Orthopedic Board Review MCQs: Hip, Shoulder & Fractures

About This Board Review Set

This is Part 184 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 184

This module focuses heavily on: Deformity, Fracture, Hip, Shoulder.

Sample Questions from This Set

Sample Question 1: 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 ...

Sample Question 2: -Which of the following neurovascular structures is at greatest risk during the introduction of acetabular component fixation screws during total hip replacement?...

Sample Question 3: Factors contributing to an increased risk of hip fracture include reduced bone mineral density of the femoral neck, cognitive status of the individual, and...

Sample Question 4: A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan ...

Sample Question 5: Which of the following would be associated with the spinal deformity shown in Figures 79a and 79b? Review Topic...

Why Active MCQ Practice Works

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

Comprehensive 100-Question Exam

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Question 1

A 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 2

Which of the following neurovascular structures is at greatest risk during the introduction of acetabular component fixation screws during total hip replacement?

Explanation

Wasielewski et al found on reviewing the literature that vascular injuries during acetabuIar screw placement are an uncommon yet devastating complication of total hip arthroplasty. Damage to the external iliac artery was the most frequent injury yet injury to the external iliac vein and the superior gluteal artery has also been reported Based upon their anatomic study and development of a quadrant
system they found that the posterior superior and posterior inferior quadrants of the acetabulum are the safest locations for screw placement because of better bone stock as well as less neurovascular structures as compared to the anterior quadrants.

Question 3

Factors contributing to an increased risk of hip fracture include reduced bone mineral density of the femoral neck, cognitive status of the individual, and

Explanation

DISCUSSION: The etiology of hip fractures in the elderly is multifactorial, and intervention and prevention can occur at multiple points. Events leading to hip fracture from a fall include fall initiation (during which the individual’s neuromuscular status, cognitive status, and vision come into play along with environmental hazards); fall descent (fall direction toward the side being the most influential, energy content of the fall, and fall height, along with muscle activity of the muscles of the thigh); impact (impact location, soft-tissue attenuation such as from trochanteric padding or from overlying fat, impact surface, and muscle activity); and the structural capacity of the femur (bone mineral density, bone geometry, and bone architecture).
Hayes and Myers noted that striking the ground in a stiff state with the trunk muscles contracted actually increased the peak impact force, whereas falling in a relaxed state actually reduced peak impact force. Flexion of the trunk at impact had no bearing on the impact force. Direction of the fall was important; falls to the side, not forward, were associated with an increased risk of hip fracture. Increased muscle activity about the hip is thought to be associated with spontaneous fractures of the hip and may actually account for up to 25% of hip fractures; however, it is not related to fractures resulting from a fall.
REFERENCE: Hayes WC, Myers ER: Biomechanical considerations of hip and spine fractures in osteoporotic bone, in Springfield D (ed): Instructional Course Lectures 46. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 431-438.

Question 4

A 35-year-old woman dislocated her right shoulder in a fall from a step stool several months ago. She now reports several painful recurrences. Examination reveals anterior and inferior apprehension that reproduces her symptoms. An MRI scan is shown in Figure 17. Management should consist of

Explanation

DISCUSSION: The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high.
REFERENCES: Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.
Bokor DJ. Conboy VB. Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br

1999;81:93-96.
Coates MH, Breidahl W: Humeral avulsion of the anterior band of the inferior glenohumeral ligament with associated subscapularis bony avulsion in skeletally immature patients. Skeletal Radiol 2001;30:661-666.

Question 5

Which of the following would be associated with the spinal deformity shown in Figures 79a and 79b? Review Topic

Explanation

The images delineate progressive osteoporotic collapse. As outlined by Kado and associates, Schlaich and associates, and Gold and associates, the progression of spinal deformity and the functional consequences of vertebral compression fractures are persistent even in those patients who are pain free. Vertebral compression fractures are associated with deteriorating gait, early satiety, further future fracture risk, and deteriorating lung function.

Question 6

A 17-year-old girl is involved in a motor vehicle collision and sustains the injury shown in Figures 46a through 46c. She is neurologically intact in her bilateral lower extremities. Definitive treatment should consist of A B C

Explanation

DISCUSSION
The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.
RECOMMENDED READINGS
Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508. View Abstract at PubMed
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.

Question 7

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

Explanation

Question 8

When comparing the failure load of an evenly tensioned four-stranded hamstring tendon anterior cruciate ligament autograft to a 10-mm bone-patellar tendon-bone autograft, the hamstring graft will fail at a tension

Explanation

DISCUSSION: The failure load of an evenly tensioned four-stranded hamstring tendon autograft has been reported to be 4,500 Newtons. The failure load of a 10-mm patellar tendon autograft has been estimated at 2,600 Newtons. The intact anterior cruciate ligament failure load has been calculated at 1,725 Newtons.
REFERENCES: Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454.
Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.
Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352.

Question 9

A 68-year-old woman undergoes a complicated four-level anterior cervical diskectomy and fusion at C3-7 with iliac crest bone graft and instrumentation for multilevel cervical stenosis. Surgical time was approximately 6 hours and estimated blood loss was 800 mL. Neuromonitoring was stable throughout the procedure. The patient’s history is significant for smoking. The most immediate appropriate postoperative management for this patient should include

Explanation

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 10

A 4-year-old girl who is undergoing chemotherapy for acute lymphocytic leukemia sustains a displaced fracture through an osteolytic lesion in the metaphysis of the distal femur as a result of a fall. Treatment should include

Explanation

In the article by Gallagher, et al, they note a 12% incidence of pathologic fractures associated with acute leukemic lesions. The fracture should be treated using standard methods. Thus, the treatment of displaced fracture through an osteolytic lesion in the metaphysis of the distal femur in a 4-year-old girl would be closed reduction and immobilization in a cast.

Question 11

Examination of a 7-year-old boy reveals 20° of valgus following a lawn mower injury to the lateral femoral epiphysis. Treatment consists of total distal femoral epiphyseodesis and varus osteotomy. Following surgery, he has a limb-length discrepancy of 3 cm and 5° of genu valgum. Assuming that he undergoes no further treatment, the patient’s predicted limb-length discrepancy at maturity would be how many centimeters?

Explanation

DISCUSSION: The distal femoral epiphysis grows approximately 1 cm per year and in boys, growth ceases at approximately age 16 years. Therefore, the patient’s limb-length discrepancy at maturity would be 12 cm (9 cm plus the 3-cm discrepancy he has from the previous surgery).
REFERENCES: Little DG, Nigo L, Aiona MD: Deficiencies of current methods for the timing of epiphyseodesis. J Pediatr Orthop 1996;16:173-179.
Westh RN, Menelaus MB: A simple calculation for the timing of epiphyseal arrest: A further report. J Bone Joint Surg Br 1981;63:117-119.

Question 12

A 26-year-old right hand-dominant man has had right shoulder pain for the past 6 months. History reveals that he was the starting pitcher for his high school team. Activity modification, physical therapy, cortisone injection, and anti-inflammatory drugs have failed to improve his symptoms. He has a positive O’Brien’s active compression test. What is the next most appropriate step in the diagnosis of this patient? Review Topic

Explanation

MRI-arthrography has been shown to be an accurate technique for assessing the glenoid labrum in patients with suspected labral tears. Often standard MRI technique will not identify labral lesions. The use of MRI-arthrography with an intra-articular injection of gadolinium provides improved visualization of labral lesions. Bencardino and associates demonstrated a sensitivity of 89%, a specificity of 91%, and an accuracy of 90% in detecting labral lesions. SLAP lesions can be visualized on coronal oblique sequences as a deep cleft between the superior labrum and the glenoid that extends well around and below the biceps anchor. Often, contrast will diffuse into the labral fragment, causing it to appear ragged or indistinct.

Question 13

What is the incidence and significance of anterior cruciate ligament laxity following tibial eminence fractures in skeletally immature individuals?

Explanation

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior

eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.

J Pediatr Orthop 1984;4:462-464.

Question 14

A 72-year-old woman has had progressively increasing pain in the right knee for the past 6 months. She denies any trauma and has no pain in any other joints, but she notes occasional swelling in the knee and a catching sensation. Figures 31a and 31b show the plain radiographs and Figure 31c shows the MRI scan. Treatment should consist of

Explanation

DISCUSSION: The plain radiograph shows a defect in the lateral femoral condyle and narrowing of the lateral joint space. The MRI scan shows a lesion consistent with osteonecrosis of the lateral femoral condyle. The treatment alternatives for this condition are an osteotomy or a total knee replacement, but a total knee replacement is the treatment of choice for a 72-year-old patient. Arthroscopy or an osteochondral bone graft will not address her symptoms. A valgus osteotomy will exacerbate the problem by overloading the lateral joint, which is already diseased.
REFERENCES: Lotke PA, Ecker ML: Osteonecrosis of the knee. J Bone Joint Surg Am 1988;70:470-473.
Ecker ML, Lotke PA: Osteonecrosis of the medial part of the tibial plateau. J Bone Joint Surg Am 1995;77:596-601.

Question 15

A 63-year-old man has had increasing left leg pain over the last several months. History reveals that he has had recurring cyclic pain in the leg for the past several years. Radiographs show an enlarged, sclerotic tibia, with thickened coarse trabeculae and varus bowing. What is the most appropriate management for this patient? Review Topic

Explanation

Based on the signs and symptoms, Paget's disease is the most likely diagnosis. In Paget's disease, an elevated alkaline phosphatase level and high output heart failure may be seen. Hearing loss can be seen when there is involvement of the skull, and malignant degeneration is uncommon but recognized as a risk. Patients are often treated with bisphosphonate medications during the active disease process to help control osteoclastic activity and pain. Vitamin D and calcium are more appropriate for treatment of osteoporosis. Methotrexate is not indicated for the treatment of Paget's disease. NSAIDs may be helpful to treat pain associated with Paget's disease but will not alter the clinical course.

Question 16

In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic

Explanation

Femoroacetabular impingement is a mechanism for the development of early osteoarthritis for most nondysplastic hips. Early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients. There are two general types of femoroacetabular impingement. In cam impingement, the femoral deformity is usually a bump on the head-and-neck junction that impinges on the acetabular rim. The pincer type of impingement is caused by deformity on the acetabular side such as a deep socket or acetabular overcoverage due to retroversion. Both mechanisms create an obstacle for flexion and internal rotation.

Question 17

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

Explanation

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

Question 18

Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?

Explanation

DISCUSSION: Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.

Question 19

The MRI scan shown in Figure 24 reveals a right-sided herniated nucleus pulposus at L4-5 in a patient with pain in the right leg. Administration of a caudal epidural steroid injection provides immediate relief. Over the next week he notes generalized weakness of the lower extremities and has one episode of urinary incontinence. What is the next most appropriate step in management?

Explanation

DISCUSSION: Whenever a patient’s condition changes following a test or a procedure, the physician must determine the cause. A steroid flare reaction will not cause incontinence or weakness of the lower extremities. An L4-5 diskectomy may alleviate the problem if the right-sided L4-5 disk herniation is the etiology of the symptoms. However, it is unlikely that a right-sided disk herniation alone will cause a cauda equina syndrome. Possible etiologies include a further extrusion of a disk fragment at L4-5 that now obliterates the spinal canal, a disk herniation at another level, or an epidural abscess following injection of corticosteroids through a caudal approach. In the presence of a possible infection, myelography should not be performed from a lumbar puncture. The fastest and least invasive way to make an appropriate diagnosis is to obtain an MRI of the lumbar spine. In this patient, the MRI revealed an epidural abscess that was compressing the cauda equina. Because of the large dose of steroids that were injected, the patient did not manifest symptoms such as fevers and chills until late in the course.
REFERENCES: Knight JW, Cordingley JJ, Palazzo MG: Epidural abscess following epidural steroid and local anaesthetic injection. Anaesthesia 1997;52:576-578.
Abram SE, O’Connor TC: Complications associated with epidural steroid injections. Reg Anesth 1996;21:149-162.

Question 20

A 15-year-old boy falls from his bicycle and sustains an injury to his elbow. Prereduction radiographs are shown in Figure 12a. Closed reduction is performed without difficulty and postreduction radiographs are shown in Figure 12b. What is the next most appropriate step in treatment?

Explanation

DISCUSSION: Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment.
REFERENCES: Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.
Beaty JH: Fractures and dislocations about the elbow in children. Instr Course Lect 1992;41:373-384.

Question 21

A 72-year-old woman was evaluated with an MRI scan for a shoulder mass that was confirmed to be a lipoma. Additional MRI findings included a 7-mm full-thickness tear of the supraspinatus tendon. Therefore, the patient was

Explanation

In patients older than age 60 years, over 30% of asymptomatic shoulders show MRI findings of full-thickness rotator cuff tears. Therefore, without significant symptoms, surgical treatment is not warranted.

Question 22

A 16-year-old right-hand dominant male pitcher has had increasing pain in his dominant shoulder for the past 6 months without treatment. A coronal T2-weighted MRI scan is shown in Figure 80. What is the most appropriate treatment plan? Review Topic

Explanation

The coronal MRI scan shows an undersurface partial-thickness rotator cuff tear. Initial treatment for this injury should include complete cessation of throwing (or other overhead activities dependent on the athlete). Despite the duration of symptoms, he has had no treatment to date; therefore, nonsurgical management should include activity cessation, a rotator cuff and periscapular strengthening program, and then a slow and supervised return to throwing with particular attention to proper pitching mechanics. Decreasing the pitch count or continued play with observation risks progression of the problem. Surgical intervention is not indicated for initial treatment.

Question 23

Which of the following is associated with the use of large femoral heads in total hip arthroplasty?

Explanation

DISCUSSION: Larger diameter femoral heads reduce the risk of hip dislocation by allowing greater range of motion before component impingement becomes a risk, and no reports have shown an increase in bearing wear. With modem bearings, volumetric wear should remain low, despite the increase in head diameter. Large femoral heads are available in all common bearing materials
REFERENCES: Peters CL, McPherson E, Jackson JD, et al: Reduction in early dislocation rate with large-diameter femoral heads in primary total hip arthroplasty. J Arthroplasty 2007;22:140-144.
Inoue A, Asaumi K, Endo H, et al: Assessment of head wear more than ten years after total hip arthroplasty: 22- mm zirconia vs metal heads. Acta Med Okayama 2006;60:311-318.

Question 24

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 25

What is the most common type of malalignment after intramedullary nailing of distal 1/3 tibia fractures?

Explanation

DISCUSSION: Puloski et al determined the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography. Malrotation was defined as an internal/external rotation deformity greater than 10 degrees. They found that 5 (22%) of the tibia were malrotated greater than 10 degrees, and of those 5 tibia, 4 were distal 1/3 fractures.
McKee et al randomized 85 patients undergoing intramedullary tibial nailing using manual traction with the leg draped free versus standard fracture table positioning and traction. They found that manual traction is an effective technique that can save a significant amount of time without sacrificing the quality of reduction or fixation of tibial shaft fractures.

Question 26

Deep posterior compartment

Explanation

DISCUSSION
The structures at risk are the anterior tibial artery and deep peroneal nerve in the anterior compartment, superficial peroneal nerve in the lateral compartment, sural nerve in the superficial posterior compartment, and posterior tibial nerve and posterior tibial and peroneal arteries and veins in the deep posterior compartment.

Question 27

A 15-year-old girl reports a 6-month history of activity-related knee pain and swelling. A radiograph, MRI scan, and biopsy specimen are shown in Figures 21a through 21c. What is the most likely diagnosis?

Explanation

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 28

Figures 4a and 4b show the radiographs of a 32-year-old man who has right groin pain with activity or prolonged standing. Which of the following factors would not prohibit consideration of acetabular liner exchange and grafting of the defects?

Explanation

DISCUSSION: Polyethylene particles generated as mechanical wear debris can be phagocytized by macrophages and enter a metabolically active state that releases cytokines, causing periprosthetic bone resorption. Significant osteolysis can occur in the pelvis with a porous-coated cementless socket without loosening of the component. If the acetabular component is modular, well positioned, well-designed with a good survivorship record, and remains undamaged after liner removal, the polyethylene liner can be exchanged and the lytic defects can be debrided and bone grafted. This implant is well positioned, has a good survivorship record, a good locking mechanism, and is modular. The hip arthroplasty needs to be aseptic for consideration of liner exchange.
REFERENCES: Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA: Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am 1997;79:1628-1634.
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 417-451.

Question 29

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Explanation

DISCUSSION: Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or “floating toe.” Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy.
REFERENCES: Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int

2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.

Question 30

Which of the following statements best describes the anatomic considerations of the popliteal artery posterior to the knee joint?

Explanation

DISCUSSION: Popliteal artery injury during total knee arthroplasty is relatively rare. Knee flexion, the position that occurs during most of the arthroplasty procedure, allows the popliteal vessels to fall posteriorly, further away from harm. Anatomically, the popliteal artery lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in

90 degrees of flexion.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 151.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-53.

Question 31

Figure 17 shows the radiograph of an 80-year-old woman who has left groin pain. She underwent a total hip arthroplasty 15 years ago and has no history of hip dislocation; however, she now reports that the pain results in functional impairment. Preoperative findings reveal that the component used has been discontinued, the locking mechanism is poor, and there is no replacement polyethylene available from the company. During surgery, the acetabular component is found to be well fixed, it is in satisfactory position, and adequate access can be obtained through the screw holes in the component to debride the osteolytic cavities. What is the best course of action for revision?

Explanation

DISCUSSION: The clinical result in this patient has been good, with no dislocations, suggesting that the components are in reasonably good position. The radiograph and examination at the time of surgery suggest that the acetabular component is well fixed. The surrounding bone of the acetabulum is osteopenic and there would most likely be considerable bone loss if the acetabular component is removed. Access to the osteolytic lesions is possible. Cementing an acetabular component into the retained socket will cause the least amount of bone loss, shorten the procedure, and most likely result in a functional hip.
REFERENCES: Maloney WJ: Socket retention: Staying in place. Orthopedics 2000;23:965-966.
Blaha JD: Well-fixed acetabular component retention or replacement: The whys and the wherefores. J Arthroplasty 2002;17:157-161.

Question 32

Compared with cobalt-chromium, the biomechanical properties of titanium on polyethylene articulation in total hip replacement result in

Explanation

DISCUSSION: The surface hardness of titanium is low compared with that of cobalt-chromium alloys. Titanium articulations are easily scratched, resulting in a significantly increased rate of wear and debris production. The wear and resulting lysis can also result in an increased rate of loosening.
REFERENCES: Simon SR (ed): Orthopaedic Basic Science. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 449-486.
Agins HJ, Alcock NW, Bansal M, et al: Metallic wear in failed titanium-alloy total hip replacements: A histological and quantitative analysis. J Bone Joint Surg Am 1988;70:347-356.
Robinson RP, Lovell TP, Green TM, Bailey GA: Early femoral component loosening in DF-80 total hip arthroplasty. J Arthroplasty 1989;4:55-64.

Question 33

A 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

Explanation

DISCUSSION: Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure.
REFERENCES: Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-252.

Question 34

When performing ankle arthroscopy through the anterolateral portal, what anatomic structure is at greatest risk?

Explanation

DISCUSSION: The superficial branch of the peroneal nerve travels subcutaneously anterior to the lateral malleolus at the ankle. It can be easily damaged by deep penetration of the knife blade when making this portal or when passing shavers in and out of the portal. Anesthesia or dysesthesia from laceration or neuroma formation can cause significant postoperative morbidity. The anterior tibialis tendon, anterior tibial artery, and the deep peroneal nerve are located much more anterior and central on the ankle. The sural nerve is posterior lateral to the ankle and is not at risk from this portal.
REFERENCES: Ferkel RD, Heath DD, Guhl JF: Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208.
Cooper PS, Murray TF Jr: Arthroscopy of the foot and ankle in the athlete. Clin Sports Med 1996;15:805-824.

Question 35

What do the T2-weighted, fat-saturated MRI scans shown in Figures 1 through 4 reveal?

Explanation

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal
disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 36

CLINICAL SITUATION Figures 1 through 3 are the radiographs of a 25-year-old man who is brought to the emergency department after a motorcycle collision. He is complaining of isolated knee pain. Examination reveals swelling, popliteal ecchymosis, joint line pain, and limited knee joint motion. His pulses and sensation are normal. This knee injury is best described as a

Explanation

Discussion: Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment.
Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making.
Supine positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to stabilize a medial partial articular pattern in the supine position from a lateral utility approach is fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral capsular avulsion repair, but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

Question 37

What is the second most common primary bone malignancy in children?

Explanation

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 38

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Explanation

Fixation of pelvic and acetabular fractures in pregnancy is not contraindicated. However, both maternal and fetal morbidity and mortality is increased in this patient subset. Factors shown to be associated with increased fetal mortality include: injury severity, mechanism of injury, and maternal hemorrhage. Surgical approach, fracture classification, fetal position, and the trimester of pregnancy have not been shown to affect fetal morbidity or mortality.

Question 39

A 25-yo man sustains the injury shown in Figures 29a and 29b as a result of high-speed trauma. Examination reveals diffuse weakness in the lower extremities that is slightly worse on the right side, and decreased rectal tone and sensation. A CT scan is shown in figures 29c and 29d. Definitive treatment of the injury to the spine is delayed because of a severe pulmonary contusion. At 15 days after the injury, the patient’s neurological status remains unchanged. Management should now consist of

Explanation

Anterior decompression is preferred for patients who have incomplete neurologic injury with a compression or burst fracture, if the posterior ligament complex has not been disrupted. Progressive ambulation with a TLSO may be indicated for a simple wedge compression fracture. If the compression is greater than 40% and no neural deficit, then posterior stabilization may be indicated to prevent further collapse and neural deficit. Wedge compression with subluxation or dislocation indicates disruption of posterior ligament complex requiring posterior instrumentation and fusion. Compression and distraction injuries of the middle complex should be treated by Harrington or C-D distraction and compression instrumentation. (Bohlman: The Spine, 1992 pp1047-1056)

Question 40

A 23-year-old man is injured in a motorcycle accident and has a Glasgow Coma Scale (GCS) score of 10. His fiance arrives shortly after he does. He has an open, IIIc tibial fracture. The patient's parents are on the way but are not expected to arrive for some time. Who should be asked to provide informed consent?

Explanation

With a GCS of 10, the patient is not capable of providing consent nor does the fiancTe have legal standing to do so. This is an emergency and waiting for the parents is not acceptable. Two surgeons of similar knowledge and experience may confirm the necessity of the procedure.

Question 41

Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic

Explanation

The moving valgus stress test is used in the diagnosis of medial collateral ligament instability of the elbow. The other tests apply a varus force to the elbow and are used to diagnose lateral ulnar collateral insufficiency.

Question 42

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

Explanation

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

Question 43

A 6-year-old girl has the bilateral foot deformity shown in Figure 1. There is no family history of disease. Examination reveals fixed hindfoot equinus, and muscle function testing shows strong posterior tibial function, fair plus anterior tibial function, poor peroneal function, and strong gastrocnemius function. A Coleman block test shows a correctable hindfoot. Nerve conduction velocity studies show diminished function in the peroneal and ulnar nerves on both sides. Pathologic changes found in a sural nerve biopsy include “onion bulb” formation, and DNA testing confirms the presence of a mutation in the MPZ gene, consistent with hereditary motor sensory neuropathy type III (HMSN-III). What is the best course of action?

Explanation

DISCUSSION: The patient has HMSN-III or Dejerine-Sottas syndrome. This form of HMSN progresses very rapidly and frequently results in severe foot deformity in early childhood. The changes are progressive and are the result of muscle imbalance during growth. Balancing of the foot musculature is essential, particularly during the phases of rapid growth of the foot. However, this cannot be accomplished using the anterior tibial muscle because it is already weak and the transfer will further weaken it. Bony procedures also may be required, and tendon transfers cannot be depended on to correct bony deformity. However, these procedures can be deferred until the foot is closer to adult size. Surgeries that lead to joint arthrodesis, such as triple arthrodesis and some midfoot osteotomies, are contraindicated because the feet may lose protective sensation as the disease progresses. Fusions in insensate feet are less successful than realignment procedures that maintain mobility.
REFERENCES: Wetmore RS, Drennan JC: Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease. J Bone Joint Surg Am 1989;71:417-422.
Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth. J Bone Joint Surg Br 1989;71:17-20.
Miller GM, Hsu JD, Hoffer MM, Rentfro R: Posterior tibial tendon transfer: A review of the literature and analysis of 74 procedures. J Pediatr Orthop 1982;2:363-370.

Question 44

Figures 75a and 75b are the radiographs after attempted reduction of an injury in a 9-year-old girl. Which anatomic structure is most likely to be interposed?

Explanation

DISCUSSION
The injury shown is a flexion-type supracondylar humerus fracture. The most commonly interposed anatomic structure is the ulnar nerve. The brachialis muscle is often interposed in extension-type fractures, as are the median nerve and radial artery. The radial nerve is at risk for entrapment in a humeral shaft fracture or distal third humeral fracture.

CLINICAL SITUATION FOR QUESTIONS 76 THROUGH 80
Figure 76 is the clinical photograph of an infant with foot deformities.

Question 45

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Explanation

The CT scan shows a stress fracture of the olecranon. This injury is the result of repetitive abutment of the olecranon into the olecranon fossa, traction from triceps activity during the deceleration phase of the throwing motion, and impaction of the medial olecranon onto the olecranon fossa from valgus forces. Fractures may be either transverse or oblique in orientation. Initial treatment consists of rest and temporary splinting. Electrical bone stimulation may also be considered. Open fixation with a large compression screw is recommended when nonsurgical management has failed to provide relief.

Question 46

Randomized controlled trials can be designed in several ways. Which of the following study designs refers to a randomized controlled trial in which two interventions are compared within the same study group?

Explanation

A factorial randomized control trial design is more easily represented in a two by two table. Practically, patients are randomized to either treatment A and B, treatment A or control, treatment B or control, or no treatment. The strength of this trial design is that two interventions can be assessed with the same study population. Also, any interaction between the treatments can be determined (for example, does treatment A work differentially when combined with treatment B). The parallel design trial is the simplest and most classic design for a randomized controlled trial. In this trial design, participants are randomized to two or more groups of different treatments and each group is exposed to a different intervention and only that intervention. In the crossover design trial, both groups receive both interventions over a randomly allocated time period. Group A can receive the treatment, and after a suitable washout period, can receive the placebo. Group B can receive the placebo and later can receive the treatment; this produces within-participant comparisons. The crossover trial design has a limited role in surgical interventions because it is difficult or impossible for patients to receive both treatment interventions, such as plate and nail fixation, or a cemented versus a cementless total hip arthroplasty. Case control and case series are not randomized trials, but observational studies.

Question 47

Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with a higher complication rate among

Explanation

DISCUSSION
Studies of titanium elastic nailing for femur fractures demonstrated a higher rate of complications, including angular deformity and construct failure, among patients weighing more than 50 kg (100 pounds). Other methods of fixation are recommended for these patients. Flexible nails are not commonly needed, but they also are not associated with a higher complication rate in children younger than age 6.5. Titanium elastic nailing works well in closed or minimally open transverse midshaft fractures, even in the setting of early or immediate weight bearing.

Video 8a
Video 8b

Question 48

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete's shoulder?

Explanation

The goal in the initial phase of shoulder rehabilitation is to improve flexibility, reestablish baseline dynamic stability, normalize muscle balance, and restore proprioception. In the advanced strengthening and final phase, the goals are to initiate aggressive strengthening drills, enhance power and endurance, perform functional drills, and to gradually initiate throwing activities.

Question 49

Figures 42a and 42b show the radiographs of a 52-year-old man who sustained a fall from a motorcycle 6 months ago and now reports pain and stiffness in his left shoulder. What is the most reliable treatment to improve function and comfort of the shoulder? Review Topic

Explanation

Appropriate treatment is based on multiple considerations, which include the chronicity of the dislocation, the amount of humeral head involvement, the medical condition, and functional limitations of the patient. It has been shown that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Transfer of the lesser tuberosity with its attached subscapularis tendon into the defect is recommended for anteromedial humeral defects that are smaller than approximately 40% of the joint surface. Subscapularis transfer as described by McLaughlin and the modification thereof later described by Hawkins and associates in which the lesser tuberosity is transferred into the defect, have yielded good results if the defect is less than 40% of the humeral head. Prosthetic replacement is preferred for larger defects. If the dislocation is less than 3 weeks old and has less than 25% of humeral head involvement, closed reduction with the patient under general anesthesia should be attempted and the stability assessed by internally rotating the arm. If the arm can be safely internally rotated to the abdomen, then 6 weeks of immobilization in an orthosis that maintains the shoulder in slight extension and external rotation can yield a good result. If the dislocation has been present for more than 3 weeks, closed reduction becomes exceedingly difficult.

Question 50

Which nerve is not included in a standard popliteal nerve block?

Explanation

42A

B
Figures 42a and 42b are the radiographs of a 32-year-old man with an accessory navicular, pes planovalgus deformity, and an associated gastrocnemius contracture. He has been treated with custom orthotics and a physical therapy program for several years and has progressed to stage II posterior tibial tendon dysfunction (PTTD). This patient is now interested in surgery. Tendon reconstruction with bony procedure to correct alignment, medializing calcaneal osteotomy with lateral column lengthening, and a subtalar arthroereisis implant are discussed with the patient.

Question 51

An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play? Review Topic

Explanation

Infectious mononucleosis commonly affects adolescents and young adults. It is a febrile illness accompanied by acute pharyngitis. Splenomegaly may occur and predispose the athlete to splenic rupture. Splenic rupture has been reported in nonathletes as well as in patients with normal-sized spleens. Clinical evidence supports a return to all sports 4 weeks after the onset of symptoms provided that the spleen has returned to normal size.

Question 52

Which of the following is an advantage of using blocking screws for tibial nailing?

Explanation

DISCUSSION: Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. There are no studies as of yet that find a blocking screw to decrease nail failure.
Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.
In a later clinical study, Krettek found that after using blocking screws, tibial healing was evident radiologically at a mean of 5.4 months with a decreased rate of malunions.
Ricci also found that blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.

Question 53

Which of the following tissues used for anterior cruciate ligament (ACL) reconstruction has the highest maximum load to failure?

Explanation

DISCUSSION: While the patellar tendon ligament is considered by many to be the tissue of choice for ACL reconstruction, more recent studies have shown that the quadruple semitendinosus and gracilis tendon graft has the greatest stiffness and offers the highest maximum load to failure.
REFERENCES: Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.
Cooper DE, Deng XH, Burstein AL, Warren RF: The strength of the central third patellar tendon graft: A biomechanical study. Am J Sports Med 1993;21:8l8-823.
Brown CH Jr, Steiner ME, Carson EW: The use of hamstring tendons for anterior cruciate ligament reconstruction: Technique and results. Clin Sports Med 1993;12:723-756.
Engebretsen L, Lewis JL: Graft selection and biomechanical considerations in ACL reconstruction. Sports Med Arthroscopy Rev 1996;4:336-341.

Question 54

A 31-year-old man sustained an unstable closed left posterior hip dislocation in a motorcycle accident. A postreduction radiograph is shown in Figure 51a. 3-D CT scans are shown in Figures 51b and 51c. What is the optimal surgical approach that will allow for the most appropriate treatment?

Explanation

The radiograph and CT scans show a posterior wall acetabular fracture with an associated femoral head fracture. As is the case in most of these injuries, the femoral head fracture is located on the anterior aspect of the femoral head. Surgical dislocation with a trochanteric flip osteotomy as described by Solberg and associates and Henle and associates allows for exposure and treatment of the posterior wall fracture as well as surgical dislocation for treatment of the femoral head fracture. A Smith-Peterson approach or Watson-Jones approach would allow for anterior exposure and may help to address the femoral head fracture, but not the posterior wall fracture. A Kocher-Langenbach approach would allow exposure of the posterior wall fracture, but not the femoral head fracture. An extensile iliofemoral approach is unnecessary for this injury pattern.

Question 55

Which of the following are considered characteristic features of degeneration of a disk?

Explanation

DISCUSSION: Gradual dessication of the disk begins in the third decade as glycosaminoglycan levels within the nucleus begin to decline. The original water content of 88% decreases to 70% in the sixth decade and beyond. As glycosaminoglycan content decreases, there is a corresponding increase in noncollagen glycoprotein.
REFERENCES: Happey F, Weissman A, Naylor A: Polysaccharide content of the prolapsed nucleus pulposus of the human intervertebral disc. Nature 1961;192:868.
Naylor A, Shentall R: Biomechanical aspects of intervertebral discs in aging and disease, in Jayson M (ed): The Lumbar Spine and Back Pain. New York, NY, Grune and Stratton Inc, 1976, pp 317-326.
Watkins RG, Collis JS: Lumbar Discectomy and Laminectomy. Rockville, MD, Aspen, 1987, pp 2-3.

Question 56

A 23-year-old baseball pitcher who has diffuse pain along the posterior deltoid reports pain during late acceleration and follow-through. Examination of his arc of motion from external rotation to internal rotation at 90 degrees of shoulder abduction reveals a significant deficit in internal rotation when compared to the nonthrowing shoulder. Initial management should consist of

Explanation

DISCUSSION: Loss of internal rotation is common among overhead throwers and tennis players. Posterior capsular stretching can improve symptoms when accompanied by rest and gradual resumption of throwing. To avoid a false impression of improvement, cortisone injection is not recommended. Pitching through pain can cause further damage to the labrum and capsule. A sling and external rotator strengthening will not improve internal rotation.
REFERENCES: Kibler WB: Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med 1995;14:79-85.
Jobe FW, Tibone JE, Jobe CM, Kvitne RS: The shoulder in sports, in Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, pp 961-990.

Question 57

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

Explanation

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

Question 58

Figure A is the lateral view of a left knee cadaveric specimen that has the extensor mechanism removed. Which two structures labeled provide the most rotational stability in knee flexion? Review Topic

Explanation

The politeus tendon (C) and the popliteofibular ligament (D) are the lateral knee structures that provide the most rotational stability in knee flexion. The lateral collateral ligament (B) provides varus stability and rotational stability in knee
extension.
The lateral knee is stabilized by 28 unique static and dynamic structures. These structures work in concert to resist varus gapping and rotational knee instability. The three primary stabilizers include the fibular or lateral collateral ligament (LCL), the popliteus tendon (PT) and the popliteofibular ligament (PFL). Injury to these ligaments results in increased forces seen on ACL and PCL ligament reconstruction grafts with combined posterolateral corner (PLC) injuries, which can result in graft failure if the PLC is not reconstructed as well.
James et al reviewed the anatomy and biomechanics of the lateral knee stabilizers, detailing the specific functional contributions of the individual structures. The LCL is the primary restraint to varus instability, the highest forces occurring at knee extension (0°-30°). The PT and PFL serve as restraints to rotational instability, the highest forces occurring at knee flexion (60°-90°).
LaPrade et al reviewed the anatomy and biomechanics of the medial knee stabilizers. The three key static stabilizers are the superficial medial collateral ligament (sMCL), the deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). The sMCL is the primary restraint to valgus instability (proximal sMCL) and secondary restraint to rotational instability (distal sMCL) at all knee flexion angles. The dMCL is a secondary restraint to valgus and rotational instability. The POL is the primary restraint to rotational instability.
Figure A depicts the lateral knee structures in a cadaver specimen (A = lateral meniscus, B = LCL, C = PT, D = PFL, E = lateral head of gastrocnemius). Illustration A is a labeled picture of the lateral knee structures. Illustration B is a table from James et al demonstrating the change in forces experienced by the different lateral stabilizers at varying degrees of knee flexion. You see the LCL resists rotation at 0°-30° (extension) while the PT and PFL resist rotation at 60°-90° (flexion).
Incorrect Responses:

Question 59

Figures 8a through 8d show the radiographs and CT scans of a 14-year-old girl who has a painful, rigid planovalgus foot. Management consisting of arch supports and anti-inflammatory drugs failed to provide relief. A below-knee walking cast resulted in pain resolution, but she now reports that the pain has recurred. Management should now consist of

Explanation

DISCUSSION: Tarsal coalitions commonly present in the preadolescent age group as a rigid, planovalgus foot. Small coalitions of the calcaneonavicular joint or the middle facet of the talocalcaneal joint can be excised with interposition of fat or muscle tissue. Isolated calcaneocuboid joint coalitions are very rare. This patient has an associated large talocalcaneal coalition; therefore, resection is contraindicated. Surgery is warranted after failure of nonsurgical management, and because of the involvement of two joints, the only viable option for the severely symptomatic foot is triple arthrodesis.
REFERENCES: Vincent KA: Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg 1998;6:274-281.
Olney BW: Tarsal coalition, in Drennan JC (ed): The Child’s Foot and Ankle. New York, NY, Raven Press, 1992, pp 169-181.

Question 60

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern?

Explanation

DISCUSSION: Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.
REFERENCE: Skubic JW, Kostuik JP: Thoracic pain syndromes and thoracic disc herniation, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, pp 1443-1464.

Question 61

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Explanation

DISCUSSION: Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position.
REFERENCES: Crawford GP: The molded polyethylene splint for mallet finger deformities.

J Hand Surg Am 1984;9:231-237.
Wehbe MA, Schneider LH: Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.

Question 62

Figures below show the radiographs obtained from a 19-year-old woman with a 3-year history of progressive hip pain in the left groin with activity, which is unresponsive to activity modification and physical therapy. Examination reveals normal range of motion, with pain on anterior impingement testing. What treatment is associated with the best long-term results?

Explanation

DISCUSSION:
This patient has symptomatic femoroacetabular impingement as well as clinical and radiographic signs of acetabular retroversion, including a cross-over sign, ischial spine sign, and posterior wall sign bilaterally. Good midterm to long-term outcomes have been reported with reverse (anteverting) Bernese periacetabular osteotomy (PAO). In patients with less retroversion, open or arthroscopic rim trimming with labral refixation have shown good short-term results, but longer-term results have yet to be fully delineated. Isolated hip arthroscopy and labral repair would not be indicated without addressing the retroversion deformity. Femoral varus rotational osteotomy plays no role in the treatment of this pathology. Open surgical dislocation with rim trimming could be considered in patients with less deformity, but some studies have shown inferior long-term results compared with reverse PAO.

Question 63

A 50 year old man who has insulin-dependent diabetes mellitus with associated neuropathy has a stress fracture of the fourth metatarsal. Examination of the foot reveals acute swelling, warmth, and erythema; however, the patient reports very little pain. Treatment should include

Explanation

The approach to the diabetic foot is a challenging problem. The team approach has taken various forms and venues with the basic principles being the same: education, prevention, follow up and aggressive care. Custom shoes, custom-molded inserts, and increased depth shoes are being used in treatment as well as prevention. Brand documented that repeated low-energy trauma is the cause of most skin breakdown with impaired sensation. Responses 3 and 5 can be eliminated since they are not custom. Compression bandage can cause minor trauma and ischemic problems if sensation is altered. Electrical stimulation is not used for acute fractures. A total contact cast will relieve pressure areas. This should be monitored closely since swelling will decrease and with movement in the cast, minor trauma may occur.

Question 64

Which of the following is associated with the use of bisphosphonates in the setting of metastatic breast cancer to the spine?

Explanation

DISCUSSION: The indications of bisphosphonate therapy in breast cancer patients range from the correction of hypercalcemia to the prevention of cancer treatment-induced bone loss. Bisphosphonates reduce metastatic bone pain in at least 50% of patients and can reduce the frequency of skeletal-related events by 30% to 40%. Osteonecrosis of the jaw could occur in up to 2.5% of breast cancer patients during long-term bisphosphonate therapy.
REFERENCE: Body JJ: Breast cancer: Bisphosphonate therapy for metastatic bone disease. Clin Cancer Res 2006;12:6258s-6263s.

Question 65

A 28-year-old man was shot in the foot with a .22 caliber handgun approximately 2 hours ago. Examination reveals an entrance wound dorsally and a plantar exit wound. The foot is neurovascularly intact. Radiographs reveal a nondisplaced fracture of the third metatarsal. Soft-tissue management for this injury should consist of

Explanation

DISCUSSION: The patient has sustained a low-velocity, low-caliber gunshot wound to the foot. Because the injury occurred within a period of 8 hours, this is classified as a type I wound. Several studies support the use of surface debridement, cleansing, and sterile dressings as the treatment of choice. More aggressive measures are reserved for high-velocity injuries and shotgun injuries.
REFERENCES: Brettler D, Sedlin ED, Mendes DG: Conservative treatment of low velocity gunshot wounds. Clin Orthop 1979;140:26-31.
Hampton OD: The indications for debridement of gunshot bullet wounds of the extremities in civilian practice. J Trauma 1961;1:368-372.
Marcus NA, Blair WF, Shuck JM, Omer GE Jr: Low-velocity gunshot wounds to extremities. J Trauma 1980;20:1061-1064.

Question 66

Which of the following is considered a limitation of the Short Form 36 (SF-36) general health status instrument when applied to musculoskeletal conditions?

Explanation

Health outcome surveys are often either general or condition specific. The SF-36 (a general health-based survey) is the most widely applied general health status instrument. It measures three aspects of health: functional ability, well being, and overall health. Eight domains of quality of life are measured to quantify these aspects. It is designed to be self-administered by the patient. Because it is a patient-derived assessment, with patient-derived outcome measures, the patient's perspective is integrated and objectivity enhanced. The inherent bias of surgeon-driven formats is thus avoided. The SF-36 has been validated and normative population data obtained.
Multilingual validated translations have been produced in addition to international population data sets. The survey can be patient self-administered via office visit, mail, or telephone. A bias of lower over upper extremity function with regard to outcome measures employing the SF-36 has been demonstrated. Limits on the detection of certain changes in quality of life status may impose ceiling and floor effects on analysis and interpretation.

Question 67

A 23-year-old otherwise healthy 6-ft, 4-in basketball player complains of pain in his knees. An examination reveals localized tenderness to palpation over the inferior pole of the patella. The patient notes a significant exacerbation of his pain when the examiner takes the knee from flexion to extension. Review Topic

Explanation

Patellar tendonitis is common in jumping sports such as basketball and volleyball. The pain is localized to the inferior border of the patella and is exacerbated by extension of the knee. Treatment for the vast majority of patients is nonsurgical and includes nonsteroidal anti-inflammatory drugs, physical therapy, and orthoses (patella tendon strap). Iliotibial band friction most commonly occurs in cyclists and runners (especially those who run up hills) and is a result of abrasion between the iliotibial band and the lateral femoral condyle. Localized tenderness with the knee flexed at 30 degrees is common. The Ober test may be helpful in making the diagnosis. Semimembranosis tendonitis most commonly occurs in male athletes during their fourth decade of life. The diagnosis is usually made with an MRI scan or nuclear imaging. Quadriceps tendonitis is similar to patellar tendonitis but is much less common. The pain may be associated with clicking and is localized to the superior border of the patella.

Question 68

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Explanation

DISCUSSION: It is well known that suprascapular nerve entrapment can be secondary to many entities, and its association with ganglion cysts and SLAP lesions has been well documented. Because of a superior labral tear, synovial fluid will leak out of the joint underneath the labrum, causing the cyst and secondary compression of the nerve.
REFERENCES: Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: A report of six cases with arthroscopic findings and review of the literature. Arthroscopy 1995;11:727-734.
Iannotti JP, Ramesey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy 1996;12:739-745.
Moore TP, Fritts HM, Quick DC, Buss DD: Suprascapular nerve entrapment caused by supraglenoid cyst compression. J Shoulder Elbow Surg 1997;6:455-462.

Question 69

A 29-year-old woman who underwent an anterior cruciate ligament (ACL) reconstruction 6 months ago now reports difficulty achieving full knee extension, and physical therapy fails to provide relief. The knee is stable on ligament testing. Figure 3 shows the findings at a repeat arthroscopy. Treatment should now include

Explanation

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.

REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 70

0 sustained a subcapital fracture of her hip. She is an avid tennis player, and history reveals no previous fractures. What is the most appropriate follow-up care? Review Topic

Explanation

A DEXA scan is most appropriately used to establish a baseline score. Even if the bone mineral density is not within the osteoporotic range (T-score less than -2.5), a prior fragility fracture is a strong risk factor for a second fracture as a result of factors other than bone density, such as worsening vision or balance, confusion, or other predispositions to falls. The guidelines of the National Osteoporosis Foundation indicate that, following a fragility hip fracture, active anti-osteoporotic medication should be initiated, whether or not a DEXA scan is performed. A recent study showed that antiresorptive therapy following a hip fracture reduces not only the risk of a second fracture but also overall mortality.

Question 71

What is the most prevalent adverse event associated with allogeneic blood transfusion?

Explanation

DISCUSSION: Clerical error leading to acute hemolysis and even death occurs in 1:12,000 to 1:50,000 transfusions. Bacterial contamination leading to sepsis/shock occurs in 1:1 million transfusions. HIV transmission is approximately 1:500,000 transfusions and hepatitis C is 1:103,000 transfusions. Anaphylactic reactions occur in 1:150,000 transfusions.
REFERENCES: Aubuchon JP, Birkmeyer JD, Busch MP: Safety of the blood supply in the United States: Opportunities and controversies. Ann Intern Med 1997;127:904-909.
Popovsky MA, Whitaker B, Arnold NL: Severe outcomes of allogeneic and autologous blood donation: Frequency and characterization. Transfusion 1995;35:734-737.

Question 72

A 13-year-old quarterback feels a “pop” in his knee while being tackled. Radiographs of the knee and results of a Lachman’s test are normal. Examination reveals tenderness over the distal femoral physis. To help confirm the diagnosis, management should first include

Explanation

Injuries involving the distal femoral epiphysis cartilage plate are fairly common. Appropriate management should include a complete knee exam with a standard series of X-rays. Of particular importance is to notice any varus or valgus deformity. Stephens et al. (JBJS 1974:56A) measured varus and valgus deformities clinically and roentgenographically. A varus or valgus deformity greater than 3 degrees as compared with the uninjured side was considered clinically significant. Such deformities are highly suggestive of a physeal injury. A MRI may show the injury, but is expensive as is an arthroscopy or examination under anesthesia.

Question 73

A 10-year-old girl is seen in the emergency department after being involved in a motor vehicle accident. She has right hip pain and is unable to bear weight. She has no neurovascular deficits and no other injuries. Radiographs reveal a posterior dislocation of the right hip without apparent fracture. The acetabulum appears to be developing normally. What is the best course of treatment? Review Topic

Explanation

Hip dislocation in the pediatric population is a rare event. However, prompt recognition and rapid care for this injury is imperative to avoid future hip problems including osteonecrosis of the femoral head (a devastating problem for a pediatric patient). Reduction maneuvers can create violent impact between the posterior wall of the (intact) acetabulum and the femoral head, resulting in shearing of the proximal femoral physis and displacement of the epiphysis from the remainder of the femoral head in skeletally immature patients. Therefore, deep sedation with good muscle relaxation, such as that achieved with general anesthetic, is recommended. Reduction is best accomplished with fluoroscopy for a number of reasons, including assessment of concentricity of the hip joint after reduction, and to detect any catastrophic femoral head physeal separation that occurs during the reduction maneuver. Sedation in the emergency department is often insufficient to achieve acceptable muscle relaxation for the patient. Open reduction is only indicated if closed reduction fails completely or if the hip is not concentric after an apparently successful closed reduction

Question 74

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to Review Topic

Explanation

Kayanja and associates, in a number of biomechanical studies, showed that in a kyphotic spine the strain is located at the apex of the deformity, the force is transmitted to the superior adjacent vertebrae, and that realignment and cement augmentation effectively normalize the load transfer.

Question 75

Figure 3 shows the radiographs of a 32-year-old man who fell 12 feet onto his outstretched arm and sustained a fracture-dislocation of the elbow. Initial management consisted of closed reduction of the dislocation. Surgical treatment should now include repair or reduction and fixation of the

Explanation

DISCUSSION: The radiographs show fractures of the coronoid and radial head. The medial collateral ligament has been avulsed from the ulnar insertion, and there is a valgus opening on the medial side. The lateral collateral ligament is always disrupted in elbow dislocations and fracture-dislocations that occur secondary to falls. This is known as the terrible triad injury (dislocation and fractures of the coronoid and radial head); it has a very poor prognosis because of its propensity for recurrent or persistent instability and late arthritis. The principle in treating this injury is to repair all of the injured parts or protect them with a hinged external fixator until they heal.
REFERENCES: Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 345-354.
Kasser JR (ed): Orthopaedic Knowledge Update 5. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 283-294.
O’Driscoll SW, Jupiter JB, King GJ, Hotchkiss RN, Morrey BF: The unstable elbow. Instr Course Lect 2001;50:89-102.

Question 76

Figures 1 through 4 are the wrist MR images of a 43-year-old right-hand-dominant bricklayer who reports gradually progressive left hand weakness for 4 months. He describes difficulty gripping objects, tying his shoes, and holding utensils. He denies any numbness, paresthesias, or a previous injury. An examination reveals intact sensation in a median, radial, and ulnar nerve distribution. He has atrophy of hand interossei and a positive Froment sign finding. He has no Tinel sign finding at the wrist or elbow and no exacerbation of symptoms with elbow hyperflexion. Electromyography shows signs of denervation in an ulnar nerve distribution distal to the wrist. What is the best next step?

Explanation

The MR images show a lesion consistent with a ganglion cyst located near the hook of the hamate. The ulnar nerve divides into motor and sensory branches just proximal to this lesion. In this case, the ganglion cyst compresses the ulnar nerve motor branch but not the sensory branch, resulting in motor dysfunction but no sensory disturbance. Excision of the ganglion cyst should alleviate his symptoms. Compression of the ulnar nerve proximal to the motor branch take-off (in either the cubital tunnel or proximal Guyon’s canal) would cause both sensory and motor dysfunction. Although chronic nonunion of the hook of the hamate can cause ulnar nerve symptoms, the hook of the hamate appears intact on the MR image. The MR image shows a lesion that is well circumscribed with high intensity on T1 and T2 images, consistent with a benign ganglion cyst, and ganglion cysts are relatively common lesions in this area.

Question 77

A 50-year-old man fell from a ladder onto his left shoulder and sustained the injury shown in the radiographs in Figures 71a and 71b. He underwent surgery with repair of the coracoclavicular ligaments and deltotrapezial fascia with coracoclavicular screw placement. Which of the following statements regarding postoperative complications is most accurate? Review Topic

Explanation

Whereas pain and functional disturbance may persist with nonsurgical management, the lack of articular surface contact prevents arthritic symptoms from developing. Cartilage injury caused by trauma and any persistent joint incongruity following repair would contribute to posttraumatic arthritis. Pinning across the acromioclavicular joint has a high incidence of hardware migration and potential catastrophic consequences. Most cases of lost fixation of coracoclavicular screws are at the level of the thread purchase in the coracoid. Routine hardware removal at 8 to 12 weeks is recommended to avoid screw breakage because of natural movement between the clavicle and scapula. The axillary nerve passes around the inferior edge of the subscapularis and is anatomically distant to the the coracoid. The musculocutaneous nerve would have the closest anatomic position to the coracoid.

Question 78

If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely

Explanation

DISCUSSION
For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder
abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation.
During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. In a prospective database of 3633 patients who sustained a traumatic anterior glenohumeral dislocation, 13.5% had a neurologic deficit following reduction, the majority of which were injuries to the axillary nerve. The injuries typically were sensory but not motor deficits and resolved spontaneously over time. These isolated axillary nerve injuries were more common in young, athletic patients. Associated rotator cuff tears and greater tuberosity fractures are commonly associated with shoulder dislocation as well and are more common in patients 60 years of age and older.
Large, engaging posterior humeral head Hill-Sachs lesions are associated with increased rates of recurrent shoulder instability. At the time of surgical arthroscopy, the Hill-Sachs lesion should be assessed for engagement with the glenoid. In the absence of significant glenoid bone loss, some patients with engaging Hill-Sachs defects may be suitable for combined Bankart repair and Hill-Sachs remplissage at the time of surgery. When these procedures are combined, patients have an approximate 10-degree decreased shoulder external rotation with the arm at the side and in abduction when compared to the contralateral, uninjured shoulder. Rates of recurrent dislocation and return to sport are comparable to those for patients undergoing Bankart repair alone.
Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can occur in isolation or, more commonly, may be associated with other abnormalities such as a tear of the rotator cuff, Bankart lesion, Hill-Sachs deformity, or labral tear. Recurrence of shoulder instability is more likely to occur if there is failure to identify a HAGL lesion. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.
RECOMMENDED READINGS
Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):675-85. PubMed PMID: 1456361. View Abstract at PubMed
Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012 Jan 4;94(1):18-26. doi: 10.2106/JBJS.J.01795. PubMed PMID: 22218378. View Abstract at PubMed
Visser CP, Coene LN, Brand R, Tavy DL. 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 Jul;81(4):679-85. PubMed PMID: 10463745. View Abstract at PubMed
Boileau P, O'Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012 Apr 4;94(7):618-26. doi: 10.2106/JBJS.K.00101. PubMed PMID: 22488618. View Abstract at PubMed
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review. PubMed PMID: 17420506. View Abstract at PubMed

Question 79

In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?

Explanation

DISCUSSION: In the Lauge-Hansen classification, the characteristic fibular fracture pattern in a pronation-abduction injury is a comminuted fibular fracture above the level of the syndesmosis. In the first stage of this injury pattern, the deltoid fails in tension, or an avulsion fracture of the medial malleolus occurs. In the second stage, the anterior inferior tibiofibular ligament ruptures, or a small bony avulsion of this ligament's insertion/origin occurs. The final stage includes the creation of a comminuted fibular fracture above the level of the syndesmosis. The referenced article by Siegel et al noted that extraperiosteal bridge plating of these ankle injuries was safe and had excellent radiographic and clinical outcomes at final follow-up.

Question 80

A 45-year-old tennis player undergoes surgery for chronic lateral epicondylitis. After returning to play, he notes increasing lateral elbow pain with mechanical catching and locking. Examination shows positive supine posterolateral rotatory instability. What ligament has been injured? Review Topic

Explanation

The patient has sustained an iatrogenic injury to the lateral ulnar collateral ligament. This injury has been reported after lateral approaches to the elbow. The orbicular, annular, and lateral radial collateral ligaments have a much less important role in lateral elbow stability. The anterior band of the ulnar collateral ligament is on the medial side of the elbow and is important for valgus stability.

Question 81

What antithrombotic agent is a selective factor I0a inhibitor? Review Topic

Explanation

Rivaroxaban is a selective factor I0a inhibitor. Aspirin is a cyclooxygenase inhibitor. Low-molecular-weight heparin is a nonspecific anticoagulant. Warfarin is a vitamin K antagonist and reduces production of clotting factors II, VII, IX, and X.

Question 82

Figure below depicts the radiograph obtained from a 30-year-old woman who began having more right than left hip pain during a recent pregnancy. Physical examination reveals increased range of motion with positive flexion abduction and external rotation and flexion adduction and internal rotation as well as pain with external logroll. Assessment of Figure below reveals

Explanation

DISCUSSION:
Studies have demonstrated that pelvic inclination can dramatically affect the interpretation of radiographs in the dysplastic hip, with 9° of increased pelvic inclination leading to the presence of crossover signs and posterior wall signs. A distance of 30 mm to 50 mm from the sacrococcygeal junction to the pubis is often used to assess the adequacy of pelvic inclination on radiographs, although Siebenrock and associates determined the mean difference to be 32 mm in men and 47 mm in women. In this patient, the pelvic inclination is dramatically increased, leading to overestimation of acetabular retroversion.

Question 83

A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Explanation

This patient has a tension pneumothorax and needs immediate decompression to convert it to a simple pneumothorax until definitive treatment with a chest tube can be performed. The other choices are inappropriate.

Question 84

An otherwise healthy 32-year-old man who underwent an uneventful L5-S1 lumbar microdiskectomy 6 weeks ago now reports increasing and severe back pain that awakens him from sleep. Examination reveals a benign-appearing wound, and the neurologic examination is normal. Laboratory studies show an erythrocyte sedimentation rate (ESR) of 90 mm/h and a WBC of 9,000/mm3. Plain radiographs are normal. What is the next most appropriate step in management?

Explanation

DISCUSSION: The patient’s history and laboratory studies are very suspicious for a postoperative diskitis. The predominant symptom often is back pain. An ESR of 90 mm/h is considered significantly elevated and normally would be expected to return to near baseline by 2 weeks postoperatively. A normal WBC result is not unusual with postoperative diskitis. Management should consist of an MRI with gadolinium to confirm the diagnosis, followed by a biopsy percutaneously to obtain tissues for pathology and microbiology. Surgical debridement is reserved for patients whose percutaneous biopsy results are negative and a high index of suspicion for diskitis remains, or when management consisting of IV antibiotics, bed rest, and spinal immobilization fails to provide relief.
REFERENCES: Garfin SR, Vaccaro AR (eds): Orthopaedic Knowledge Update: Spine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 257-271.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 713-721.

Question 85

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Explanation

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,

WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.

Acta Chir Scand 1941;84:1.

Question 86

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Explanation

Open chain exercises of the lower extremity are defined as "The foot is mobile, and motion at the knee joint occurs independent of motion at the hip and ankle joints, as opposed to closed chain exercises in which the foot is fixed and motion at the knee joint is accompanied by motion at the hip and ankle joints in a predictable manner.

Question 87

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Explanation

DISCUSSION: The maximum stress in a bone occurs at the periosteal surface (the greatest distance from the center of the bone). The magnitude of the stress is equal to the magnitude of the applied moment (M) multiplied by the distance to the surface (roughly the radius of the bone, r) divided by the area moment of inertia (I), so that stress = Mr/I. Of the possible answers, only area moment of inertia of the cross section contains any of these three items. The stress can also depend on the length of the bone, but it cannot be determined without knowing the location at which the bending load is applied, information that was not given in the problem. The type of structural support may influence local stresses where the support contacts the bone, but it has little effect on the maximum stress in the bone. The cross-sectional area is not as important as the area moment of inertia because the stress is not evenly distributed over the cross-section. Plastic modulus is a material property, not a geometric or structural property, and it does not affect stress.
REFERENCES: Hayes WC, Bouxsein ML: Biomechanics of cortical and trabecular bone: Implications for assessment of fracture risk, in Mow VC, Hayes WC (eds): Basic Orthopaedic Biomechanics, ed 2. New York, NY, Lippincott-Raven, 1997, pp 76-82.
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 161-167.

Question 88

A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. What is the most common sentinel event related to spine surgery?

Explanation

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 89

A 56-year-old man who underwent a left total hip arthroplasty 8 years ago is seen following a fall from a standing height. A radiograph obtained at 2 years postoperatively is shown in Figure 55a and a current radiograph obtained in the emergency department is shown in Figure 55b. On further questioning, he reports pain in this thigh for the past 3 years that has been increasing in intensity. Appropriate management at this time includes which of the following?

Explanation

DISCUSSION: The patient has a Vancouver type B2 periprosthetic femoral fracture with a loose, cementless femoral component. Radiographs show subsidence of the femoral component and the patient reports pain in the thigh for several years prior to the fall. When the femoral component is loose, revision is mandated to treat both the loose component and the fracture. Nonsurgical management is associated with a high risk of medical complications related to extended recumbency as well as a high rate of malunion and nonunion. Cementless femoral component revision has been shown to fare better than cemented femoral components, particularly for treating periprosthetic fractures of the femur.
REFERENCES: Masri BA, Meek RM, Duncan CP: Periprosthetic fractures evaluation and treatment. Clin Orthop Relat Res 2004;420:80-95.
Springer BD, Berry DJ, Lewallen DB: Treatment of periprosthetic femoral fractures following total hip
arthroplasty with femoral component revision. J Bone Joint Surg Am 2003;85:2156-2162. Question 56
A 62-year-old woman who underwent a primary total knee arthroplasty under a combined spinal-epidural anesthetic presents 5 hours postoperatively with severe pain in the extremity that is unresponsive to narcotic pain medication. A tourniquet was used during the procedure. On examination, the patient is unable to dorsiflex or plantar flex the foot and the pulses appear to be asymmetric. What is the next most appropriate step in management?
Discontinuation of the epidural and serial neurologic exams
Loosening of the surgical bandages and elevation of the extremity
MRI of the spine to evaluate for an epidural hematoma
Return to the operating room for angiography and vascular bypass
Return to the operating room for angiography, vascular bypass, and four-compartment fasciotomy PREFERRED RESPONSE: 5
DISCUSSION: The patient has clinical evidence of vascular injury and compartment syndrome. An emergent
vascular consult and a return to the operating room for an angiogram and revascularization are needed. In these situations, thrombectomy alone is often not sufficient and a bypass is typically required. A four-compartment fasciotomy should be done following revascularization of the extremity.
REFERENCES: Calligaro KD, Dougherty MJ, Ryan S, et al: Acute arterial complications associated with total hip and knee arthroplasty. J Vase Surg 2003;38:1170-1177.
Smith DE, McGraw RW, Taylor DC, et al: Arterial complications and total knee arthroplasty. J Am Acad Orthop Surg 2001;9:253-257.
Ninomiya JT, Dean JC, Goldberg VM: Injury to the popliteal artery and its anatomic location in total knee
arthroplasty. J Arthroplasty 1999;14:803-809.

Question 90

A 32-year-old man sustains a pilon fracture which is treated initially with a spanning external fixator, as shown in figure A. He is now 3 weeks from injury and skin swelling has subsided significantly. What is the most appropriate definitive treatment?

Explanation

External fixation is a temporizing treatment that allows the soft tissues to return to normal while maintaining your overall alignment. A fibular plate can help keep the length. Final treatment involves restoration of the tibial plafond articular surface which can only be done with ORIF +/- bone grafting. There is no role for primary arthrodesis in this young patient.
OrthoCash 2020

Question 91

A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

Explanation

This is a simple (no associated fracture) elbow dislocation. Such dislocations can be treated with closed reduction followed by mobilization after 5 to 7 days to avoid stiffness, provided the elbow is stable through a full arc of motion at the time of reduction. If the elbow is unstable but has a short arc of stability, then using a hinged brace in the stable arc may be considered. (Note: It may be necessary to splint the elbow in pronation if the medial collateral ligament [MCL] is intact and the lateral collateral ligament [LCL] is disrupted, or in supination if the LCL is intact but the MCL disrupted.) Surgical reconstruction of the LCL and MCL may be required only if the elbow does not have a stable arc at the time of reduction. If unstable after reconstruction,
application of a hinged external fixator may be considered.

Question 92

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

Explanation

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

Question 93

The gluteus maximus is innervated by which of the following nerves?

Explanation

DISCUSSION: The inferior gluteal nerve supplies the gluteus maximus muscle. The superior gluteal nerve supplies the gluteus medius, gluteus minimus, and tensor fascia lata muscles. The femoral nerve supplies the quadriceps, sartorius, and pectineus muscles. The pudendal nerve is primarily a sensory nerve.
REFERENCE: Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill Livingstone, 1978, pp 146-147.

Question 94

An 18-year-old female Marine Corps recruit enters basic training. Her enlistment history and physical examination showed that she was an elite high school cross country runner. What is her most significant risk factor for a femoral or pelvic stress fracture during basic training?

Explanation

DISCUSSION: Approximately 5% of female recruits incur a stress fracture during the 13 weeks of Marine Corps basic training. Approximately 40% of these were femoral or pelvic stress fractures that were more severe than in civilian athletes or male military recruits. Only women who reported no menses during the previous year had a greater likelihood of femoral or pelvic stress fractures than did women who reported 10 to
12 menses. The referenced study did not find a statistically significant increase in risk of stress fracture in those recruits who had lesser menstrual irregularities in the year prior to recruit training, but there was a trend toward increased risk of stress fracture.
REFERENCES: Shaffer RA, Rauh MJ, Brodine SK, et al: Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006;34:108-115.
Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of
Orthopaedic Surgeons, 2004, pp 273-283.

Question 95

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Explanation

DISCUSSION: The biopsy specimens show a chondromyxoid fibroma with varying amounts of cartilage, benign fibrous tissue, giant cells, and loose myxoid areas. Chondromyxoid fibroma is a benign active bone lesion that is best treated with aggressive curettage and bone grafting. Although recurrences are common, more aggressive treatment is not warranted initially.
REFERENCES: Wilson AJ, Kyriakos M, Ackerman LV: Chondromyxoid fibroma: Radiographic appearance in 38 cases and in a review of the literature. Radiology 1991;179:513-518.
Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 167-189.

Question 96

A 17-year-old presents with persistent left knee pain after a twisting injury during a soccer match 24 hours ago. On physical exam he has a mild effusion. He has tenderness to palpation on the medial joint line. Lachman test, anterior drawer test and posterior drawer test are attempted but limited secondary to pain. Dial test reveals a side-to-side external rotation difference of roughly 5 degrees. His MRI images are seen in Figures A-D. These findings would be most consistent with: Review Topic

Explanation

The patient has sustained a complex tear involving the posterior horn of the medial meniscus. Localizing joint line tenderness is the most sensitive physical examination finding for this injury.
Many provocative tests have been described to aid in the diagnosis of meniscus tears.
The Apley test is performed with the patient prone, by axially loading the tibiofemoral joint at 90° of knee flexion. Pain with compression and external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Ege's test is performed by having the patient squat with their knees maximally externally rotated or internally rotated. The test is positive when pain and/or a click is felt by the patient.
The McMurray test is performed by passively moving the knee from flexion to extension while externally or internally rotating the leg. A palpable click at the joint line with external rotation (medial meniscus) or internal rotation (lateral meniscus) is considered positive.
The Thessaly test is performed by supporting the patient as they internally or externally rotate their knee and body while keeping the foot planted, with the knee in 5° of flexion and then 20° of flexion. The test is positive when joint line pain and/or sense of locking/catching is experienced by the patient.
Ryzewicz et al. performed a systematic review of prospective cohort studies comparing magnetic resonance imaging (MRI) and clinical examination to arthroscopy in the diagnosis of meniscus tears. The Apley test, Ege's test, McMurray test and Thessaly test at 5° were shown have high specificity but low sensitivity. Joint line tenderness has a higher sensitivity, but lower specificity. The Thessaly test at 20° demonstrated the highest sensitivity and specificity, although there was only one available study evaluating this test.
Abdon et al. performed a prospective study looking at 68 clinical parameters to
determine which combinations of symptoms and signs indicated the presence of a meniscus tear. They found that joint-line tenderness and mechanical locking were predictive of a meniscus tear, while the McMurray sign did not prove valuable. Pain at rest, sick leave and medial patellar tenderness all negated the presence of a meniscus tear. The clinical accuracy in diagnosing meniscal tears was 61% in this study.
Figures A and B are T1 sagittal MR images demonstrating an intact anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL), respectively. Figures C and D are T2 coronal and sagittal MR images showing a complex tear of the posterior horn of the medial meniscus. Illustration A demonstrates the Ege's test. Illustration B shows the Thessaly test at 5° of flexion.
Incorrect

Question 97

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Explanation

DISCUSSION: SIS is a devastating but preventable complication of head injury. It occurs when return to activities is allowed prior to complete resolution of the symptoms of the first head injury. A second, sometimes trivial, head injury can lead to a devastating series of events that can result in sudden death. The symptoms tend to progress rapidly and often involve the brain stem. The prognosis is poor.
REFERENCES: Cantu RC: Second-impact syndrome. Clin Sports Med 1998;17:37-44.
Saunders RL, Harbaugh RE: Second impact in catastrophic contact-sports head trauma. JAMA 1984;252:538-539.
Stevenson KL, Adelson PD: Pediatric sports-related head injuries, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, vol 1, p 781.

Question 98

A 19-year-old woman reports lower back pain following a motor vehicle accident. Radiographs obtained immediately after the accident and a bone scan obtained 4 weeks later are shown in Figures 25a through 25c. The patient asks questions regarding the cause, genetics, and natural history of her condition. She should be informed that the condition was

Explanation

DISCUSSION: The radiographs show L5 spondylolysis without spondylolisthesis (slip). The bone scan is normal, indicating that the pars interarticularis fractures are not acute. The incidence of spondylolysis is approximately 5% in the general population. The lesion generally develops in children age 5 to 6 years, and there is a second peak in the adolescent population. There is a familial predisposition, with reported rates of 27% to 69% in close relatives. A recent long-term follow-up study found that 90% of the spondylolisthesis had occurred before the patient’s first visit to the physician. Spondylolisthesis tends to progress during the initial growth spurt and is similar in some respects to idiopathic scoliosis. Progression of a lytic spondylolysis to spondylolisthesis in adulthood has been reported; however, this is exceedingly rare.
REFERENCES: Lauerman WC, Cain JE: Isthmic spondylolisthesis in the adult. J Am Acad Orthop Surg 1996;4:201-208.
Hensinger RN: Spondylolysis and spondylolisthesis in children and adolescents. J Bone Joint Surg Am 1989;71:1098-1107.
Seitsalo S, Osterman K, Hyvarinen H, Tallroth K, Schlenzka D, Poussa M: Progression of spondylolisthesis in children and adolescents: A long-term follow-up of 272 patients. Spine 1991;16:417-421.
Fredrickson BE, Baker D, McHolik WJ, Yuan HA, Lubicky JP: The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am 1984;66:699-707.

Question 99

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

Explanation

DISCUSSION: In the thrower’s elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin.
REFERENCES: Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75.
Eaton RG, Crowe JF, Parkes JC III: Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am 1980;62:820-825.

Question 100

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Explanation

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

Full Question & Answer Text (for Search Engines)

Question 1:

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 2:

- Which of the following neurovascular structures is at greatest risk during the introduction of acetabular component fixation screws during total hip replacement?

Options:

Sciatic nerve
Superior gluteal artery
Profunda femoris artery
Femoral artery and nerve
External iliac artery and vein

Correct Answer: External iliac artery and vein

Explanation:

Question 3:

Factors contributing to an increased risk of hip fracture include reduced bone mineral density of the femoral neck, cognitive status of the individual, and

Options:

increased trunk muscle activity.
increased muscle activity about the hip.
increased muscle activity about the shoulder.
a flexed hip configuration during impact.
falling forward on an outstretched hand.

Correct Answer: increased trunk muscle activity.

Explanation:

Question 4:

Options:

open repair of the lateral joint capsule disruption.
open Bankart-type repair of the labral-glenoid tear.
arthroscopic repair of the Bankart lesion.
physical therapy for rotator cuff strengthening.
immobilization for 6 weeks, followed by rehabilitation.

Correct Answer: open repair of the lateral joint capsule disruption.

Explanation:

DISCUSSION: The MRI findings reveal a disruption of the humeral insertion of the glenohumeral ligaments and joint capsule (humeral avulsion of the glenohumeral ligament). This lesion has been reported to account for an 8% rate of recurrent dislocation in a subset of patients who are typically older than those with the more common lesions of the glenoid labrum (Bankart lesion). Open repairs have been reported to be successful in the prevention of recurrent instability. Since there is no Bankart lesion, open or arthroscopic labral repairs are not indicated. Nonsurgical management is possible if the patient does not want to undergo surgery; however, the recurrence rate is very high.
REFERENCES: Wolf EM, Cheng JC, Dickson K: Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607.
Bokor DJ. Conboy VB. Olson C: Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases. J Bone Joint Surg Br
1999;81:93-96.
Coates MH, Breidahl W: Humeral avulsion of the anterior band of the inferior glenohumeral ligament with associated subscapularis bony avulsion in skeletally immature patients. Skeletal Radiol 2001;30:661-666.

Question 5:

Which of the following would be associated with the spinal deformity shown in Figures 79a and 79b? Review Topic

Options:

Improved gait
Deformity progression
Delayed satiety
No further risk of fracture
Improved lung function

Correct Answer: Deformity progression

Explanation:

Question 6:

Options:

anterior reduction, stabilization, and fusion at L1-2.
anterior reduction, stabilization, and fusion at T12-L3.
posterior reduction, stabilization, and fusion at L1-2.
posterior reduction, stabilization, and fusion at T12-L4.

Correct Answer: posterior reduction, stabilization, and fusion at T12-L4.

Explanation:

DISCUSSION
The figures reveal a fracture-dislocation at L1-2. Proper treatment consists of posterior reduction, stabilization, and fusion 2 levels above and below the level of injury. Short-segment stabilization schemes do not stabilize the injury properly, and longer-segment constructs are not necessary. Anterior treatment is not indicated in fracture-dislocations.
RECOMMENDED READINGS
Mikles MR, Stchur RP, Graziano GP. Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):424-35. Review. PubMed PMID: 15615508.
View
Abstract at PubMed
Bono CM, Rinaldi MD. Thoracolumbar trauma. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:201-216.

Question 7:

Options:

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

Correct Answer: C1-C2 posterior cervical fusion

Question 8:

Options:

equal to the bone-patellar tendon-bone graft.
one half the failure load of the bone-patellar tendon-bone graft.
one quarter the failure load of the bone-patellar tendon-bone graft.
approximately two times the failure load of the bone-patellar tendon-bone graft.
four times the failure load of the bone-patellar tendon-bone graft.

Correct Answer: approximately two times the failure load of the bone-patellar tendon-bone graft.

Explanation:

Question 9:

Options:

normal postoperative orders with frequent neurologic evaluations for the first 24 hours.
administration of IV steroids and placement of a soft cervical collar for 24 hours.
placement of both deep and superficial surgical drains prior to wound closure.
administration of IV mannitol and placement of a soft collar.
maintaining intubation for up to 24 to 48 hours.

Correct Answer: maintaining intubation for up to 24 to 48 hours.

Explanation:

DISCUSSION: Airway complications after anterior cervical surgery can be a catastrophic event necessitating emergent intubation for airway protection. Multilevel surgeries requiring long intubation and prolonged soft-tissue retraction as well as preexisting comorbidities may predispose a patient to postoperative airway complications. Sagi and associates reported that surgical times greater than 5 hours, blood loss greater than 300 mL, and multilevel surgery at or above C3-4 are risk factors for airway complications. In surgical procedures with the aforementioned factors, serious consideration should be given to elective intubation for 1 to 3 days to avoid urgent reintubation.
REFERENCES: Sagi HC, Beutler W, Carroll E, et al: Airway complications associated with surgery on the anterior cervical spine. Spine 2002;27:949-953.
Epstein NE, Hollingsworth R, Nardi D, et al: Can airway complications following multilevel anterior cervical surgery be avoided? J Neurosurg 2001;94:185-188.
Emery SE, Smith MD, Bohlman HH: Upper-airway obstruction after multi-level cervical corpectomy for myelopathy. J Bone Joint Surg Am 1991;73:544-551.

Question 10:

Options:

Above-knee amputation
En bloc resection of the lesion and reconstruction with a bone graft
Closed reduction and immobilization in a cast
Open reduction and internal fixation, followed by radiation therapy
Open reduction, curettage, and cementing of the lesion

Correct Answer: Closed reduction and immobilization in a cast

Explanation:

Question 11:

Options:

Less than 7
7 to 10
11 to 13
14 to 17
Greater than 17

Correct Answer: 11 to 13

Explanation:

Question 12:

Options:

Diagnostic arthroscopy
MRI-arthrography
Stress radiographs
CT
Weighted radiographs of the arm

Correct Answer: MRI-arthrography

Explanation:

Question 13:

What is the incidence and significance of anterior cruciate ligament laxity following tibial eminence fractures in skeletally immature individuals?

Options:

Common and frequently symptomatic
Common and infrequently symptomatic
Common but generally resolves spontaneously
Rare but when present, usually symptomatic
Rare and if present, infrequently symptomatic

Correct Answer: Common and infrequently symptomatic

Explanation:

DISCUSSION: Measurable anterior cruciate ligament laxity, while frequently seen after tibial eminence fractures, usually does not cause symptoms. It is found even in patients whose fractures have been anatomically reduced and fixed, leading to speculation that it is due to stretching of the ligament at the time of injury.
REFERENCES: Willis R, Blokker C, Stall TM, et al: Long-term follow-up of anterior
eminence fractures. J Pediatr Orthop 1993;13:361-364.
Smith JB: Knee instability after fracture of the intercondylar eminence of the tibia.
J Pediatr Orthop 1984;4:462-464.

Question 14:

Options:

arthroscopy and subtotal meniscectomy.
arthroscopy and shaving chondroplasty.
osteochondral bone graft.
high tibial valgus osteotomy.
total knee replacement.

Correct Answer: total knee replacement.

Explanation:

Question 15:

Options:

Vitamin D
Calcium supplement
Methotrexate
Nonsteroidal antiinflammatory drugs (NSAIDs)
Bisphosphonate therapy

Correct Answer: Bisphosphonate therapy

Explanation:

Question 16:

In the absence of developmental dysplasia of the hip, what is the most common cause of osteoarthritis? Review Topic

Options:

Legg-Calve-Perthes disease
Traumatic labral tear
Repetitive high-impact activity such as football
Femoroacetabular impingement
Hip injury resulting from a direct impact such as a knee hitting a dashboard

Correct Answer: Femoroacetabular impingement

Explanation:

Question 17:

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

Options:

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

Correct Answer: Quadruple semitendinosus and gracilis tendons

Explanation:

Question 18:

Options:

Decreased joint penetration of distal screws
Increased rigidity
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation

Correct Answer: Decreased joint penetration of distal screws

Explanation:

Question 19:

Options:

Nonsteroidal anti-inflammatory drugs and reassurance that this is a steroid flare reaction that should subside within 2 to 3 days
Emergent L4-5 diskectomy
Repeat epidural steroid injection at L4-5 under fluoroscopy
MRI of the lumbar spine
Myelography and CT

Correct Answer: MRI of the lumbar spine

Explanation:

Question 20:

Options:

Conversion to cast immobilization for 6 weeks
Application of an articulated external fixator
Begin early motion as soon as pain resolves
Open reduction
MRI to assess ligament integrity

Correct Answer: Open reduction

Explanation:

DISCUSSION: Elbow dislocations in children are rare injuries and usually result from a fall on an outstretched arm. The incidence of these injuries increases as patients age and concurrently the incidence of supracondylar humerus fractures decreases. In adolescent patients, simple elbow dislocations are treated with splint immobilization and the initiation of physical therapy once comfortable. The practitioner must be aware of structures that may get caught in the joint on reduction. These include the median nerve as well as the medial epicondyle. In this patient, the radiographs reveal a medial epicondyle fracture. Postreduction radiographs show the joint to be incongruous secondary to intra-articular displacement. At this point, the most appropriate treatment is to perform an open reduction and repair of the medial epicondyle fragment.
REFERENCES: Rasool MN: Dislocations of the elbow in children. J Bone Joint Surg Br 2004;86:1050-1058.
Beaty JH: Fractures and dislocations about the elbow in children. Instr Course Lect 1992;41:373-384.

Question 21:

Options:

Observation
Arthroscopic rotator cuff debridement
Arthroscopic rotator cuff repair with acromioplasty
Arthroscopic biceps tendon tenotomy
Open rotator cuff repair with bone tunnels

Correct Answer: Observation

Explanation:

Question 22:

Options:

Decreased pitch count for 4 weeks
Continued play with close observation
Cessation of all throwing for 6 weeks
Arthroscopic repair
Mini-open repair

Correct Answer: Cessation of all throwing for 6 weeks

Explanation:

Question 23:

Which of the following is associated with the use of large femoral heads in total hip arthroplasty?

Options:

Increased risk of total hip dislocation
Decreased range of motion
Fewer options for femoral head bearing material
Acceptable wear with modern bearing surfaces
Increased component impingement

Correct Answer: Acceptable wear with modern bearing surfaces

Explanation:

Question 24:

Options:

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

Correct Answer: HLA-B27

Explanation:

Question 25:

What is the most common type of malalignment after intramedullary nailing of distal 1/3 tibia fractures?

Options:

Varus
Valgus
Translational
Rotational
Apex anterior

Correct Answer: Varus

Explanation:

Question 26:

Deep posterior compartment

Options:

Anterior tibial artery
Posterior tibial artery
Superficial peroneal nerve
Deep peroneal nerve

Correct Answer: Posterior tibial artery

Explanation:

Question 27:

Options:

Enchondroma
Giant cell tumor
Chondroblastoma
Osteoblastoma
Chondromyxoid fibroma

Correct Answer: Chondroblastoma

Explanation:

DISCUSSION: The epiphyseal location on the radiograph and MRI scan and the histologic findings of polyhedral cells separated by a chondroid matrix with pericellular, lattice-like “chicken wire” calcification all suggest chondroblastoma. Although giant cell tumors of bone typically occupy an epiphyseal location, they are rare in children and when present are often metaphyseal in skeletally immature patients. Enchondromas and osteoblastomas are generally metaphyseal and, along with giant cell tumors, have very different histology than seen here. Chondromyxoid fibromas are typically metaphyseal in location.
REFERENCES: Huvos AG: Bone Tumors: Diagnosis, Treatment, and Prognosis. Philadelphia, PA, WB Saunders, 1991, pp 295-313.
Lin PP, Thenappan A, Deavers MT, et al: Treatment and prognosis of chondroblastoma. Clin Orthop Relat Res 2005;438:103-109.

Question 28:

Options:

Malposition of the components
A poor survivorship record of the implant
A high-powered intraoperative frozen section that reveals a count of 20 WBCs per high-powered field
A nonmodular acetabular component
A well-fixed modular acetabular component

Correct Answer: A well-fixed modular acetabular component

Explanation:

Question 29:

What complication is frequently associated with the Weil lesser metatarsal osteotomy (distal, oblique) in the treatment of claw toe deformities?

Options:

Floating toe
Nonunion
Osteonecrosis
Inadequate shortening
Dorsal displacement

Correct Answer: Floating toe

Explanation:

DISCUSSION: Weil osteotomies are useful in achieving shortening of a lesser metatarsal with preservation of the distal articular surface. The osteotomy is oriented from distal-dorsal to proximal-plantar; therefore, proximal displacement of the distal fragment is associated with plantar (not dorsal) displacement as well. Plantar displacement can result in the intrinsics acting dorsal to the center of the metatarsophalangeal joint and the development of an extended or “floating toe.” Nonunion, osteonecrosis, and inadequate shortening are infrequent complications associated with the Weil lesser metatarsal osteotomy.
REFERENCES: Trnka HJ, Nyska M, Parks BG, et al: Dorsiflexion contracture after the Weil osteotomy: Results of cadaver study and three-dimensional analysis. Foot Ankle Int
2001;22:47-50.
Trnka HJ, Muhlbauer M, Zettl R, et al: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.

Question 30:

Which of the following statements best describes the anatomic considerations of the popliteal artery posterior to the knee joint?

Options:

It lies posterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies lateral to the popliteal vein and 15 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies medial to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.
It lies anterior to the popliteal vein and 15 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.

Correct Answer: It lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.

Explanation:

DISCUSSION: Popliteal artery injury during total knee arthroplasty is relatively rare. Knee flexion, the position that occurs during most of the arthroplasty procedure, allows the popliteal vessels to fall posteriorly, further away from harm. Anatomically, the popliteal artery lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in
90 degrees of flexion.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 151.
Anderson JE: Grant’s Atlas of Anatomy, ed 7. Baltimore, MD, Lippincott Williams & Wilkins, 1978, pp 4-53.

Question 31:

Options:

Remove the component and replace it with a “jumbo” cup with bone graft or substitute.
Remove the component and replace it with a bipolar component with bone graft or substitute.
Remove the component and replace it with a support ring with graft or graft substitute and cement a cup into the support ring.
Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.
Use a structural acetabular graft to reconstruct the acetabulum and cement a cup into the structural graft.

Correct Answer: Score the component for improved cement interdigitation and cement a cup into the retained socket with bone graft or substitute.

Explanation:

Question 32:

Compared with cobalt-chromium, the biomechanical properties of titanium on polyethylene articulation in total hip replacement result in

Options:

an increased rate of volumetric wear.
increased stability.
decreased frictional force.
a decreased rate of acetabular loosening.
a decreased rate of femoral stem loosening.

Correct Answer: an increased rate of volumetric wear.

Explanation:

Question 33:

Options:

open reduction and internal fixation with a plate and screws.
open treatment with calcaneal bone graft.
percutaneous screw fixation with a 4.5-mm screw.
weight-bearing cast for 8 weeks.
spanning external fixation.

Correct Answer: percutaneous screw fixation with a 4.5-mm screw.

Explanation:

Question 34:

When performing ankle arthroscopy through the anterolateral portal, what anatomic structure is at greatest risk?

Options:

Anterior tibialis tendon
Anterior tibial artery
Sural nerve
Deep peroneal nerve
Superficial peroneal nerve

Correct Answer: Superficial peroneal nerve

Explanation:

Question 35:

What do the T2-weighted, fat-saturated MRI scans shown in Figures 1 through 4 reveal?

Options:

Posterior cruciate ligament (PCL) tear, isolated
PCL tear and medial meniscus tear
Anterior cruciate ligament (ACL) tear, isolated
ACL tear and medial meniscus tear

Correct Answer: ACL tear and medial meniscus tear

Explanation:

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal
disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly
indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 36:

Options:

posterior partial articular tibial plateau fracture.
lateral split depression tibial plateau fracture.
medial plateau fracture dislocation.
knee dislocation with lateral collateral ligament tear .

Correct Answer: medial plateau fracture dislocation.

Explanation:

Question 37:

What is the second most common primary bone malignancy in children?

Options:

Rhabdomyosarcoma
Osteosarcoma
Ewing’s sarcoma
Fibrosarcoma
Adamantinoma

Correct Answer: Ewing’s sarcoma

Explanation:

DISCUSSION: Ewing’s sarcoma is the second most common bone tumor in children with an incidence of three per one million Caucasian children younger than 21 years of age. Ewing’s sarcoma is rare in African Americans. Osteosarcoma is the most common bone tumor in children. Rhabdomyosarcoma is the most common soft-tissue sarcoma in children. Fibrosarcoma is a rare primary bone tumor most commonly seen in adults. Adamantinoma is a rare primary bone malignancy also most commonly seen in adults in the tibia.
REFERENCES: Menendez LR (ed): Orthopaedic Knowledge Update: Musculoskeletal Tumors. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 195.
Gibbs CP Jr, Weber K, Scarborough MT: Malignant bone tumors. Instr Course Lect 2002;51:413-428.

Question 38:

Which of the following is associated with increased fetal morbidity and mortality in acetabular fractures during pregnancy?

Options:

Fetal position
Surgical approach
Mechanism of injury
Fracture classification
Trimester of pregnancy

Correct Answer: Mechanism of injury

Explanation:

Question 39:

- A 25-yo man sustains the injury shown in Figures 29a and 29b as a result of high-speed trauma. Examination reveals diffuse weakness in the lower extremities that is slightly worse on the right side, and decreased rectal tone and sensation. A CT scan is shown in figures 29c and 29d. Definitive treatment of the injury to the spine is delayed because of a severe pulmonary contusion. At 15 days after the injury, the patient’s neurological status remains unchanged. Management should now consist of

Options:

Posterior fusion at T10-L3 with segmental instrumentation
Laminectomy and fusion of T12-L2 with segmental instrumentation
Bed rest in a hyperextension brace
L1 vertebrectomy and anterior decompression with strut graft fusion and instrumentation
Progressive ambulation as tolerated in a custom-molded thoracolumbosacral orthosis

Correct Answer: L1 vertebrectomy and anterior decompression with strut graft fusion and instrumentation

Explanation:

Question 40:

Options:

The patient
The fiance
The surgeon performing the procedure along with another physician with similar experience and knowledge
The surgeon performing the procedure and a nurse taking care of the patient
Wait for the patient's parents to arrive and have them provide informed consent

Correct Answer: The surgeon performing the procedure along with another physician with similar experience and knowledge

Explanation:

Question 41:

Which of the following clinical tests is used to diagnose medial instability of the elbow? Review Topic

Options:

Posterolateral rotatory drawer test
Lateral pivot-shift test
Moving valgus stress test
Chair test (apprehension or dislocation on terminal extension of the supinated forearm when rising from a seated position)
Pushup sign

Correct Answer: Moving valgus stress test

Explanation:

Question 42:

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

Options:

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

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

Explanation:

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

Question 43:

Options:

Triple arthrodesis
Midfoot closing wedge resection osteotomy
Calcaneal and metatarsal osteotomies
Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening
Serial casting

Correct Answer: Plantar release, posterior tibial tendon transfer to the dorsum, and Achilles tendon lengthening

Explanation:

Question 44:

Figures 75a and 75b are the radiographs after attempted reduction of an injury in a 9-year-old girl. Which anatomic structure is most likely to be interposed?

Options:

Brachialis muscle
Radial nerve
Median nerve
Ulnar nerve

Correct Answer: Ulnar nerve

Explanation:

Question 45:

Figure 7 shows the CT scan of a 22-year-old professional baseball pitcher who has had elbow pain for the past 6 months despite rest from throwing. Management should consist of Review Topic

Options:

cast immobilization for 6 weeks.
brief immobilization followed by rest for 6 weeks.
internal fixation with a compression screw.
internal fixation with a tension band wire.
bone stimulation.

Correct Answer: internal fixation with a compression screw.

Explanation:

Question 46:

Options:

Parallel
Case control
Case series
Factorial
Crossover

Correct Answer: Factorial

Explanation:

Question 47:

Use of titanium elastic nailing for treatment of pediatric femur fractures is associated with a higher complication rate among

Options:

patients younger than age 6.5.
patients who bear weight immediately after surgery.
patients weighing more than 50 kg (110 pounds).
patients with grade 1 open transverse midshaft fractures.

Correct Answer: patients weighing more than 50 kg (110 pounds).

Explanation:

Question 48:

What is the primary goal of the initial (acute) rehabilitation phase of an overhead athlete's shoulder?

Options:

Improve flexibility
Strengthen muscles
Enhance power and endurance
Regain neuromuscular control
Perform functional drills

Correct Answer: Improve flexibility

Explanation:

Question 49:

Options:

Vigorous physical therapy
Manipulation under anesthesia
Arthroscopic capsular release
Hemiarthroplasty
Arthroscopic capsular plication

Correct Answer: Hemiarthroplasty

Explanation:

Question 50:

Which nerve is not included in a standard popliteal nerve block?

Options:

Sural nerve
Saphenous nerve
Superficial peroneal nerve
Deep peroneal nerve

Correct Answer: Saphenous nerve

Explanation:

DISCUSSION
A standard popliteal nerve block is performed with the patient prone. The injection aims for the area at, or close to, the peroneal and tibial nerves. The sural nerve branches distal to the injection site, so this nerve and the superficial peroneal, deep peroneal, and tibial nerves are covered with the injection. The saphenous nerve is in an anteromedial location at knee level and is not close enough to the area covered by the posterior injection to be included in the analgesic effect.
RECOMMENDED READINGS
Varitimidis SE, Venouziou AI, Dailiana ZH, Christou D, Dimitroulias A, Malizos KN. Triple nerve block at the knee for foot and ankle surgery performed by the surgeon: difficulties and efficiency. Foot Ankle Int. 2009 Sep;30(9):854-9. PubMed PMID: 19755069.
View Abstract at
PubMed
Hromádka R, Barták V, Popelka S, Jahoda D, Pokorný D, Sosna A. [Regional anaesthesia of the foot achieved from two cutaneous points of injection: an anatomical study]. Acta Chir Orthop Traumatol Cech. 2009 Apr;76(2):104-9. Czech. PubMed PMID: 19439129.
View
Abstract at PubMed
Tran D, Clemente A, Finlayson RJ. A review of approaches and techniques for lower extremity nerve blocks. Can J Anaesth. 2007 Nov;54(11):922-34. Review. PubMed PMID: 17975239.
View Abstract at PubMed
CLINICAL SITUATION FOR QUESTIONS 42 THROUGH 44
42A
B
Figures 42a and 42b are the radiographs of a 32-year-old man with an accessory navicular, pes planovalgus deformity, and an associated gastrocnemius contracture. He has been treated with custom orthotics and a physical therapy program for several years and has progressed to stage II posterior tibial tendon dysfunction (PTTD). This patient is now interested in surgery. Tendon reconstruction with bony procedure to correct alignment, medializing calcaneal osteotomy with lateral column lengthening, and a subtalar arthroereisis implant are discussed with the patient.

Question 51:

An 18-year-old lacrosse player is diagnosed with infectious mononucleosis. What is the recommendation for return to play? Review Topic

Options:

Full participation once symptoms resolve
Full participation once the splenomegaly resolves
Full participation 4 weeks after the onset of symptoms regardless of the size of the spleen
Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen
No participation for 8 weeks

Correct Answer: Full participation 4 weeks after both the onset of illness and findings of a normal-sized spleen

Explanation:

Question 52:

Which of the following is an advantage of using blocking screws for tibial nailing?

Options:

Decrease risk of nail breakage
Eliminate use of interlocking screws
Allow for larger nail use
Enhance construct stiffness
Decrease torsional rigidity

Correct Answer: Decrease risk of nail breakage

Explanation:

Question 53:

Which of the following tissues used for anterior cruciate ligament (ACL) reconstruction has the highest maximum load to failure?

Options:

Allograft ACL
Bone-patellar tendon-bone with a width of 10 mm
Fascia lata with a width of 15 mm
Central quadriceps tendon with a width of 15 mm
Quadruple semitendinosus and gracilis tendons

Correct Answer: Quadruple semitendinosus and gracilis tendons

Explanation:

Question 54:

Options:

Surgical hip dislocation (“Berne” approach)
Watson-Jones approach
Smith-Peterson approach
Kocher-Langenbeck approach
Extensile iliofemoral approach

Correct Answer: Surgical hip dislocation (“Berne” approach)

Explanation:

Question 55:

Which of the following are considered characteristic features of degeneration of a disk?

Options:

Reduced water and glycosaminoglycan content and increased noncollagen glycoprotein
Reduced water and glycosaminoglycan content and reduced noncollagen glycoprotein
Reduced water content, increased glycosaminoglycan content, and increased noncollagen glycoprotein
Increased water and glycosaminoglycan content and increased noncollagen glycoprotein
Increased water and glycosaminoglycan content and reduced noncollagen glycoprotein

Correct Answer: Reduced water and glycosaminoglycan content and increased noncollagen glycoprotein

Explanation:

Question 56:

Options:

a cortisone injection to the subscapular bursa.
posterior capsular stretching.
strengthening of the external rotators and scapular stabilizers.
continued pitching and working through the pain.
a sling and rest.

Correct Answer: posterior capsular stretching.

Explanation:

Question 57:

Options:

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

Correct Answer: deficient anterior capsule.

Explanation:

Question 58:

Options:

A + C
B + C
B + D
C + D
C + E

Correct Answer: A + C

Explanation:

Question 59:

Options:

custom orthotics.
a below-knee non-weight-bearing cast.
exploration and resection of the calcaneocuboid joint.
exploration and resection of the talocalcaneal joint.
triple arthrodesis.

Correct Answer: triple arthrodesis.

Explanation:

Question 60:

Radiating pain associated with a posterolateral thoracic disk herniation typically follows what pattern?

Options:

Extending down the spine into the lumbosacral region
Down the inner aspect of either upper extremity
Cephalad up to the cervicothoracic junction
Around or through the chest to the anterior wall
Down the contralateral lower extremity

Correct Answer: Around or through the chest to the anterior wall

Explanation:

DISCUSSION: Although symptomatic thoracic disk herniations can affect more caudal structures, even to the point of paralysis, the pattern of radiating pain has been described as either following the dermatomal band around the chest or feeling to the patient as if the pain passes straight anteriorly to the chest wall.
REFERENCE: Skubic JW, Kostuik JP: Thoracic pain syndromes and thoracic disc herniation, in Frymoyer JW (ed): The Adult Spine: Principles and Practice. New York, NY, Raven Press, 1991, pp 1443-1464.

Question 61:

Options:

buddy taping to the adjacent digit.
open reduction and surgical fixation of the bony fragment.
excision of the bony fragment and advancement of the terminal extensor mechanism.
splinting of the DIP joint with intermittent removal and range-of-motion exercises to prevent stiffness.
full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Correct Answer: full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Explanation:

DISCUSSION: Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position.
REFERENCES: Crawford GP: The molded polyethylene splint for mallet finger deformities.
J Hand Surg Am 1984;9:231-237.
Wehbe MA, Schneider LH: Mallet fractures. J Bone Joint Surg Am 1984;66:658-669.

Question 62:

Options:

Hip arthroscopy with labral repair
Reverse periacetabular osteotomy
Varus rotational osteotomy
Open surgical dislocation with rim trimming

Correct Answer: Reverse periacetabular osteotomy

Explanation:

Question 63:

- A 50 year old man who has insulin-dependent diabetes mellitus with associated neuropathy has a stress fracture of the fourth metatarsal. Examination of the foot reveals acute swelling, warmth, and erythema; however, the patient reports very little pain. Treatment should include

Options:

a total contact cast.
electrical stimulation.
an off the shelf fracture brace.
an elastic compression bandage and crutches.
a hard soled shoe until the patient is asymptomatic.

Correct Answer: a total contact cast.

Explanation:

Question 64:

Which of the following is associated with the use of bisphosphonates in the setting of metastatic breast cancer to the spine?

Options:

Reduction in skeletal-related events by 30% to 40%
Jaw osteonecrosis in 15% of patients
Pain improvement in only 30% of patients
Improvement in serum hypocalcemia in 40% of patients
Accelerated bone destruction in 10% of patients

Correct Answer: Reduction in skeletal-related events by 30% to 40%

Explanation:

DISCUSSION: The indications of bisphosphonate therapy in breast cancer patients range from the correction of hypercalcemia to the prevention of cancer treatment-induced bone loss. Bisphosphonates reduce metastatic bone pain in at least 50% of patients and can reduce the frequency of skeletal-related events by 30% to 40%. Osteonecrosis of the jaw could occur in up to 2.5% of breast cancer patients during long-term bisphosphonate therapy.
REFERENCE: Body JJ: Breast cancer: Bisphosphonate therapy for metastatic bone disease. Clin Cancer Res 2006;12:6258s-6263s.

Question 65:

Options:

surface debridement and pulsatile lavage.
wide debridement and internal fixation.
extensive prophylactic compartment fasciotomy.
immediate arteriography.
observation and IV antibiotics for 7 weeks.

Correct Answer: surface debridement and pulsatile lavage.

Explanation:

Question 66:

Which of the following is considered a limitation of the Short Form 36 (SF-36) general health status instrument when applied to musculoskeletal conditions?

Options:

Potential for "ceiling" and "floor" effects
Normative population data have not been attained
Patient's perspective is marginalized or ignored
Must be performed on-site by investigator
Better upper than lower extremity application

Correct Answer: Potential for "ceiling" and "floor" effects

Explanation:

Question 67:

Options:

Semimembranosis tendonitis
Patellar tendonitis
Iliotibial band friction syndrome
Quadriceps tendonitis

Correct Answer: Patellar tendonitis

Explanation:

Question 68:

What is the most common associated pathology in patients who have suprascapular nerve entrapment secondary to ganglion cysts?

Options:

Glenohumeral arthritis
Fracture of the clavicle
Tear of the rotator cuff
Rupture of the long head of the biceps tendon
Superior labrum anterior and posterior (SLAP) lesion

Correct Answer: Superior labrum anterior and posterior (SLAP) lesion

Explanation:

Question 69:

Options:

revision of the failing ACL reconstruction.
arthroscopic lysis of adhesions and manipulation of the knee.
surgical removal of hypertrophic fibrous tissue.
excision of the torn medial meniscus.
continued aggressive physical therapy.

Correct Answer: surgical removal of hypertrophic fibrous tissue.

Explanation:

DISCUSSION: The patient has a cyclops lesion. This is a nodule of fibroproliferative tissue that originates from either drilling debris from the tibial tunnel or remnants of the ACL stump; more rarely it is the result of broken graft fibers. The treatment of choice is excision of the nodule and, if needed, additional notchplasty. Marked improvements in function and symptoms have been noted after removal of the extension block and resumption of a rehabilitation program.
REFERENCES: Delince P, Krallis P, Descamps PY, et al: Different aspects of the cyclops lesion following anterior cruciate ligament reconstruction: A multifactorial etiopathogenesis. Arthroscopy 1998;14:869-876.
Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating anterior cruciate ligament reconstruction. Am J Sports Med 1993;4:558-564.

Question 70:

0 sustained a subcapital fracture of her hip. She is an avid tennis player, and history reveals no previous fractures. What is the most appropriate follow-up care? Review Topic

Options:

Antiresorptive bisphosphonate medication
A repeat dual-energy x-ray absorptiometry scan (DEXA) and treatment if the T-score is less than -2.5
A repeat DEXA scan and treatment if the T-score is greater than -1.5
No treatment since the BMD is not in osteoporotic range
(PTH) taraparatide hormone followed by surgery

Correct Answer: Antiresorptive bisphosphonate medication

Explanation:

Question 71:

What is the most prevalent adverse event associated with allogeneic blood transfusion?

Options:

Clerical error leading to transfusion reaction
Anaphylactic reaction
HIV transmission
Hepatitis C transmission
Bacterial contamination leading to sepsis/shock

Correct Answer: Clerical error leading to transfusion reaction

Explanation:

DISCUSSION: Clerical error leading to acute hemolysis and even death occurs in 1:12,000 to 1:50,000 transfusions. Bacterial contamination leading to sepsis/shock occurs in 1:1 million transfusions. HIV transmission is approximately 1:500,000 transfusions and hepatitis C is 1:103,000 transfusions. Anaphylactic reactions occur in 1:150,000 transfusions.
REFERENCES: Aubuchon JP, Birkmeyer JD, Busch MP: Safety of the blood supply in the United States: Opportunities and controversies. Ann Intern Med 1997;127:904-909.
Popovsky MA, Whitaker B, Arnold NL: Severe outcomes of allogeneic and autologous blood donation: Frequency and characterization. Transfusion 1995;35:734-737.

Question 72:

- A 13-year-old quarterback feels a “pop” in his knee while being tackled. Radiographs of the knee and results of a Lachman’s test are normal. Examination reveals tenderness over the distal femoral physis. To help confirm the diagnosis, management should first include

Options:

an MRI scan
arthroscopic examination
AP and frog-lateral radiographs of the pelvis and hips
varus and valgus stress radiographs of the knee
physical examination of the knee under anesthesia

Correct Answer: varus and valgus stress radiographs of the knee

Explanation:

Question 73:

Options:

Open reduction under general anesthesia
Closed reduction under general anesthesia with fluoroscopy
Closed reduction under general anesthesia without fluoroscopy
Conscious sedation in the emergency department and closed reduction with fluoroscopy
Conscious sedation in the emergency department and closed reduction without fluoroscopy

Correct Answer: Closed reduction under general anesthesia with fluoroscopy

Explanation:

Question 74:

Kyphosis from a vertebral osteoporotic compression fracture often results in progressive kyphosis due to Review Topic

Options:

progressive increase in lumbar lordosis.
load transfer to the superior adjacent vertebra.
normalization of load transfer with working kyphosis.
reduced strain at the occipito-cervical junction.
reduced strain at the apex of the deformity.

Correct Answer: load transfer to the superior adjacent vertebra.

Explanation:

Question 75:

Options:

medial and lateral collateral ligaments, radial head, and coronoid.
medial collateral ligament and coronoid.
lateral collateral ligament and radial head.
medial and lateral collateral ligaments.
radial head and coronoid.

Correct Answer: medial and lateral collateral ligaments, radial head, and coronoid.

Explanation:

Question 76:

Options:

Cubital tunnel release
Guyon's canal release
Hook-of-hamate excision
Excision of the ganglion cyst

Correct Answer: Excision of the ganglion cyst

Explanation:

Question 77:

Options:

Hardware migration is more likely than with acromioclavicular pinning.
Failure of fixation is usually at the level of the clavicle.
Hardware removal is avoided to prevent late displacement.
Neurologic injury most likely involves the axilllary nerve.
Acromioclavicular arthritis is more likely than with nonsurgical management.

Correct Answer: Acromioclavicular arthritis is more likely than with nonsurgical management.

Explanation:

Question 78:

If the site of the pathologic lesion is revealed in Figure 54f and not in Figure 54e after traumatic anterior shoulder dislocation, the mechanism of shoulder injury is likely

Options:

axial loading of the glenohumeral joint.
isolated hyperabduction.
combined 45-degree abduction and external rotation.
combined hyperabduction and external rotation.

Correct Answer: combined hyperabduction and external rotation.

Explanation:

DISCUSSION
For patients with anterior shoulder instability, most commonly, a Bankart lesion, or detachment of the anteroinferior labrum with the attached inferior glenohumeral ligament from the glenoid rim is found. A medialized anteroinferior capsulolabral attachment (ALPSA lesion) is a common finding in shoulders with chronic anterior instability. The anterior band of the inferior glenohumeral ligament is tightest with the arm in 90 degrees of abduction with the shoulder externally rotated, creating a “hammock” that supports the humeral head. At 45 degrees of shoulder
abduction, the capsuloligamentous components of the shoulder are at their loosest, resulting in the most total superior-inferior translation.
During traumatic anterior glenohumeral dislocation, associated injuries commonly occur. In a prospective database of 3633 patients who sustained a traumatic anterior glenohumeral dislocation, 13.5% had a neurologic deficit following reduction, the majority of which were injuries to the axillary nerve. The injuries typically were sensory but not motor deficits and resolved spontaneously over time. These isolated axillary nerve injuries were more common in young, athletic patients. Associated rotator cuff tears and greater tuberosity fractures are commonly associated with shoulder dislocation as well and are more common in patients 60 years of age and older.
Large, engaging posterior humeral head Hill-Sachs lesions are associated with increased rates of recurrent shoulder instability. At the time of surgical arthroscopy, the Hill-Sachs lesion should be assessed for engagement with the glenoid. In the absence of significant glenoid bone loss, some patients with engaging Hill-Sachs defects may be suitable for combined Bankart repair and Hill-Sachs remplissage at the time of surgery. When these procedures are combined, patients have an approximate 10-degree decreased shoulder external rotation with the arm at the side and in abduction when compared to the contralateral, uninjured shoulder. Rates of recurrent dislocation and return to sport are comparable to those for patients undergoing Bankart repair alone.
Humeral avulsion of the glenohumeral ligaments (HAGL) has become a well-recognized cause of recurrent shoulder instability and is reported in 1% to 9% of patients. HAGL lesions can occur in isolation or, more commonly, may be associated with other abnormalities such as a tear of the rotator cuff, Bankart lesion, Hill-Sachs deformity, or labral tear. Recurrence of shoulder instability is more likely to occur if there is failure to identify a HAGL lesion. HAGL lesions can result from trauma in the setting of combined hyperabduction and external rotation. This is in contrast to a Bankart lesion, which is a result of trauma when the shoulder is hyperabducted without substantial associated rotation.
RECOMMENDED READINGS
Warner JJ, Deng XH, Warren RF, Torzilli PA. Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med. 1992 Nov-Dec;20(6):675-85. PubMed PMID: 1456361.
View Abstract at PubMed
Robinson CM, Shur N, Sharpe T, Ray A, Murray IR. Injuries associated with traumatic anterior glenohumeral dislocations. J Bone Joint Surg Am. 2012 Jan 4;94(1):18-26. doi: 10.2106/JBJS.J.01795. PubMed PMID: 22218378.
View Abstract at PubMed
Visser CP, Coene LN, Brand R, Tavy DL. 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 Jul;81(4):679-85. PubMed PMID: 10463745.
View Abstract at PubMed
Boileau P, O'Shea K, Vargas P, Pinedo M, Old J, Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012 Apr 4;94(7):618-26. doi: 10.2106/JBJS.K.00101. PubMed PMID: 22488618.
View Abstract at PubMed
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments: the HAGL lesion. Am J Sports Med. 2007 Nov;35(11):1960-6. Epub 2007 Apr 9. Review. PubMed PMID: 17420506.
View Abstract at PubMed

Question 79:

In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?

Options:

Transverse fracture at or below the level of the syndesmosis
Short oblique fracture running from anteroinferior to posteriosuperior
Short oblique fracture running from posteroinferior to anteriosuperior
Comminuted fracture above the level of the syndesmosis
Wagstaff fracture

Correct Answer: Transverse fracture at or below the level of the syndesmosis

Explanation:

Question 80:

Options:

Annular
Anterior band of the medial collateral
Lateral orbicular
Lateral radial collateral
Lateral ulnar collateral

Correct Answer: Lateral ulnar collateral

Explanation:

Question 81:

What antithrombotic agent is a selective factor I0a inhibitor? Review Topic

Options:

Warfarin
Low-molecular-weight heparin
Rivaroxaban
Aspirin

Correct Answer: Rivaroxaban

Explanation:

Question 82:

Options:

classic dysplasia with volume deficient acetabula.
acetabular retroversion with positive crossover signs and ischial spine signs.
no substantial dysplasia, with normal acetabular volume and anteversion.
inadequate radiographic evidence to assess for hip dysplasia.

Correct Answer: inadequate radiographic evidence to assess for hip dysplasia.

Explanation:

Question 83:

- A patient is in respiratory distress as a result of a high-speed motor vehicle accident. After emergent intubation, the arterial blood is poorly oxygenated, and examination shows left-sided tracheal deviation, absence of breath sounds on the right side and tympany on percussion over the right side of the chest. Management should include

Options:

Positive-pressure ventilation
An immediate radiograph of the chest
Adjustment of the position of the endotrachael tube
Insertion of a large-bore needle into the pericardial space
Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Correct Answer: Insertion of a large-bore needle in the right second intercostal space, midclavicular line

Explanation:

Question 84:

Options:

Oral antibiotics for staphylococcus
Repeat laboratory studies in 1 week to recheck the ESR
MRI with gadolinium
Biopsy of the surgical disk space
Irrigation and debridement of the surgical wound in the operating room

Correct Answer: MRI with gadolinium

Explanation:

Question 85:

Figure 36 shows the hip arthrogram of a newborn. Which of the following structures is enclosed by the circle?

Options:

Limbus
Pulvinar
Ligamentum teres
Transverse acetabular ligament
Acetabular labrum

Correct Answer: Acetabular labrum

Explanation:

DISCUSSION: The structure enclosed by the circle is the acetabular labrum. It is visible as the white point of tissue outlined by the darkly radiopaque contrast. The appearance of the contrast surrounding the sharp white point of a normal labrum is called the “rose thorn sign.” The limbus is the term reserved for a rounded, infolded labrum seen with arthrography. The pulvinar is the fatty tissue seen in the empty acetabulum when the hip is dislocated. The ligamentum teres is seen as a white stripe outlined by contrast coursing from the central acetabulum to the dislocated femoral head. The transverse acetabular ligament courses across the inferior portion of the acetabulum and is not clearly seen with arthrography.
REFERENCES: Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA,
WB Saunders, 2002, vol 1, pp 532-533.
Severin E: Contribution to the knowledge of congenital dislocation of the hip joint.
Acta Chir Scand 1941;84:1.

Question 86:

Which of the following terms describe a rehabilitative exercise in which the foot is mobile and the motion of the knee is independent of hip and ankle motion?

Options:

Isotonic
Isokinetic
Isometric
Open kinetic chain
Dynamic variable resistance

Correct Answer: Open kinetic chain

Explanation:

Question 87:

When a structure like a long bone is under a bending load, its maximum stress is most dependent on what factor?

Options:

Length of the bone
Type of structural support
Size of cross-sectional area
Plastic modulus of material used
Area moment of inertia of the cross section

Correct Answer: Area moment of inertia of the cross section

Explanation:

Question 88:

Options:

Surgery on the wrong patient
Surgery on the wrong side
Incorrect procedure performed
Intraoperative death
Surgery on the wrong level

Correct Answer: Surgery on the wrong level

Explanation:

DISCUSSION: Patient safety and prevention of medical errors is a major focus of recent national advocacy groups. Analysis has shown that the most common sentinel event in spine surgery is surgery on the wrong level. Therefore, it is recommended that every patient have the surgical site signed, the level of surgery marked intraoperatively, and a radiograph taken. Surgery on the wrong level is most likely to occur in single-level decompressive procedures.
REFERENCES: Wong DA, Watters WC III: To err is human: Quality and safety issues in spine care. Spine 2007;32:S2-S8.
Wong DA: Spinal surgery and patient safety: A systems approach. J Am Acad Orthop Surg 2006;14:226-232.

Question 89:

Options:

Nonsurgical management with the use of a cast-brace
Nonsurgical management with skeletal traction
Open treatment with a locked plate with or without strut allograft
Revision of the femoral component to a cemented femoral component that bypasses the fracture site by two cortical diameters
Revision of the femoral component to a cementless femoral component that bypasses the fracture site by at least two cortical diameters

Correct Answer: Revision of the femoral component to a cementless femoral component that bypasses the fracture site by at least two cortical diameters

Explanation:

Question 90:

Options:

open reduction internal fixation of the fibula only
open reduction internal fixation of the tibia and fibula
removal of external fixator and conversion to a walking cast
dynamization of the external fixator
tibio-talar arthrodesis

Correct Answer: open reduction internal fixation of the tibia and fibula

Explanation:

Question 91:

A 42-year-old woman sustains a closed posterior elbow dislocation. A closed reduction is performed, and the elbow appears stable under fluoroscopic examination. Initial treatment should consist of

Options:

early mobilization only.
surgical reconstruction of medial and lateral collateral ligaments.
active motion in a hinged brace from 30° to 120°.
application of hinged external fixator with early mobilization.

Correct Answer: early mobilization only.

Explanation:

Question 92:

Options:

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

Correct Answer: Aspiration of the right hip

Explanation:

Question 93:

The gluteus maximus is innervated by which of the following nerves?

Options:

Superior gluteal
Inferior gluteal
Pudendal
Anterior division of the femoral
Posterior division of the femoral

Correct Answer: Inferior gluteal

Explanation:

Question 94:

Options:

Running mileage during the 2 months prior to basic training
Self-rated fitness
Running frequency during the 2 months prior to basic training
No menstrual bleeding during the year prior to basic training
Race/ethnicity

Correct Answer: No menstrual bleeding during the year prior to basic training

Explanation:

Question 95:

Figures 6a through 6d show the radiographs and biopsy specimens of an 8-year-old girl with leg pain. Management of the lesion should consist of

Options:

wide resection and salvage of the physis.
resection and hemicondylar osteoarticular allograft.
cryosurgery.
radiation therapy.
curettage and bone grafting.

Correct Answer: curettage and bone grafting.

Explanation:

Question 96:

Options:

ACL tear and medial meniscal tear
Medial mensical tear only
PCL tear and medial meniscal tear
PLC tear and meniscal tear
PCL tear only

Correct Answer: ACL tear and medial meniscal tear

Explanation:

Question 97:

Second impact syndrome (SIS) after head injury is characterized by which of the following?

Options:

Gradual progression of neurologic symptoms
Preventable by restricting return to play until symptom-free
Excellent prognosis for full recovery
Rarely involves brain stem compromise
CT rarely shows brain edema

Correct Answer: Preventable by restricting return to play until symptom-free

Explanation:

Question 98:

Options:

caused by the accident, exists in 5% of the population, has no familial predisposition, and is unlikely to progress.
caused by the accident, exists in 12% of the population, has no familial predisposition, and is unlikely to progress.
preexisting to her accident, exists in 3% of the population, has no familial predisposition, and should be monitored for progression yearly until age 25 years.
preexisting to her accident, exists in 5% of the population, has a familial predisposition, and is unlikely to progress.
preexisting to her accident, exists in 12% of the population, has a familial predisposition, and is likely to progress throughout adulthood.

Correct Answer: preexisting to her accident, exists in 5% of the population, has a familial predisposition, and is unlikely to progress.

Explanation:

Question 99:

Options:

Further rehabilitation
Corticosteroid injection
Reconstruction of the medial collateral ligament
Subcutaneous transposition of the ulnar nerve
Arthroscopic debridement of medial osteophytes

Correct Answer: Subcutaneous transposition of the ulnar nerve

Explanation:

Question 100:

Of the following clinical situations, which is most likely to lead to osteonecrosis associated with a slipped capital femoral epiphysis (SCFE)?

Options:

A girl younger than age 15 years
A boy younger than age 15 years
An unstable SCFE
A stable SCFE
A stable SCFE associated with morbid obesity

Correct Answer: An unstable SCFE

Explanation:

DISCUSSION: Osteonecrosis of the femoral head is the most devastating complication of SCFE. There is a 47% incidence of ischemic necrosis associated with an unstable SCFE. By definition, the patient with an unstable SCFE is unable to bear weight even with crutches. Osteonecrosis is most likely associated with the initial femoral head displacement rather than the result of either tamponade from hemarthrosis or from gentle repositioning prior to stabilization. Age, sex, and obesity are not risk factors for osteonecrosis.
REFERENCES: Loder RT, Richards BS, Shapiro PS, et al: Acute slipped capital femoral epiphysis: The importance of physeal stability. J Bone Joint Surg Am 1993;75:1134-1140.
Herring JA: Tachdjian’s Pediatric Orthopaedics, ed 3. Philadelphia, PA, WB Saunders, 2002, vol 2, pp 711-745.

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

Orthopedic Board Review MCQs: Hip, Shoulder, Fracture & Deformity | Part 184

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 184

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index