The radiograph shows posttraumatic tibiofibular synostosis. This condition typically follows an eversion (high) ankle sprain that results in disruption of the interosseous membrane. Ossification usually develops within 6 to 12 months after the injury. Return to sports is possible despite the lack of normal ankle dorsiflexion and mobility between the tibia and fibula. Surgical excision is reserved for persistent pain that fails to respond to nonsurgical management once the ossification is “cold” on bone scintigraphy.
REFERENCES: Whiteside LA, Reynolds FC, Ellsasser JC: Tibiofibular synostosis and recurrent ankle sprains in high performance athletes. Am J Sports Med 1978;6:204-208.
Henry JH, Andersen AJ, Cothren CC: Tibiofibular synostosis in professional basketball players. Am J Sports Med 1993;21:619-622.
Andrish J: The leg, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2155-2181.

Question 69

What is the most common neurologic problem associated with a simple shoulder dislocation? Review Topic

Explanation

The most common nerve injury associated with dislocation of the shoulder involves the axillary nerve. This is typically a stretch injury, or neurapraxia, that occurs with anterior displacement of the humeral head out of the glenoid. The suspected diagnosis can be confirmed with neurodiagnostic testing after the first 2 to 3 weeks. A gradual return to normal function is the expected result, though mild deficits may remain. A neurotmetic injury, in which there is complete disruption of the entire nerve, would show no return of function. This type of injury is more likely associated with a penetrating injury, a laceration secondary to a fracture fragment, or occasionally with a direct blow of sufficient force.

Question 70

A 3-year-old girl developed torticollis eight months ago after a severe respiratory tract infection. A initial trial of halter traction was attempted without success. A trial of halo traction was then performed for 3 weeks and then a dynamic computed tomographic (CT) was obtained and shown in Figure A. Panel (a) shows an axial image with maximal rotation to the left. Panel (b) shows an axial image with maximal rotation to the right. What is the most appropriate next step in management? Review Topic

Explanation

Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 71

The quadrilateral space in the shoulder contains which of the following structures?

Explanation

DISCUSSION: The quadrilateral or quadrangular space of the shoulder is formed laterally by the humerus, proximally by the subscapularis (and teres minor viewed from posterior), distally by the teres major, and medially by the long head of triceps. The posterior humeral circumflex artery and axillary nerve pass through it. The axillary artery is more proximal. The radial nerve and profunda brachii pass through a triangular space more inferior. The circumflex scapular artery passes through a triangular space more medial.
REFERENCES: Hollinshead WH: Textbook of Anatomy, ed 3. Hagerstown, MD, Harper and Row, 1974, pp 205-206.
Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 61-62.

Question 72

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

Explanation

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

Question 73

Six weeks after open reduction internal fixation of a closed tibial pilon fracture, a patient has a draining wound with surrounding erythema and swelling. Radiographs show lucency around screws. What is the most appropriate treatment sequence?

Explanation

Discussion: Management of acutely infected wounds is primarily surgical. Osteomyelitis frequently involves Orthopaedic hardware, which would ideally be removed or replaced given biofilm involvement. Multiple operative cultures of fluid collections, soft tissues and bone should routinely be obtained. Culture yield is highest if cultures are obtained before empiric antibiotic treatment is started. Tissue samples are greatly preferred to swabs, which are notoriously inaccurate.

Question 74

The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Explanation

Figure 50A: AP pelvis with a 1 cm lucency in the calcar region of the femoral neck and diffuse osteopenia of the proximal femur. Figure 50B: CT scan of the same patient showing a well demarcated lcm lesion in the femoral neck with an obvious nidus. Careful evaluation of the radiographs is critical in this question. First the obvious osteoid osteoma must be recognized. From there answers 2 and 3 can be eliminated. Neither radiograph reveals any sign that treatment has occurred, and the CT scan shows no signs of extensive involvement, thus answer 5 should also be eliminated. The real key is believing that such diffuse osteoporosis could occur in such a young child, as Jones described in his article from 1969.

Question 75

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

Explanation

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

Question 76

When using surgery extending to the pelvis to treat long spinal deformity in adults, the addition of anterior interbody structural support at the lumbosacral junction serves what biomechanical function?

Explanation

DISCUSSION: Shufflebarger and others have reported that the placement of anterior interbody structural support at the lumbosacral junction increases the overall construct stiffness and reduces the strain on posterior instrumentation, thereby reducing the risk of screw pull-out or fracture. The stiffness of the posterior instrumentation actually increases, whereas the actual strength of the instrumentation remains the same. Actual strain measured at an adjacent intervertebral disk to a fusion construct is expected to increase.
REFERENCES: Shufflebarger HL: Moss-Miami spinal instrumentation system: Methods of fixation of the spondylopelvic junction, in Margulies JI, Floman Y, Farcy JPC, et al (eds): Lumbosacral and Spinal Pelvic Fixation. Philadelphia, PA, Lippincott-Raven, 1996, pp 381-393.
Cunningham BW: A biomechanical approach to posterior spinal instrumentation: principles and applications, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 588-600.
Kostuik JP, Valdevit A, Chang HG, et al: Biomechanical testing of the lumbosacral spine. Spine 1998;23:1721-1728.

Question 77

Two years ago, a 63-year-old man underwent right total hip arthroplasty (THA) with a modular femoral head-neck and neck-stem prosthesis (a photograph of the removed implant is shown in Figure 181). He now has increasing hip pain. Radiographs reveal a stable hip arthroplasty and elevated serum cobalt and chromium levels. MR imaging is obtained, and, based on these findings, the patient’s hip is revised. Which corrosion type likely is responsible for this THA failure?

Explanation

DISCUSSION
Micromotion at the femoral head-neck or stem-neck junction can lead to fretting corrosion. Fretting corrosion is among the most common causes of failure in modular components. Modularity gives surgeons additional intraoperative flexibility but has resulted in corrosion-related failure and an implant recall. Although titanium and cobalt-chrome contain a protective surface oxide layer, continued micromotion at the modular junction may disrupt the protective layer, resulting in fretting corrosion. This may eventually lead to excessive metal ion formation and painful synovitis that necessitates a revision procedure. Galvanic corrosion is attributable to a mismatch in electrochemical gradients between dissimilar metals. Crevice or pitting corrosion occurs in fatigue cracks because of differences in oxygen tension.

Question 78

Kinematic testing of patellofemoral motion demonstrates that malalignment that produces increased Q angle causes a shift of the patella laterally in the trochlear groove and is most pronounced during what phase of the flexion arc? Review Topic

Explanation

Dynamic patellofemoral joint contact measurements on cadaveric knees with simulated increased Q angle demonstrated that forces shifted to the lateral facet. The lateral shift in the patella was most pronounced from 40 to 90 degrees of flexion. At lower degrees of flexion, the lateral shift was significantly less. At higher degrees of flexion, the continued shift of the patella was not as pronounced.

Question 79

A 28-year-old woman sustained an injury to her dominant right arm after falling off her porch. Examination reveals a deformity at the elbow. She is neurovascularly intact. Figures 46a and 46b show the radiographs obtained before closed reduction, and postreduction radiographs are shown in Figure 46c and 46d. What is the most likely early complication?

Explanation

DISCUSSION: The patient has a complex fracture-dislocation of the elbow. The radial head is fractured, and there is a displaced coronoid fracture. These associated fractures indicate that the elbow is at high risk for recurrent instability after initial treatment. To prevent this complication, surgical treatment will most likely be required and will consist of some or all of the following: radial head open reduction and internal fixation or replacement, coronoid open reduction and internal fixation, medial and lateral ligament repairs, and even articulated external fixation. This patient was treated with open reduction and internal fixation of the radial head, and the elbow redislocated postoperatively.
REFERENCES: Ring D, Jupiter JB: Reconstruction of posttraumatic elbow instability. Clin Orthop 2000;370:44-56.
O’Driscoll SW: Classification and evaluation of recurrent instability of the elbow. Clin Orthop 2000;370:34-43.
O’Driscoll SW, Morrey BF, Korinek S, An KN: Elbow subluxation and dislocation. Clin Orthop 1992;280:186-197.

Question 80

A 20-year-old college baseball pitcher reports the insidious onset of medial elbow pain. Examination reveals medial elbow tenderness, a normal neurologic examination, and no obvious valgus laxity. Plain radiographs are normal. MRI scans are shown in Figures 39a and 39b. Management should consist of

Explanation

DISCUSSION: Throwers and in particular, pitchers, are prone to high valgus loads to the elbow. A constellation of medial elbow pathology can develop, including medial epicondylitis, ulnar nerve neuritis, medial ulnar collateral ligament injuries, and posteromedial osteophytes of the olecranon. The MRI scans show significant increases in signal intensing as well as fiber disruption of the medial collateral ligament, indicating a complete tear. The common flexor origin shows a homogeneous signal and normal morphology. Therefore, excision of posterior osteophytes and debridement of the common flexor origin are not indicated. Likewise, this patient’s symptoms do not indicate ulnar nerve pathology; therefore ulnar nerve transposition is not indicated. Primary repair of medial collateral ligament tears of the elbow lead to unpredictable results with an unacceptable rate of reoperation. The most predictable result in treating this high-demand athlete is reconstruction of the medial collateral ligament with autogenous tissue.
REFERENCES: Norris TR (ed): Athletic Injuries of the Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 311-323.
Hyman J, Breazeale NM, Altchek DW: Valgus instability of the elbow in athletes. Clin Sports Med 2001;20:11-24.

Question 81

A 40-year-old male patient sustains a bimalleolar ankle fracture and undergoes open reduction and internal fixation. Four months later, he returns for follow-up with mild ankle discomfort, and a radiograph is shown in Figure A. What is the most appropriate next step in treatment?

Explanation

This patient has undergone ORIF of the lateral malleolus with shortening of the lateral malleolus and lateral tibiotalar tilt. Revision surgery would entail bone grafting and re-plating of the fibula.
Malunion of the fibula component of ankle fractures lead to tibiotalar instability and post-traumatic ankle arthritis. The distal fragment is usually shortened and externally rotated. The osteotomy can restore length and correct rotation. Markers for potential instability include: (1) asymmetry of the medial-lateral clear spaces, (2) talar tilt
>2mm, (3) talar subluxation, (4) abnormal talocrural angle (normal, 75-86deg).
Chu et al. opined that reconstruction for distal fibula malunions should include: (1) osteotomy, (2) +/- syndesmotic fixation and (3) autologous bone graft. They recommend: (1) low oblique osteotomy for fractures below the syndesmosis, (2) transverse osteotomy above the syndesmosis for high fractures (PER4) and low fractures with tibiofibular instability, (3) inspection of the tibiofibular joint through an anterolateral window to ensure anatomic reduction.
Weber et al. described a method of corrective lengthening osteotomy of the fibula in 23 cases. They described 3 criteria for assessing normal fibular length. Seventeen patients had good-excellent results, and 6 had fair-poor results (1 of these 6 needed ankle fusion).
Figure A is an AP radiograph of a distal fibula fracture fixed in a shortened position with lateral talar tilt and degenerative changes at the anterolateral tibiotalar joint. Illustration A is an anteroposterior radiograph after fibular osteotomy and correction
with medial distal tibial autograft to correct talar tilt and restore anatomic fibular length. Illustration B shows the normal talocrural angle. Illustration C shows the Weber-Simpson method of fibula lengthening used in Illustration A.
Incorrect Answers:

Question 82

Figure 53 shows the pedigree of a family with an unusual type of muscular dystrophy. This pedigree is most consistent with what type of inheritance pattern?

Explanation

DISCUSSION: The pedigree documents involvement of male offspring only, and it also shows transmission through an uninvolved female carrier. This inheritance pattern is most consistent with a x-linked recessive inheritance. It would be inconsistent with a dominant inheritance pattern unless there was incomplete penetrance. Autosomal-recessive inheritance would be possible only if the family member labeled II.F was also a carrier of the same gene; however, this is unlikely. Mitochondrial inheritance is possible, but as with autosomal patterns, mitochondrial inheritance normally affects both male and female offspring. It is transmitted only through the maternal line.
REFERENCE: Gelehrter TD, Collins FS: Principles of Medical Genetics. Baltimore, Md, Williams & Wilkins, 1990, pp 27-45.

Question 83

Which of the following best describes the use of epidural morphine and steroid paste after laminectomy?

Explanation

DISCUSSION: Kramer and associates conducted a retrospective review during an “epidemic” period to identify the risk factors associated with a sudden increase in the rate of surgical site infections. They found in a multivariate analysis that the use of morphine nerve paste resulted in a 7.6-fold increase in postoperative surgical wound debridement, and an 11% rate of surgical site complications.
REFERENCES: Kramer MH, Mangram AJ, Pearson ML, et al: Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy. Infect Control Hosp Epidemiol 1999;20:183-186.
Lowell TD, Errico TJ, Eskenazi MS: Use of steroids after discectomy may predispose to infection. Spine 2000;25:516-519.

Question 84

The injury seen in the CT scan shown in Figure 56 is related to or associated with injury to which of the following structures?

Explanation

DISCUSSION: The right syndesmosis appears disrupted on the CT scan when compared to the normal left side. CT can be helpful in determining injury to the syndesmosis, especially with occult clinical findings.
REFERENCES: Ebraheim NA, Lu J, Yang H, et al: The fibular incisure of the tibia on CT scan: A cadaver study. Foot Ankle Int 1998;19:318-321.
Ebraheim NA, Lu J, Yang H, et al: Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: A cadaver study. Foot Ankle Int 1997;18:693-698.
Harper MC: Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18.

Question 85

A 29-year-old woman is seen in the emergency department with a 24-hour history of severe back and leg pain precipitated by weight-lifting. The patient reports bilateral leg pain and is unable to urinate. She has dense anesthesia in the perineal region on examination. A MRI scan is shown in Figure 38. The patient is taken to surgery urgently. What is her prognosis for recovery? Review Topic

Explanation

The patient with cauda equina syndrome should be taken to surgery urgently to provide the best chance of symptom resolution. However, many studies indicate that patients with cauda equina syndrome do not return to a completely normal status even following urgent surgery. Whereas pain is typically relieved after surgery, other deficits, especially bladder and sexual dysfunction, may persist. Particularly in light of the patient's severe saddle anesthesia, she may have a poor prognosis for recovery of normal bladder function.

Question 86

When planning scoliosis surgery for a patient with a 50-degree thoracolumbar curve and spinal muscular atrophy, it is most important to include

Explanation

DISCUSSION: Typically, posterior spinal fusion to the pelvis is recommended for patients with spinal muscular atrophy and advanced scoliosis. Examination for lower extremity muscle contractures is important because the contractures may interfere with good sitting balance. Anterior release and fusion usually are not advised. Diaphragmatic pacing is not indicated because diaphragm function usually is not affected. Patients with spinal muscular atrophy usually are not ambulatory or only marginally ambulatory at the time of scoliosis surgery; therefore, gait analysis usually is not relevant. While a muscle biopsy may have a role in the diagnosis of this disorder, it plays no subsequent role in determining life expectancy or the value of spinal surgery.
REFERENCES: Daher YH, Lonstein JE, Winter RB, Bradford DS: Spinal surgery in spinal muscular atrophy. J Pediatr Orthop 1985;5:391-395.
Aprin H, Bowen JR, MacEwen GD, et al: Spinal arthrodesis in patients with spinal muscle atrophy. J Bone Joint Surg Am 1982;64:1179-1187.

Question 87

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

Explanation

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

Question 88

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

Explanation

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

Question 89

A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. During fluoroscopic-aided fixation, a lateral sacral view is required for proper placement of which of the following fixation methods?

Explanation

DISCUSSION: The lateral sacral view is used to place percutaneous iliosacral screws. Sacral alar morphology has been shown to be variable from patient to patient. Therefore, intraoperative fluoroscopy is recommended. During placement of the screws, the L5 nerve root is at risk.
Routt et al (1997) examined the sacral slope and sacral alar anatomy in cadavers and a series of patients. They determined that the pelvic outlet and lateral sacral plain films provide the best plain radiographic view of the sacral ala. They recommended routine usage of these views intraoperatively to guide screw placement.
Routt et al (2000) reported on the early complications of percutaneous placement of iliosacral screws for treatment of posterior pelvic ring disruptions. While technically challenging, this technique leads to less blood loss and lower rates of infection compared to traditional open techniques.
Barei et al described methods of anterior and posterior pelvic ring disruptions. They determined that successful placement depends on accurate closed reduction, excellent intraoperative fluoroscopic imaging, and detailed preoperative planning. Early treatment decreased hemorrhage, provides patient comfort, and allows early mobilization.

Question 90

Which of the following anatomic structures are in contact with internal impingement in the throwing athlete?

Explanation

DISCUSSION: Internal impingement occurs in the late cocking phase of throwing with humeral head abduction and maximal external rotation. It is a physiologic phenomenon occurring in
85% of patients undergoing arthroscopy for various indications in one study. Internal impingement is defined as impingement of the posterior-superior rotator cuff between the humerus and posterior-superior glenoid rim. Symptomatic internal impingement is felt to be due to the frequency and magnitude of the impingement in throwers.
REFERENCES: Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 252.
Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the overhand throwing athlete: Evidence for posterior internal impingement of the rotator cuff. Arthroscopy 2000;16:35-40.

Question 91

A 6 year-old-boy falls from his bunk bed and suffers the injury seen in Figures A and B. Upon presentation to the emergency room he is noted to have a pink hand with brisk capillary refill, but no palpable pulses. After closed reduction in the operating room and the procedure seen in Figures C and D, he remains well perfused, pulses are still not palpable, but triphasic pulses can be heard on doppler examination. What is the most appropriate course of action? Review Topic

Explanation

A "pink pulseless" hand, especially those with strong triphasic doppler signals can be treated with observation. In the presented case it would be appropriate to place long arm immobilization (cast or splint) and observe.
Pediatric supracondylar humerus fractures presenting with vascular compromise can present a challenge for clinical decision making. If the hand lacks adequate perfusion on presentation it requires emergent treatment with closed reduction and pinning. If perfusion does not return, then surgical exploration of the antecubital fossa is required. Treatment of the "pink pulseless hand" remains controversial. If the hand is well perfused but lacks palpable pulses then it should be expeditiously reduced and pinned. If the hand remains well perfused with triphasic doppler signals, no additional intervention is required. Recommendations vary if the hand is perfused, and pulses cannot be detected on palpation or doppler.
If there is a normal neurovascular exam on presentation, but abnormal after reduction and pinning, then one must consider that the reduction may have entrapped the brachial artery. If hardware removal and fracture re-displacement does not improve pulses/perfusion of the hand, or if the fracture can not be reduced without diminishing perfusion, then open reduction is indicated to evaluate the brachial artery.
Shah et al. present their preferred algorithm for treatment of a pink pulseless hand. They note that even with good clinical perfusion there may be a vascular injury or entrapment of the brachial artery. Thus they recommend if the hand is pink with no palpable pulse, perform a doppler exam. Triphasic doppler signals allow for observation, while abnormal or non-detectable doppler signals require surgical exploration. If an AIN or median nerve injury is present, exploration is considered. A diagram of their algorithm can be seen in Illustration A.
Weller et al. present a retrospective review of 1297 supracondylar humerus fractures. They had 20 patients (1.5%) with a pink pulseless hand with good doppler signals following closed reduction and fixation. These patients were treated with close observation. One patient developed inadequate perfusion nine hours after reduction and required vascular repair. The remaining 19 patients regained palpable pulses prior to discharge or prior to the first follow-up visit. They recommend observation despite non-palpable pulses as long as other signs of perfusion (capillary refill and doppler signals) suggest the hand is well perfused.
Figures A and B are AP and lateral radiographs of a type III supracondylar humerus fracture. Figures B and C demonstrate this fracture following closed reduction and percutaneous pinning with three lateral pins. Illustration A is a flow chart of a proposed decision making algorithm for a pink pulseless hand as presented by Shah et al.
Incorrect Answers:
reduction and fixation. Answer 2- Changing the pattern of fixation would only be indicated if the current construct did not provide stable fixation of the fracture. Answer 3- Following reduction and fixation of a supracondylar humerus fracture the most appropriate dressing is rigid long arm immobilization in a splint or cast. If there is concern for edema or perfusion then a cast should be bivalved. Answer 5- Surgical exploration of the antecubital fossa would be indicated if the hand had inadequate perfusion, or if the fracture could not be reduced and fixed without causing a notable decrease in pulses or perfusion.

Question 92

A 21-year-old woman is struck by a car and sustains a Gustillo IIIB fracture of the tibia. The wound was debrided and immobilized with an external fixator. Radiographs are shown in Figure A. The soft tissue defect was covered with a free flap. Her recovery was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli. One month after her injury, she underwent intramedullary nailing and placement of an antibiotic spacer measuring 15cm in length. Radiographs are shown in Figure B. At the next stage of surgery 6 weeks later, the surgeon should plan to do all of the following:

Explanation

The second stage of the Masquelet technique requires removal of the cement bolus, incision into the induced membranes and bone grafting. The existing hardware is preserved where possible as the fracture is still not stable. Bone graft is inserted INTO the membranous cavity, AROUND the nail.
The Masquelet staged technique of induced membranes is an option for filling large bone defects up to 25cm in length. This technique protects against autograft resorption, stimulates mesenchymal cell-to-osteoblast differentiation, maintains graft position, and prevents soft tissue interposition. Cement impregnation achieves high local antibiotic concentration without risk of systemic toxicity.
Ashman et al. discussed the techniques of addressing bone defects. Options include:
(1) acute limb shortening (up to 4cm in the tibia and humerus, and 7cm in the femur);
(2) distraction osteogenesis for defects up to 10cm long (at 1mm/day with consolidation period of 5days per mm, or total treatment time of up to 60days/cm), (3) autograft (up to 25cm of vascularized fibula, or 3cm of nonvascularized iliac crest),
and (4) Masquelet technique.
Taylor et al. reviewed the induced membranes technique. They found that the membrane is well vascularized and composed of type I collagen with fibroblasts with an inner epithelial cell layer. There is a high concentration of VEGF, RUNX2 (CBFA1), TGFß1, and BMP2. The membrane is sutured over bone graft to create a closed pouch. When a nail is present, they note a second internal membrane around the nail, potentially increasing local vascularity and osteoinductive factor concentration.
Figure A shows a Gustillo IIIB tibia fracture with a large bone defect held in a temporizing external fixator. Figure B shows the same defect following intramedullary nailing and with a cement spacer placed circumferentially around the nail in the defect.
Incorrect Answers

Question 93

Figure 70 is the radiograph of a 14-year-old girl with increasing posterior ankle pain, especially during pointe technique exercises. Nonsurgical measures such as modification, stretching, and injection have been unsuccessful. Which nerve is most vulnerable to injury during endoscopic excision of this lesion?

Explanation

DISCUSSION
The pathology is that of posterior ankle impingement, which is secondary to a symptomatic os trigonum. Endoscopic excision necessitates posteromedial and posterolateral ankle portals. Although plantar numbness has been described as a relatively common postsurgical complication, the neurovascular structure most commonly injured is the sural nerve.

Question 94

The arrow in Figure 11 points toward a finding consistent with which of the following?

Explanation

DISCUSSION: The finding of a unilateral absent pedicle is often referred to as a winking owl sign and is a manifestation of pedicle destruction from metastatic disease. As the vertebral body is destroyed from the neoplastic process, it extends into the pedicle and destroys the cortical rim that normally creates the oval ring of the pedicle on an AP image.
REFERENCES: McLain R, Weinstein J (eds): Rothman-Simeone: The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 1173.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 674.

Question 95

A Spanish speaking child sustained the injury seen in Figure A after a fall at school. He was casted in the emergency department without the assistance of an interpreter and advised to return to see an orthopaedic surgeon in 1 week. However, the family returns to the emergency department with the child 3 months later, still in the cast. What is the most likely reason the child did not attend the recommended orthopaedic follow-up visit.?

Explanation

The most likely reason the child did not attend the recommended orthopaedic followup visit was a language barrier preventing effective communication of the intended follow-up instructions.
Communication skills and cultural competence is a key element in good orthopaedic care. Poor communication can often lead to devastating outcomes. In this example, poor communication resulted in this patient being lost to follow-up. Language barriers must be accommodated and alternative methods of communication must be utilized.
Levinson et al. examined how patients present their medical issues in clinical encounters and how physicians respond to these clues in routine primary care and surgical settings. They showed that good communication relies mostly on the physicians ability to identify patient clues within the clinical encounter. Poor communication between the physician tended to delay clinical visits, poor follow-up and unsatisfactory outcomes.
Figure A is an AP radiograph of the elbow in a skeletally immature patient. Figure B is a lateral radiograph of the elbow with a posterior fat pad sign, suggestive of an occult fracture.
Incorrect Answers:

Question 96

A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include

Explanation

The radiograph illustrates a middle third clavicular fracture with bone loss. According to Jupiter and associates, the biomechanics of the clavicle predisposes the middle third to be prone for fracture secondary to both moments of tension and bending and also torsional forces. In their study, fixation was best accomplish with plate fixation and a bone graft.[JBJS 1987, 69-A pg. 753-759]
Selection (1) would not provide adequate fixation to promote healing. (2) Electrical stimulation would not be sufficient for the above reasons. (3) Resection of the distal clavicle would not be indicate for this case because it promote further instability of the clavicle and increasing the affected forces to the clavicle.
(5) Kirschner wire fixation with bone graft, the author stated would provide fixation, but they achieved better results with plate fixation and bone graft Question 6 -
A 75-year-old woman sustains a fracture below the level of a total hip prosthesis. Radiographs demonstrate loosening of the prosthetic component. Treatment should consist of
a cast brace
a spica cast
plate fixation
allograft strut fixation
long stem revision
The key to this question lies in the radiographic evidence of loosening of the prosthetic component. The long stem revision is clearly indicated in this case because of various factors, one decreases impingement of the loose stem against the lateral femoral cortex. A non-surgical approach in the elderly patient will only increase the many risk factors such as atelectasis, pneumonia, and thromboembolic disease.[Instructional Course 44 pg. 293-303]

Question 97

Figures 70a and 70b show the sagittal MRI scan and axial CT of a patient who has decreased range of motion in the cervical spine. In which of the following directions would the cervical motion be most significantly limited?

Explanation

MRI and CT demonstrate an abnormality in the alantoaxial region (C1-C2). See chart in reference. “C1-C2 -Flexion/Extension 30 degrees - Sidebending 10 degrees - Rotation – 70 degrees”

Question 98

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 99

A 35-year-old man has numbness and tingling in the index, middle, and ring fingers. History reveals that he also has had vague wrist pain and stiffness since being injured in a motorcycle accident 1 year ago. Radiographs are shown in Figures 47a through 47c. Management should consist of

Explanation

DISCUSSION: The patient has a chronic unrecognized volar lunate dislocation. Median nerve compression is the result of the lunate displaced into the carpal tunnel. The diagnosis can be made by radiographs; MRI is not necessary. A volar approach allows median nerve decompression with excision of the lunate, whereas a dorsal approach facilitates excision of the scaphoid and triquetrum.
REFERENCES: Rettig ME, Raskin KB: Long-term assessment of proximal row carpectomy for chronic perilunate dislocations. J Hand Surg Am 1999;24:1231-1236.
Howard FM, Dell PC: The unreduced carpal dislocation: A method of treatment. Clin Orthop 1986;202:112-116.

Question 100

A 15-year-old girl reports popping and clicking at the sternoclavicular joint and an intermittent asymmetrical prominence of the medial head of the clavicle. She denies any history of trauma or other symptoms. Management should consist of

Explanation

DISCUSSION: Atraumatic subluxation or dislocation of the sternoclavicular joint typically occurs in individuals with generalized ligamentous laxity. It is generally not painful, has no long-term sequelae, and needs no treatment. In fact, it is more likely to be painful following surgery than if managed nonsurgically.
REFERENCES: Rockwood CA Jr, Odor JM: Spontaneous atraumatic anterior subluxation of the sternoclavicular joint. J Bone Joint Surg Am 1989;71:1280-1288.
Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998,

p 583.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

Joining an ongoing surgery without repeating a surgical timeout
Arriving late to an elective surgery as a member of the surgical team
Wearing the same set of scrubs under your surgical scrubs and gown that you wore attire during your didactic session
Using an alcohol-based gel rather than a formal surgical scrub for the first case of the day
Operating on a patient without personally marking the surgical site in the pre-operative holding area

Correct Answer: Arriving late to an elective surgery as a member of the surgical team

Explanation:

Question 2:

- Which of the following nerves lying between the gluteus medius and minimus is at risk for injury in a lateral approach to the hip?

Options:

Femoral
Obturator
Inferior gluteal
Superior gluteal
Lateral femoral cutaneous

Correct Answer: Superior gluteal

Explanation:

Question 3:

Figures 16a and 16b show the radiographs of an otherwise healthy 3 1/2-year-old boy who has an isolated deformity of the left leg. Definitive primary treatment of this condition should consist of

Options:

distraction osteogenesis.
an intramedullary nail and onlay bone graft.
a short leg cast.
a vascularized free fibular graft.
plate fixation and an autogenous bone graft.

Correct Answer: an intramedullary nail and onlay bone graft.

Explanation:

Question 4:

Options:

ankle joint arthrodesis.
ankle ligament reconstruction.
supramalleolar osteotomy.
total ankle joint arthroplasty.
corticosteroid injection into the ankle.

Correct Answer: ankle joint arthrodesis.

Question 5:

Options:

Revision hip arthroplasty with a bipolar implant
Revision hip arthroplasty with impaction grafting on the femoral and acetabular side
Revision hip arthroplasty with a cemented jumbo acetabular component
Revision hip arthroplasty with a cementless acetabular component
Acetabular component revision with a tri-flange protrusio ring

Correct Answer: Revision hip arthroplasty with a cementless acetabular component

Explanation:

DISCUSSION: The radiographs reveal acetabular component failure with bone loss. There
are several treatment options available. The best option for survivorship is a cementless
porous-coated acetabular component. This patient may or may not require structural bone graft, which may need to be determined at the time of surgery. Bipolar implants and cemented acetabular components for revision surgery have not demonstrated long-term success. The use of a protrusio ring is reserved primarily for massive bone loss such as a Paprosky type III bone loss with significant superior migration of the acetabular component. The best clinical results for acetabular component revision have been achieved with cementless porous-coated implants.
REFERENCES: Haddad FS, Masri BA, Garbuz DS, et al: Acetabulum, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 923-936.
D’Antonio JA: Periprosthetic bone loss of the acetabulum: Classification and management. Orthop Clin North Am 1992;23:279-290.
Rubash HE, Sinha RK, Paprosky W, et al: A new classification system for the management of acetabular osteolysis after total hip arthroplasty. Instr Course Lect 1999;48:37-42.

Question 6:

Options:

Gender
Age
Race
Environment

Correct Answer: Race

Explanation:

Question 7:

Options:

a short leg cast and elevation of the foot.
fasciotomies of the foot.
MRI.
CT.
stress radiographs.

Correct Answer: fasciotomies of the foot.

Explanation:

Question 8:

Figure 32 shows the radiograph of a laborer who jammed his thumb in a fall. Examination reveals pain at the base of the thumb and proximal thenar eminence region. Management should consist of

Options:

open reduction and internal fixation.
closed reduction, percutaneous pin fixation, and casting.
dynamic thumb traction.
external fixation.
functional bracing followed by occupational therapy.

Correct Answer: closed reduction, percutaneous pin fixation, and casting.

Explanation:

Question 9:

The patient develops an inability to dorsiflex her foot 2 days after surgical intervention while she is sitting in a chair after physical therapy. Initial treatment should consist of

Options:

lying completely supine in bed.
remaining seated and placing the postsurgical leg on a stool.
transferring back to bed with the head of the bed no lower than 60 degrees.
transferring back to bed with the head of the bed level and the surgical knee flexed.

Correct Answer: transferring back to bed with the head of the bed level and the surgical knee flexed.

Explanation:

Question 10:

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 11:

Iliosacral screws placed for stabilization of posterior pelvic ring injuries (eg, sacroiliac dislocation) that exit the sacrum anteriorly are most likely to injure which of the following structures?

Options:

L4 nerve root
L5 nerve root
S1 nerve root
Internal iliac artery
External iliac artery

Correct Answer: L5 nerve root

Explanation:

Question 12:

Options:

a long arm cast for 6 weeks, followed by a short arm cast for 6 weeks.
vascularized bone graft from the 1,2 intercompartmental supraretinacular artery.
open reduction and internal fixation with a differential pitch screw via a dorsal approach.
open reduction and internal fixation with a differential pitch screw via a volar approach
a removable thumb spica splint.

Correct Answer: open reduction and internal fixation with a differential pitch screw via a dorsal approach.

Explanation:

Question 13:

The sartorius muscle is innervated by which of the following nerves?

Options:

Femoral
Obturator
Superior gluteal
Inferior gluteal
Ilioinguinal

Correct Answer: Femoral

Explanation:

Question 14:

Based on the type of articulation shown in Figure 32, wear is not affected by which of the following factors?

Options:

Radial mismatch of the femoral head to the acetabular component
Sphericity of the bearings
Surface finish of the articulation
Carbon content of the metal-on-metal bearing
Head-to-neck ratio

Correct Answer: Head-to-neck ratio

Explanation:

DISCUSSION: Wear in total hip arthroplasty is a very complex phenomenon. The radial mismatch of the femoral head to the acetabular component has been shown in multiple studies to be a significant factor in wear. The mismatch can neither be too small nor too large. When the mismatch is too small, seizing of the implants can occur. When the mismatch is too large, contact stresses increase and produce exceptionally high wear. The ideal radial mismatch should be approximately 50 microns. Surface roughness and ball sphericity are two items that are extremely important with respect to wear. High carbon content has been shown to decrease wear. This device has a very large head-to-neck ratio, so impingement-related wear is unlikely.
REFERENCES: Amstutz HC, Grigoris P: Metal on metal bearings in hip arthroplasty. Clin Orthop 1996;329:S11-S34.
Amstutz HC, Campbell P, McKellop H, et al: Metal on metal total hip replacement workshop consensus document. Clin Orthop 1996;329:S297-S303.
McKellop H, Park SH, Chiesa R, et al: In vivo wear of three types of metal on metal hip prostheses during two decades of use. Clin Orthop 1996;329:S128-S140.

Question 15:

Figures 38a and 38b show the CT scans of a 64-year-old woman. What is the most likely diagnosis?

Options:

Calcaneal fibular abutment
Symmetrical narrowing of the subtalar joint consistent with an inflammatory arthropathy
Cystic lesion of the tibia consistent with enchondroma
Stress fracture of the talus
A lateral malleolar fracture

Correct Answer: Calcaneal fibular abutment

Explanation:

DISCUSSION: The CT scans show large cystic lesions in the talus and calcaneus with complete subluxation of the subtalar joint, allowing the calcaneus to slide laterally until it becomes blocked by the fibula. The cause of this subluxation is severe posterior tibial tendon dysfunction. Although no fibular fracture has yet appeared, it can occur with continued stress from the calcaneus. There is, however, a pathologic fracture in the medial calcaneus through a medial degenerative cyst. The joint space is irregular and not symmetrical as would be seen in an inflammatory arthropathy. Cystic lesions are not present in the tibia. No stress fracture is seen in the talus.
REFERENCES: Coughlin MJ: Sesamoids and accessory bones of the foot, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 437-499.
Anderson RB, Davis WH: Management of the adult flatfoot deformity, in Myerson M (ed):
Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, pp 1017-1039.

Question 16:

What is the most common cause of the new onset of amenorrhea in a female endurance athlete who is not sexually active?

Options:

Insufficient caloric intake
Physical stress
Use of oral contraceptives
Diabetes mellitus
Chromosomal abnormalities

Correct Answer: Insufficient caloric intake

Explanation:

Question 17:

During fracture healing, granulation tissue tolerates the greatest strain before failure so that mature bone can eventually bridge the fracture gap during healing. What is the definition of strain?

Options:

Amount of force an object can withstand until plastic deformation is lost
Change in length / original length of an object due to an external force
Relationship of stiffness to time-dependent loading
Force intensity / volume
Force intensity / cross sectional area

Correct Answer: Amount of force an object can withstand until plastic deformation is lost

Explanation:

Question 18:

Options:

Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.
Site A is the AER. Site A tissue expresses FGF8.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses Shh protein.
Site A is the zone of polarizing activity (ZPA). Site A tissue expresses FGF8 protein.
Site A is non-AER ectoderm. Site A tissue expresses WNT7a.

Correct Answer: Site A is the apical ectodermal ridge (AER). Site A tissue expresses Shh protein.

Explanation:

Question 19:

Options:

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

Correct Answer: full supination.

Explanation:

Question 20:

Options:

Residual foreign body
Lateral plantar nerve laceration
Impingement of Baxter’s nerve
Interdigital neuroma
Digital nerve laceration

Correct Answer: Lateral plantar nerve laceration

Explanation:

DISCUSSION: The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter’s nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel’s sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder’s click. A digital nerve laceration would exhibit isolated numbness more distally.
REFERENCES: Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992;279:229-236.
Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Philadelphia, PA, JB Lippincott, 1983.

Question 21:

Options:

Rehabilitation initially focused on closed chain quadriceps strengthening
Rehabilitation initially focused on hamstring strengthening
Anterior cruciate ligament (ACL) reconstruction using autograft tissue
Posterior cruciate ligament (PCL) reconstruction using autograft tissue

Correct Answer: Rehabilitation initially focused on closed chain quadriceps strengthening

Explanation:

Question 22:

A patient undergoing joint arthroplasty is put on a drug that competitively inhibits the activation of an enzyme that breaks down Factor Ia. The drug is

Options:

Dabigatran
Tranexamic acid
Rivaroxaban
Fondaparinux
Heparin

Correct Answer: Heparin

Explanation:

Question 23:

A 27-year-old man has neck pain after being involved in a motor vehicle accident. A lateral cervical radiograph is shown in Figure 21. What would be the most common neurologic finding?

Options:

Cruciate paralysis
Quadraplegia
Normal function
Absent bulbocavernosus reflex
Greater occipital nerve dysesthesia

Correct Answer: Normal function

Explanation:

Question 24:

Options:

Arthroscopic debridement
Arthroscopic rotator cuff repair
Hemiarthroplasty with rotator cuff repair
Total shoulder arthroplasty
Reverse shoulder arthroplasty

Correct Answer: Reverse shoulder arthroplasty

Explanation:

Question 25:

Which of the following statements best describes the relationship between tissue response to thermal capsulorrhaphy and the type of device used?

Options:

Laser devices produce photon excitation, which produces less effect than electromagnetic devices.
Bipolar devices cause less tissue damage than monopolar devices.
Monopolar devices cause less tissue damage than bipolar devices.
The tissue response is the same regardless of the device.
Tissue response is greatest with bipolar devices when not in ablate mode.

Correct Answer: The tissue response is the same regardless of the device.

Explanation:

Question 26:

Options:

Surgical repair of the Bankart lesion
Exploration of the axillary nerve
MRI neurography
Repeat EMG studies
Continued observation and physical therapy

Correct Answer: Repeat EMG studies

Explanation:

Question 27:

Figures 63a and 63b show the radiographs of an 11-year-old girl who sustained a twisting injury of the knee playing soccer. She is now asymptomatic. What is the appropriate treatment of the lesion?

Options:

Needle biopsy
Incisional biopsy
Observation
Curettage and grafting
Chemotherapy and en bloc resection

Correct Answer: Observation

Explanation:

DISCUSSION: This is a nonossifying fibroma of the proximal tibia. The lesion is eccentric, cortically based, with sclerotic margins and no evidence of a soft-tissue mass. Nonossifying fibromas are benign lesions that need no biopsy or surgical treatment when classic findings appear on radiographs. A follow-up radiograph should be performed 2 to 3 months after the initial presentation to ensure that the lesion is not progressive. Surgery is reserved for large lesions with risk of pathologic fracture or for cases where a displaced pathologic fracture has occurred and internal fixation is needed for fracture treatment. Nondisplaced pathologic fractures through nonossifying fibromas are best treated by allowing the fracture to heal and observation of the lesion.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 197-215.
Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 77-85.

Question 28:

Options:

Valgus osteotomy
Removal of the hardware
Intramedullary fixation after removal of the hardware
Conversion to total hip arthroplasty with a long cementless stem
Conversion to total hip arthroplasty with a primary tapered stem

Correct Answer: Conversion to total hip arthroplasty with a long cementless stem

Explanation:

Question 29:

Options:

Interphalangeal joint arthritis
Laceration of the flexor hallucis longus tendon
Sesamoid entrapment
Metatarsal malunion
Phalangeal malunion

Correct Answer: Laceration of the flexor hallucis longus tendon

Explanation:

Question 30:

Options:

Surgical reconstruction
Rest, followed by physical therapy
Splinting in 15 degrees of flexion
Primary repair
Arthroscopic debridement, followed by bracing in full extension for 4 weeks

Correct Answer: Surgical reconstruction

Explanation:

Question 31:

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 32:

A 22-month-old girl has cerebral palsy. Which of the following findings is a good prognostic indicator of the child’s ability to walk in the future? Review Topic

Options:

Asymmetric tonic neck reflex
Moro reflex
Extensor thrust
Positive parachute reaction
Absent foot placement

Correct Answer: Positive parachute reaction

Explanation:

Question 33:

Options:

Ankle arthroscopy and debridement of an osteochondral lesion
Peroneal retinacular reconstruction
Brostrom-Gould lateral ligament reconstruction
Immobilization in a walker boot in plantar flexion
Ankle rehabilitation and physical therapy

Correct Answer: Peroneal retinacular reconstruction

Explanation:

Question 34:

Options:

Open fracture
Smoking history
Pseudomonas organism
Tibia fracture DISCUSSION -Berkes and associates showed that in a single-center retrospective study of all patients treated with open reduction and internal fixation of extremity fractures that resulted in early postsurgical deep wound infections, the only variables that showed statistical significance were history of open fracture as the initial injury or use of an intramedullary nail. Smoking history, intraoperative cultures showing pseudomonas species, and involvement of the lower extremity were not significant. Rightmire and associates examined patients at longer follow up, and showed smoking to be a risk factor for clinical failure.

Correct Answer: Open fracture

Question 35:

Options:

The examiner brings a finger from medial to lateral across the antecubital fossa, feeling for a cord-like structure.
The examiner brings a finger from lateral to medial across the antecubital fossa, feeling for a cord-like structure.
With the elbow flexed to 90°and the forearm pronated, the examiner resists patient supination, evaluating for pain at the bicipital groove.
With the patient’s arm elevated to 90° of forward flexion, the elbow extended, and the forearm supinated, the examiner resists elevation distal to the elbow, evaluating for pain at the bicipital groove.

Correct Answer: The examiner brings a finger from lateral to medial across the antecubital fossa, feeling for a cord-like structure.

Explanation:

EXPLANATION:

Question 36:

Options:

Correct Answer: C7

Explanation:

Question 37:

What nerve is at greatest risk of harm from the portal shown in Figure 36?

Options:

Radial
Ulnar
Median
Lateral antebrachial cutaneous
Posterior antebrachial cutaneous

Correct Answer: Radial

Explanation:

Question 38:

Options:

Knee-ankle-foot orthosis with locking joints
Knee and ankle fusion
Soft-tissue release of the ankle and a locked knee orthosis
Soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint
Ankle fusion and a knee-ankle-foot orthosis

Correct Answer: Soft-tissue release of the ankle and a knee-ankle-foot orthosis with a locked ankle and drop-lock knee joint

Explanation:

Question 39:

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

Options:

Amenorrhea
Osteoporosis
Low LDL levels
Decreased immune function
Insufficient caloric intake

Correct Answer: Amenorrhea

Explanation:

Question 40:

In addition to pain, which of the following factors are considered most predictive of the risk of pathologic fracture?

Options:

Anatomic location and pattern of bony destruction
Anatomic location and age
Anatomic location and weight of patient
History of cancer and metaphyseal versus cortical destruction
Radiation dose and soft-tissue mass

Correct Answer: Anatomic location and pattern of bony destruction

Explanation:

Question 41:

Antibiotic-loaded bone cement prostheses, such as that shown in Figure 8, are best created by using which of the following methods?

Options:

Using commercially available antibiotic-loaded bone cement
Adding 0.5 g vancomycin to commercially available antibiotic-loaded bone cement
Adding 0.5 g tobramycin and 0.5 g vancomycin/unit of standard bone cement
Adding either 1.0 g vancomycin or 1.2 g tobramycin per 40 g of standard bone cement
Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Correct Answer: Adding a minimum of 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement

Explanation:

DISCUSSION: In a review of the practical applications of antibiotic-loaded bone cement for the treatment of the infected total joint arthroplasties, Hanssen and Spangehl described commercially available antibiotic-loaded bone cement as low-dose antibiotic cements. These cements generally contained 0.5 g of either tobramycin or gentamicin per 40 g of cement. They are indicated for use in prophylaxis and not for treatment of infected total joint arthroplasties.
High-dose antibiotic-loaded bone cements are described as those containing greater than 1.0 g of antibiotic per 40 g of cement. Effective elution levels have been documented with 3.6 g tobramycin and 1.0 g vancomycin per 40 g of bone cement. This was documented by Penner and associates. Furthermore, it was shown that the combination of the two antibiotics in the bone cement improved the elution of both antibiotics.
REFERENCES: Hanssen AD, Spangehl MJ: Practical applications of antibiotic-loaded bone cement for treatment of infected joint replacements. Clin Orthop 2004;427:79-85.
Penner MJ, Masri BA, Duncan CP: Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement. J Arthroplasty 1996;11:939-944.

Question 42:

Options:

immobilization with a halo ring and vest with reduction when medically stable.
closed traction reduction using Gardner-Wells tongs.
posterior open reduction, stabilization, and fusion.
cervical MRI followed by reduction.
anterior open reduction, stabilization, and fusion.

Correct Answer: cervical MRI followed by reduction.

Explanation:

DISCUSSION: The patient has a bilateral facet dislocation of C6-C7 with preservation of at least some neurologic function. Urgent reduction is necessary. However, because she is sedated and unable to follow commands, an MRI scan is necessary before any closed or open posterior reduction to look for an associated disk herniation. If a disk herniation is present, it must be removed prior to any reduction maneuver to prevent iatrogenic neurologic injury. It is very unlikely that this injury can be reduced with an open anterior procedure alone.
REFERENCES: Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 189-199.
Kwon BK, Vaccaro AR, Grauer JN, et al: Subaxial cervical spine trauma. J Am Acad Orthop Surg 2006;14:78-89.

Question 43:

Options:

Conversion to a reverse total shoulder arthroplasty
Conversion to a standard total shoulder arthroplasty
Conversion to a glenohumeral fusion
Resection arthroplasty
Biologic resurfacing of the glenoid

Correct Answer: Conversion to a standard total shoulder arthroplasty

Explanation:

Question 44:

Options:

Chairback brace
Thoracolumbosacral orthosis (TLSO) molded in extension
Posterior stabilization of the fracture with segmental fixation and iliac crest bone grafting
Anterior corpectomy, strut grafting, and plating
Combined anterior corpectomy, structural grafting and plating, and posterior stabilization and fusion

Correct Answer: Thoracolumbosacral orthosis (TLSO) molded in extension

Explanation:

Question 45:

What is the most common presenting sign or symptom in an adult with lumbar pyogenic infection?

Options:

Fever
Night sweats
Unexplained weight loss
Foot drop
Back pain

Correct Answer: Back pain

Explanation:

Question 46:

Options:

Self-directed exercise therapy
Supervised exercise therapy
Supervised exercise therapy with static progressive elbow splinting
Continuous passive motion device
Closed manipulation under anesthesia

Correct Answer: Continuous passive motion device

Explanation:

Question 47:

A 22-year-old man who plays recreational soccer (Figure 41)

Options:

Ligamentous reconstruction
Meniscal repair
Meniscectomy
Immobilization

Correct Answer: Immobilization

Question 48:

Options:

Semiconstrained total elbow arthroplasty
Unconstrained total elbow arthroplasty
Fascial arthroplasty
Open synovectomy
Arthroscopic synovectomy

Correct Answer: Semiconstrained total elbow arthroplasty

Explanation:

DISCUSSION: The radiographs reveal severe arthritic changes with no joint space, and the AP view shows a progressive malalignment secondary to the radial head resection. A prosthetic arthroplasty is indicated given the severe arthritis (Larsen grade III). Unconstrained arthroplasties have not performed as well as semiconstrained arthroplasties after previous radial head resections. However, both types of arthroplasties performed better in native elbows. Synovectomies should be reserved for less advanced disease states.
REFERENCES: Whaley A, Morrey BF, Adams R: Total elbow arthroplasty after previous resection of the radial head and synovectomy. J Bone Joint Surg Br 2005;87:47-53.
Maenpaa HM, Kuusela PP, Kaarela KK, et al: Reoperation rate after elbow synovectomy in rheumatoid arthritis. J Shoulder Elbow Surg 2003;12:480-483.
Schemitsch EH, Ewald FC, Thornhill TS: Results of total elbow arthroplasty after excision of the radial head and synovectomy in patients who had rheumatoid arthritis. J Bone Joint Surg Am 1996;78:1541-1547.

Question 49:

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 50:

Options:

Recurrent branch of the deep peroneal
Recurrent branch of the sural
Terminal cutaneous branch of the saphenous
Dorsomedial cutaneous branch of the superficial peroneal
Medial plantar

Correct Answer: Dorsomedial cutaneous branch of the superficial peroneal

Explanation:

DISCUSSION: Painful incisional neuromas after bunion surgery frequently involve the dorsomedial cutaneous branch of the superficial peroneal nerve. This is the medial branch of the superficial peroneal nerve that terminates as the dorsomedial cutaneous nerve to the hallux. Branches of the deep peroneal nerve to this area are rare, and no branches to this area exist from the sural nerve. The saphenous nerve branches are generally more proximal, and the medial plantar nerve lies plantarly.
REFERENCES: Kenzora JE: Sensory nerve neuromas: Leading to failed foot surgery. Foot Ankle 1986;7:110-117.
Sarrafian
SK
: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional, ed 2. Philadelphia, PA, JB Lippincott, 1993.

Question 51:

Options:

Posterior “Y” plate fixation
Dual one third tubular plate fixation with a hinged external fixator
Dual one third tubular plate fixation
Dual 3.5-mm reconstruction plate fixation
Single lateral plate fixation with transcortical screw fixation

Correct Answer: Dual 3.5-mm reconstruction plate fixation

Explanation:

Question 52:

Options:

rest and a sling followed by a gradual return to activities.
physical therapy and extension-block bracing.
repair of the biceps tendon to the brachialis muscle.
repair of the common flexor origin.
anatomic repair of the distal biceps tendon.

Correct Answer: anatomic repair of the distal biceps tendon.

Explanation:

Question 53:

Options:

lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.
lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery.
medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery.
medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery.

Correct Answer: lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.

Explanation:

Question 54:

A subtrochanteric femur fracture in which the lesser trochanter is intact is associated with what deformity?

Options:

Adduction and extension of the proximal fragment
Adduction and flexion of the proximal fragment
Abduction and extension of the proximal fragment
Abduction and flexion of the proximal fragment
Predominantly internal rotation of the proximal fragment

Correct Answer: Abduction and flexion of the proximal fragment

Explanation:

Question 55:

Which of the following complications is more likely with an inside-out repair technique compared to an all-inside techniques for a medial meniscus tear?

Options:

Failure
Intra-articular synovitis
Peroneal nerve injury
Saphenous nerve injury
Arthrofibrosis

Correct Answer: Saphenous nerve injury

Explanation:

Question 56:

Options:

Continued observation
Open reduction and internal fixation of the fracture
Excision of the hook of the hamate
Carpal tunnel release
Guyon’s canal release

Correct Answer: Excision of the hook of the hamate

Explanation:

Question 57:

Options:

Reverse total shoulder arthroplasty
Hemiarthroplasty of the shoulder
Arthroscopic biceps tenolysis
Open subacromial debridement
Total shoulder arthroplasty

Correct Answer: Reverse total shoulder arthroplasty

Explanation:

Question 58:

Figures 38a and 38b

Options:

Open reduction and internal fixation (ORIF)
Walking boot and weight bearing as tolerated until pain subsides
Nonweight-bearing cast for 6 weeks
Physical therapy
Closed reduction and weight bearing as tolerated
Closed reduction and percutaneous fixation
Figures 38a and 38b

Correct Answer: Open reduction and internal fixation (ORIF)

Explanation:

DISCUSSION
Inversion of the ankle can cause various injuries about the foot and ankle, all via the same mechanism. Fifth metatarsal base avulsion (Figure 35) fractures can be treated with use of a walking boot until pain subsides. Jones fractures (Figure 36) can be treated with surgical or nonsurgical treatment, although young, active patients are perhaps better treated with ORIF, which can decrease disability time. Treatment of an anterior process calcaneus fracture (Figure 37) is similar to that for a fifth metatarsal base avulsion fracture. Figures 38a and 38b show a calcaneal fracture-dislocation, which necessitates ORIF.
RECOMMENDED READINGS
Schepers T, Backes M, Schep NW, Carel Goslings J, Luitse JS. Functional outcome following a locked fracture-dislocation of the calcaneus. Int Orthop. 2013 Sep;37(9):1833-8. PubMed PMID: 23959223.
View Abstract at PubMed
Polzer H, Polzer S, Mutschler W, Prall WC. Acute fractures to the proximal fifth metatarsal bone: development of classification and treatment recommendations based on the current evidence. Injury. 2012 Oct;43(10):1626-32. doi: 10.1016/j.injury.2012.03.010. Epub 2012 Mar 30. Review. PubMed PMID: 22465516.
View Abstract at PubMed
Roche AJ, Calder JD. Treatment and return to sport following a Jones fracture of the fifth metatarsal: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1307-15. doi: 10.1007/s00167-012-2138-8. Epub 2012 Sep 6. Review. PubMed PMID: 22956165.
View Abstract at
PubMed
Berkowitz MJ, Kim DH. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005 Dec;13(8):492-502. Review. PubMed PMID: 16330511.
View Abstract at PubMed

Question 59:

Options:

a custom-molded orthotic and anti-inflammatory drugs.
partial weight-bearing ambulation with crutches.
weight bearing as tolerated with a walking boot.
casting for 6 weeks with bone stimulation.
internal fixation.

Correct Answer: internal fixation.

Explanation:

Question 60:

Options:

Symmetric knee pathology
Excessive joint laxity
Recurrent patella instability
Extra-articular manifestations

Correct Answer: Symmetric knee pathology

Explanation:

Question 61:

Options:

Dorsalis pedis artery
Perforating peroneal artery
Lateral tarsal artery
Artery of the tarsal canal
Artery of the tarsal sinus

Correct Answer: Artery of the tarsal canal

Explanation:

Question 62:

Options:

a technetium Tc 99m scan.
an indium scan.
an ultrasound examination.
aspiration.
revision.

Correct Answer: aspiration.

Explanation:

Question 63:

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 64:

What are the four most common soft-tissue sarcomas to spread via the lymph node system?

Options:

Rhabdomyosarcoma, malignant fibrous histiocytoma, epithelioid sarcoma, clear cell sarcoma
Malignant fibrous histiocytoma, synovial sarcoma, clear cell sarcoma, epithelioid sarcoma
Liposarcoma, rhabdomyosarcoma, synovial sarcoma, clear cell sarcoma
Rhabdomyosarcoma, clear cell sarcoma, epithelioid sarcoma, synovial sarcoma
Liposarcoma, clear cell sarcoma, rhabdomyosarcoma, epithelioid sarcoma

Correct Answer: Rhabdomyosarcoma, clear cell sarcoma, epithelioid sarcoma, synovial sarcoma

Explanation:

DISCUSSION: Soft-tissue sarcomas most frequently metastasize to the lung, but certain histologic types have a predilection for the lymph node system as well. Rhabdomyosarcoma, clear cell sarcoma, epithelioid sarcoma, and synovial sarcoma are four of the most common types to spread in this fashion. Careful evaluation and/or sentinel lymph node biopsy plays a role in disease staging and prognosis.
REFERENCES: Riad S, Griffin AM, Liberman B, et al: Lymph node metastasis in soft-tissue sarcoma in an extremity. Clin Orthop Relat Res 2004;426:129-134.
Blazer DG III, Sabel MS, Sondak VK: Is there a role for sentinel lymph node biopsy in the management of sarcoma? Surg Oncol 2003;12:201-206.

Question 65:

Which of the following statements best describes synovial fluid?

Options:

Erythrocytes are present at one tenth the normal concentration of blood.
White blood cells are present at one tenth the normal concentration of blood.
Synovial fluid is produced by type A synoviocytes.
Synovial fluid exhibits non-Newtonian fluid characteristics.
Synovial fluid contains similar concentrations of clotting factors as serum.

Correct Answer: Synovial fluid exhibits non-Newtonian fluid characteristics.

Explanation:

Question 66:

Options:

Clostridium
Acinetobacter
Pseudomonas
Mycobacterium
Staphylococcus aureus

Correct Answer: Clostridium

Explanation:

Question 67:

Options:

Glucose tolerance test
CBC count with differential
Urethral swab and culture
HLA-B27
Antiphospholipid antibody

Correct Answer: HLA-B27

Explanation:

Question 68:

Options:

Chronic ankle instability
Persistent pain
Progressive loss of ankle plantar flexion
Development of ankle arthritis
Instability of the proximal tibiofibular joint

Correct Answer: Persistent pain

Explanation:

Question 69:

What is the most common neurologic problem associated with a simple shoulder dislocation? Review Topic

Options:

A neurapraxic brachial plexus injury
A neurapraxic axillary nerve injury
A neurapraxic musculocutaneous nerve injury
A neurotmetic axillary nerve injury
An axonotmetic musculocutaneous nerve injury

Correct Answer: A neurapraxic axillary nerve injury

Explanation:

Question 70:

Options:

No further treatment
Closed reduction under conscious sedation
Closed reduction under general anesthesia in the operating room with neurologic monitoring
Occipitocervical fusion
Posterior atlantoaxial fusion

Correct Answer: No further treatment

Explanation:

The clinical presentation is consistent with chronic torticollis caused by Atlantoaxial rotatory displacement (AARD). Because both halter traction and halo traction were attempted and failed, the next most appropriate next step in management is posterior atlantoaxial fusion.
Common causes of Atlantoaxial rotatory displacement (AARD) include infection, trauma, and recent neck surgery. Diagnosis is challenging and is best confirmed with dynamic CT (CT with the head turned maximally to either side and at neutral). If the symptoms are acute (less than 7 days) then initial treatment with a soft collar and anti-inflammatory medications is indicated. If the condition has been present for more than a week, more aggressive treatment with halter traction (present 1 week to 1 month) or halo traction (present for 1-3 months) is indicated. If nonoperative modalities fail, the condition has been present for > 3 months, or the patient has neurologic deficits, then posterior C1-C2 fusion is indicated.
Copley et al discuss the evaluation and treatment of various congenital and traumatic conditions of the pediatric cervical spine. They report that the underlying mechanism of Atlantoaxial rotatory displacement (AARD) is inflammation and spasm which can be caused by infection, prior surgery, trauma, and rheumatoid arthritis.
Subach et al reviewed at 20 children with atlantoaxial rotatory subluxation. They found that of the 20 patients treated overall, conservative management failed in 6 (30%), and they required posterior fusion because of recurrence of the atlantoaxial rotatory subluxation or unsuccessful reduction. The major factor predicting the failure of conservative management was the duration of subluxation before initial reduction. Patients with long-standing subluxation were more likely to experience recurrence and require surgery.
Figure A shows an asymmetric placed odontoid within the ring of C1. There is an increased distance from the odontoid to the right arch of C1 which is fixed and minimally changes with maximal rotation to the left. This radiographic finding is indicative of fixed subluxation. Illustration A further demonstrates this.
Incorrect
(SBQ12SP.1) A 65-year-old female with a history of breast cancer presents with bilateral buttock and leg pain that is worse with walking and improves with sitting. In addition, she reports that she feels unsteady on her feet and requires holding the railing when going up and down stairs. On physical exam she is unable to complete a tandem gait and has hip flexion weakness, ankle dorsiflexion weakness, and ankle plantar flexion weakness. Her reflex exam shows 3+ bilateral patellar reflexes. Radiographs and an MRI are shown in Figure A and B. What is the next most appropriate step in management.
Review
Topic
Lumbar epidural injection
Physical therapy with core strengthening and anti-inflammatory medications as needed
Lumbar decompression
Lumbar decompression and fusion
MRI of the cervical and thoracic spine
The clinical scenario is consistent with a patient with symptoms of degenerative spondylolisthesis AND symptoms of myelopathy. Myelopathy must be ruled out by performing an MRI of the cervical and thoracic spine.
Tandem stenosis occurs in approximately 5 to 25% of patients. Because of the stepwise progressive nature of myelopathy, treatment of myelopathy often takes precedence over lumbar spinal stenosis.
Rhee et al. found that the sensitivity and specificity of specific physical exam findings varies. Both the upward babinski reflex and the presence of clonus were found to be very non-sensitive (13%). The most sensitive provacative test was found to be the Hoffman sign (59%).
Salvi et al. reviewed the classic presentations for cervical myelopathy including demographics, history, and physical exam findings (the inability to preform a tandem gait, hyperreflexia, an abnormal babinksi and hoffman reflex, the inability to preform rapid movements and bilateral muscle weakness). Additionally they identify other potential causes for myelopathy, including multiple sclerosis, amyotrophic lateral sclerosis, multifocal motor neuropathy, and Guillain-Barre´syndrome.
Maezawa et al. showed that gait analysis can identify a pattern in patients with myelopathy. Patients with severe myelopathy have a characteristic gait with hyperextension of the knee in the stance phase without plantar flexion of the ankle in the swing phase. They also have decreased walking speed and stride length with a prolonged stance phase.
Figure A and B show a classic degenerative spondylolisthesis.
Incorrect Answers:

Question 71:

The quadrilateral space in the shoulder contains which of the following structures?

Options:

Axillary nerve and posterior humeral circumflex artery
Axillary artery and radial nerve
Axillary artery and axillary nerve
Recurrent suprascapular nerve and artery
Profunda brachii artery

Correct Answer: Axillary nerve and posterior humeral circumflex artery

Explanation:

Question 72:

Options:

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

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

Explanation:

Question 73:

Options:

Start IV antibiotics, obtain wound swab for culture, perform irrigation and debridement and retain hardware
Start IV antibiotics, obtain deep soft tissue and bone cultures in OR, perform irrigation and debridement and remove hardware
Obtain wound swab for culture, start IV antibiotics, perform irrigation and debridement and remove hardware
Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform irrigation and debridement and remove hardware

Correct Answer: Obtain deep bone and soft tissue cultures in OR, start IV antibiotics, perform irrigation and debridement and remove hardware

Explanation:

Question 74:

- The radiograph shown in Figure 50a and the CT scan shown in Figure 50b reveal a lesion in the left femoral neck of a 12-year-old boy who has pain in the left hip. The most likely cause of the osteopenia of the left proximal femur is

Options:

disuse osteopenia
paraendocrine effect of the tumor
abnormally increased density on the right side
side effect of the treatment of the lesion
extensive tumor involvement of the left hip

Correct Answer: disuse osteopenia

Explanation:

Question 75:

Options:

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

Correct Answer: loss of external rotation.

Explanation:

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

Question 76:

Options:

Improves the bone mineral density of the vertebral bodies
Reduces the strain at the adjacent intervertebral disk
Reduces the stiffness of the posterior instrumentation
Reduces the strain on posterior instrumentation
Increases the strength of the posterior instrumentation

Correct Answer: Reduces the strain on posterior instrumentation

Explanation:

Question 77:

Options:

Galvanic
Pitting
Fretting
Crevice

Correct Answer: Fretting

Explanation:

Question 78:

Options:

0 to 15 degrees
20 to 30 degrees
40 to 90 degrees
100 to 120 degrees
130 to 140 degrees

Correct Answer: 40 to 90 degrees

Explanation:

Question 79:

Options:

Radial nerve injury
Intra-articular loose body causing a block to motion
Lack of active elbow flexion
Recurrent dislocation
Forearm compartment syndrome

Correct Answer: Recurrent dislocation

Explanation:

Question 80:

Options:

repair of the medial collateral ligament.
excision of the posterior olecranon osteophyte.
debridement of the degenerative portion of the common flexor origin.
autograft reconstruction of the medial collateral ligament.
ulnar nerve transposition.

Correct Answer: autograft reconstruction of the medial collateral ligament.

Explanation:

Question 81:

Options:

Syndesmosis sagittal plane reduction and fixation
Syndesmosis coronal plane reduction and fixation
Osteotomy and revision of the fibula and syndesmosis
Retrieval of osteochondral fragment
Revision plating of the fibula and syndesmosis reduction and fixation.

Correct Answer: Syndesmosis sagittal plane reduction and fixation

Explanation:

Question 82:

Figure 53 shows the pedigree of a family with an unusual type of muscular dystrophy. This pedigree is most consistent with what type of inheritance pattern?

Options:

Autosomal-dominant
Autosomal-recessive
X-linked dominant
X-linked recessive
Mitochondrial inheritance

Correct Answer: X-linked recessive

Explanation:

Question 83:

Which of the following best describes the use of epidural morphine and steroid paste after laminectomy?

Options:

Associated with an 11% rate of postoperative surgical site complications
Associated with a less than 1% rate of surgical site infections
Associated with a decreased rate of postoperative urinary retention
Considered the standard for outpatient microdiskectomy
Should only be used in the absence of radiculopathy

Correct Answer: Associated with an 11% rate of postoperative surgical site complications

Explanation:

DISCUSSION: Kramer and associates conducted a retrospective review during an “epidemic” period to identify the risk factors associated with a sudden increase in the rate of surgical site infections. They found in a multivariate analysis that the use of morphine nerve paste resulted in a 7.6-fold increase in postoperative surgical wound debridement, and an 11% rate of surgical site complications.
REFERENCES: Kramer MH, Mangram AJ, Pearson ML, et al: Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy. Infect Control Hosp Epidemiol 1999;20:183-186.
Lowell TD, Errico TJ, Eskenazi MS: Use of steroids after discectomy may predispose to infection. Spine 2000;25:516-519.

Question 84:

The injury seen in the CT scan shown in Figure 56 is related to or associated with injury to which of the following structures?

Options:

Anterior talofibular ligament
Calcaneofibular ligament
Subtalar joint
Syndesmosis
Superior peroneal retinaculum

Correct Answer: Syndesmosis

Explanation:

Question 85:

Options:

Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction
Decreased pain following surgery; sensory deficits and bladder function are not likely to improve
No change in her symptoms following surgery
Complete resolution of pain and will have normal sensation and bladder function following surgery
Improvement in her pain and complete return of bladder function following surgery; sensation may not return

Correct Answer: Improvement in her pain and sensory symptoms following surgery but may have residual bladder dysfunction

Explanation:

Question 86:

When planning scoliosis surgery for a patient with a 50-degree thoracolumbar curve and spinal muscular atrophy, it is most important to include

Options:

an anterior release and fusion.
a diaphragmatic pacer to assist postoperative pulmonary function.
a preoperative gait analysis.
an evaluation for lower extremity muscle contractures.
assessment of muscle biopsy findings obtained within the last 6 months to clarify the patient’s life expectancy and thus the value of the surgery.

Correct Answer: an evaluation for lower extremity muscle contractures.

Explanation:

Question 87:

Options:

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

Correct Answer: Closed reduction with a towel clip

Explanation:

Question 88:

Options:

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

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

Explanation:

Question 89:

Options:

Anterior column percutaneous screw placement
Posterior column percutaneous screw placement
Pubic symphysis plating
Supra-acetabular pin placement
Percutaneous iliosacral screw placement

Correct Answer: Anterior column percutaneous screw placement

Explanation:

Question 90:

Which of the following anatomic structures are in contact with internal impingement in the throwing athlete?

Options:

Humerus and posterior-superior glenoid
Humerus and anterior inferior glenoid
Humerus and acromion
Biceps and acromion
Rotator cuff and acromion

Correct Answer: Humerus and posterior-superior glenoid

Explanation:

Question 91:

Options:

Remove fixation and repeat vascular exam
Add a medial pin, remove two of the lateral pins and repeat vascular exam
Maintain hardware position, apply a soft dressing and observe
Maintain hardware position, apply long arm immobilization and observe
Surgically explore the antecubital fossa

Correct Answer: Remove fixation and repeat vascular exam

Explanation:

Question 92:

Options:

Excise the spacer
Excise the spacer, debride all membranous tissue, perform exchange nailing
Excise the spacer, debride all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity
Excise the spacer, preserve all membranous tissue, bone graft the cavity, remove the nail

Correct Answer: Excise the spacer

Explanation:

Question 93:

Options:

Sural
Deep peroneal
Medial plantar
Posterior tibial

Correct Answer: Sural

Explanation:

Question 94:

The arrow in Figure 11 points toward a finding consistent with which of the following?

Options:

Metastatic disease
Hemangioma
Flexion-compression fracture
Infection
Diastomatomyelia

Correct Answer: Metastatic disease

Explanation:

DISCUSSION: The finding of a unilateral absent pedicle is often referred to as a winking owl sign and is a manifestation of pedicle destruction from metastatic disease. As the vertebral body is destroyed from the neoplastic process, it extends into the pedicle and destroys the cortical rim that normally creates the oval ring of the pedicle on an AP image.
REFERENCES: McLain R, Weinstein J (eds): Rothman-Simeone: The Spine, ed 4. Philadelphia, PA, WB Saunders, 1999, p 1173.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 674.

Question 95:

Options:

The child is a victim of neglect
The child had no symptoms of pain
He was allowed to return to school wearing the cast
Concerns of cost
Follow-up instructions were not effectively communicated

Correct Answer: The child is a victim of neglect

Explanation:

Question 96:

- A 17-year old boy who sustained a closed clavicle fracture after he was ejected from an all-terrain vehicle was treated with a figure-of-8 brace 1 year ago. He now reports continuous pain at the site of the fracture and is unable to actively raise his arm above his head. A radiograph is shown in Figure 1. Management should now include

Options:

an onlay bone graft
electrical stimulation
resection of the distal clavicle
plate fixation and a bone graft
smooth Kirschner wire fixation and a bone graft

Correct Answer: smooth Kirschner wire fixation and a bone graft

Explanation:

Question 97:

Options:

Flexion
Extension
Axial rotation
Left lateral bending
Right lateral bending

Correct Answer: Axial rotation

Explanation:

MRI and CT demonstrate an abnormality in the alantoaxial region (C1-C2). See chart in reference. “C1-C2 -Flexion/Extension 30 degrees - Sidebending 10 degrees - Rotation – 70 degrees”

Question 98:

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 99:

Options:

splinting and injections for carpal tunnel syndrome.
scaphoid excision and four-bone fusion.
proximal row carpectomy via dorsal and volar incisions.
MRI of the wrist.
carpal tunnel release.

Correct Answer: proximal row carpectomy via dorsal and volar incisions.

Explanation:

Question 100:

Options:

figure-of-8 splinting to maintain the clavicle in a reduced position.
an exercise program to stabilize the joint in a reduced position.
elective reconstruction of the sternoclavicular joint ligaments.
reassurance and local symptomatic treatment.
closed reduction and temporary pin fixation to stabilize the joint.

Correct Answer: reassurance and local symptomatic treatment.

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

Orthopedic Board Review MCQs: Adult Reconstruction, Trauma, & Deformity | Part 182

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 182

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index